Process-Based Strategy Yields Sustained Reductions in Surgical Site Infections

Work part of quality review at Center for Spine Health

By Tagreed Khalaf, MD, and Ajit Krishnaney, MD

Advertising Policy

Cleveland Clinic is a non-profit academic medical center. Advertising on our site helps support our mission. We do not endorse non-Cleveland Clinic products or services Policy

At Cleveland Clinic’s Center for Spine Health, we are increasingly convinced that value in healthcare — understood as Value = Outcome/Cost — must help define the framework for performance improvement to optimize patient care and outcomes.

Value can be increased in two ways: by improving the quality of care delivered or by reducing costs while maintaining quality. At the Center for Spine Health, we are employing both of these approaches to enhance the value of the care we provide to our patients. Since quality is central to both approaches, we have formed a multidisciplinary quality improvement team tasked with overseeing and continuously improving the quality of care we provide.

The quality team and its charge

The quality team is made up of physicians ‒ both spine surgeons and medical spine specialists ‒ as well as midlevel providers, nurses and representatives from Cleveland Clinic’s Quality & Patient Safety Institute. Team members meet monthly to review various quality metrics, including:

  • The surgical site infection rate during spine procedures
  • Readmissions
  • Patient safety indicators, including venous thromboembolism rates
  • Patient experience metrics
  • Outcomes using Cleveland Clinic’s Knowledge Program database, an interactive platform for multidomain data collection

The team then identifies opportunities for performance improvement and defines a process improvement measure or protocol. The process includes identifying specific goals to be achieved and determining specific outcomes or metrics to be measured to monitor progress toward these goals.

Case study: Curbing SSIs

A good example of this process at work has been our effort to curb surgical site infections (SSIs), which has yielded sustained improvement in the rate of postoperative wound infections over the most recent 18 months of monitoring.

The SSI rate has been reported to vary by the type of spine surgery performed. According to the National Nosocomial Infections Surveillance System Report, the rate is 2.46 percent for laminectomies and 6.35 percent for fusion surgeries.1,2 These rates can vary further based on patient risk factors and other variables.

Monitoring SSIs is important, as SSIs affect patient outcomes and can be associated with increases in morbidity and mortality rates, length of stay, and the likelihood of hospital readmission or ICU stay ‒ as well as increased costs of care.

The best approach to managing postoperative infections is obviously to prevent them in the first place. The key to prevention is identifying factors that may increase the risk and minimizing those factors around the time of surgery.

Center for Spine Health staff work collaboratively with colleagues from Cleveland Clinic’s Department of Infectious Disease to monitor closely the SSI rate across all spine surgeries performed. We recently designated reducing our SSI rate as a center goal and target measure for performance improvement. To that end, we identified a variety of potential factors associated with SSIs and developed and implemented a number of protocols to address them. The protocols were divided into preoperative, intraoperative and postoperative interventions, as detailed below.

Preoperative Interventions

Antiseptic shower

Advertising Policy
  • We developed a standardized protocol for a chlorhexidine gluconate (CHG) bath the evening before surgery. We also incorporated preoperative patient education as well as education regarding the rationale for the bath.
  • Clear evidence to support a decrease in SSIs with CHG baths is lacking, but the cost of the bath is minor and the potential benefit is likely great enough to outweigh the cost. Several studies have demonstrated a greater decrease in skin colonization with CHG bath vs. iodine or medicated soap.2,3

Nasal S. aureus surveillance and decolonization protocols

  • Twenty-five to 30 percent of the population are carriers of Staphylococcus aureus, the leading cause of SSIs in spine surgery. An association has been noted between nasal carriage of S. aureus and SSI occurrence. A short course of treatment with mupirocin ointment has been shown to eliminate S. aureus in many carriers.2
  • We developed a standardized preoperative protocol that includes detection and treatment of S. aureus (sensitive and resistant strains) nasal colonization.
  • Patients undergo a nasal swab before surgery to test for the presence of S. aureus. Preoperative education regarding rationale also is provided.
  • Patients with positive results are treated with nasal mupirocin ointment before surgery.
  • Patients who have the resistant strain of S. aureus (MRSA) are given a dose of vancomycin in addition to standard prophylactic antibiotic therapy immediately prior to incision.

