Variability in spinal surgery outcomes among children's hospitals in the United States.

BACKGROUND: We performed a retrospective cohort study of 7637 spinal fusion surgical cases from 2004 to 2006 at 38 children's hospitals participating in the Pediatric Health Information System database to evaluate the variability of in-hospital outcomes by patient factors and between facilities in children who underwent spinal surgery. METHODS: Outcomes were stratified by whether children did or did not have neurological impairment. Multilevel multivariate logistic regression models were used to determine patient and hospital factors associated with in-hospital infections, surgical complications, and length of stay (LOS)≥10 days. RESULTS: Neurologically impaired (NI) children (N=2117 out of 7637) represented 28% of the cases. The interhospital interquartile range of LOS for NI children was 6 to 8 days (median 7 d) and for non-neurologically impaired (NNI) children was 5 to 6 days (median 5 d). Children with NI had roughly 6 times higher rates of in-hospital infection and 3 times higher complication rates: major interhospital variation was seen for both of these outcomes. Hospital rates of infection ranged from 0% to 27% (median 10%) for NI and from 0% to 14% (median 2%) for NNI children. Complication rates ranged from 0% to 89% (median 33%) for NI and from 3% to 68% (median 9%) for NNI children. The following factors were associated with a LOS≥10 days: in-hospital infection (P<0.0001), surgical complication (P<0.0001), and anterior/posterior versus posterior-only surgery (P<0.0001). Hospital case volume was not associated with infection, surgical complication, or LOS≥10 days. CONCLUSIONS: Substantial variation exists in reported outcomes for children undergoing spinal surgery in children's hospitals within the United States. Further study is needed to characterize hospital-level factors related to surgical outcome to direct future quality improvement.

A multidisciplinary approach improves infection rates in pediatric spine surgery.

BACKGROUND: Surgical site infections (SSI) associated with elective pediatric spinal surgery are a commonly reported complication, increasing hospital length of stay, readmissions, operations, and financial costs. In July 2007, a multidisciplinary task force, designated Target Zero, was created to address this issue and establish prevention protocols at our institution. METHODS: A consecutive series of 394 patient charts from April 2006 to September 2008 were retrospectively reviewed to identify patients who developed an SSI secondary to elective spinal surgery. Four cohorts were evaluated; high-risk (HR) and low-risk (LR) patients who underwent surgery before (April 2006 to June 2007) and after (July 2007 to September 2008) Target Zero initiation. The definition of HR included diagnoses of cerebral palsy, spina bifida, muscle disease, paralytic deformities, and vertebral column resections. Patients were followed for 1 year to meet The Center for Disease Control-National Health Safety Network's definition of an SSI with an implantable device. Overall infection rates were determined for each group and compared statistically. RESULTS: A total of 192 patients (70 HR and 122 LR) underwent surgery before, and 202 patients (92 HR and 110 LR) underwent surgery after Target Zero initiation. Overall infection rates were reduced from 7.8% to 4.5% (P=0.203), 12.9% to 6.5% (P=0.183), and 4.9% to 2.7% (P=0.505) for all patients, HR patients, and LR patients, respectively. The relative risk reduction was 43.0% for all patients, 49.3% for HR patients, and 44.6% for LR patients. CONCLUSIONS: Although decreases in overall infection rates were not statistically significant, the results from Target Zero were shown to be clinically meaningful with a relative risk reduction approaching 50% overall and in defined subgroups. Based on the number needed to treat analysis, 1 infection in every 16 patients within the HR group, and 1 in 30 overall, was prevented up to 1 year postoperatively. This study is the first to document the effectiveness of a multidisciplinary team implementing protocols for decreasing infection rates in pediatric spine surgery.