Intraoperative Interventions

Operating room hygiene

Maintaining appropriate sterile fields in the OR and decreasing OR traffic have been priorities. Audits of OR personnel and techniques have been carried out and new rules adopted to ensure proper maintenance of sterile fields and to minimize OR traffic during surgery.

Antibiotic prophylaxis

Preoperative administration of antibiotics within an hour of incision has been proven to reduce SSIs. Ongoing audits of Center for Spine Health procedures have shown near 100 percent compliance with administration of appropriate antibiotics within this time frame.

Skin preparation

  • We introduced a standardized prep protocol in 2012 to ensure optimal skin preparation for all surgical patients.
  • Administration of vancomycin powder locally in the wound prior to closure for high-risk cases has been used by many Center for Spine Health surgeons. This practice is in keeping with a recent study showing that adjunctive local application of vancomycin powder decreased the SSI rate in posterior thoracolumbar fusions with no reported adverse clinical outcomes.4

Postoperative Interventions

Early mobilization

Early mobilization of patients promotes wound healing by reducing pressure on back and neck wounds. We have implemented protocols to ensure that all able patients are assisted in getting out of bed on the first postoperative day and ambulated as soon as possible.

Wound care

Advertising Policy

Many Center for Spine Health surgeons now ask patients to undergo a postoperative wound check by a clinical nurse within two weeks of surgery to ensure proper wound healing.

Outcomes and implications of the SSI initiative

These efforts, initiated in 2012, corresponded with a reduction in the Center for Spine Health’s overall SSI rate from 3.7 percent in 2012 to 1.5 percent in 2013. Review of SSI rates by quarter (Figure) reveals a generally sustained reduction over the six most recent quarters, including two quarters in 2013 with rates of approximately 1 percent or less. Moreover, the center’s readmission rate has decreased in tandem with these SSI reductions, to an average of less than 7 percent in 2013-2014 from approximately 12 percent in 2011 and 2012.



Figure. Rates of surgical site infections (SSIs) in the Center for Spine Health have been reduced since implementation of protocols to reduce SSI risk factors in 2012.

Results like these have reinforced the center’s commitment to continuous quality improvement initiatives. These include such as the Spine Care Path to reduce unnecessary testing and referrals for cases of acute low back pain and a patient triaging system to ensure that patients are directed to the appropriate physician right away.

Our experience from the SSI initiative and these other efforts demonstrates that improving quality not only improves lives by reducing recovery times and improving outcomes, but it also reduces costs to both the patient and the system, thereby increasing the value of the care we provide.

Dr. Khalaf is a medical spine specialist int he Center for Spine Health.

Dr. Krishnaney is a spine surgeon in the Center for Spine Health.


  1. National Nosocomial Infections Surveillance System. National Nosocomial Infections Surveillance (NNIS) System Report, data summary from January 1992 through June 2004, issued October 2004. Am J Infect Control. 2004;32(8):470-485.
  2. Jones GA, Miele V, Benzel E. Prevention of operative infections: an evidence-based approach. In: Benzel E, ed. Spine Surgery: Techniques, Complication Avoidance, and Management. 3rd ed. Philadelphia: Elsevier Saunders; 2012:1891-1895.
  3. Edmiston CE Jr, Krepel CJ, Seabrook GR, et al. Preoperative shower revisited: can high topical antiseptic levels be achieved on the skin surface before surgical admission? J Am Coll Surg. 2008;207(2):233-239.
  4. Sweet F, Roh M, Sliva C. Intrawound application of vancomycin for prophylaxis in instrumented thoracolumbar fusions: efficacy, drug levels, and patient outcomes. Spine. 2011;36(24):2084-2088.