609 - Hydrogen Peroxide Fogging of the Operating Room Reduces Deep Spinal Surgical Site Infections in Pediatric Scoliosis Patients Undergoing Posterior Spinal Fusion: A Quality Improvement Project

Publication Number: 2594.609

Alexandria Rundell, Akron Children's Hospital, Medina, OH, United States; Lorena Floccari, Akron Children's Hospital, Akron, OH, United States; Kenzie D. Lundqvist, Akron Children's Hospital, Akron, OH, United States; Todd Ritzman, Akron Children's Hospital, Akron, OH, United States; Richard P. Steiner, Akron Children's Hospital, Akron, OH, United States; Michael T. Bigham, Akron Children’s Hospital, Akron, OH, United States

Background: Surgical site infection (SSI) in pediatric patients undergoing posterior spinal fusion (PSF) can result in significant patient morbidity or mortality. The purposes of this quality improvement project were to implement and test feasibility of an operating room (OR)-based hydrogen peroxide fogging (HPF) program and to assess its effect on the incidence of deep spine SSI.

Objective: To reduce Risk of surgical site infections in posterior spinal fusions by testing the feasibility of the use of operating room-based hydrogen peroxide fogging.

Design/Methods: This improvement project was performed at a freestanding children's hospital. A biweekly HPF program was initiated in two dedicated spine ORs in October 2022. Patients undergoing PSF from January 2021 to December 2024 were identified and separated into pre-fogging and post-fogging groups for retrospective analysis. The primary patient outcome measure was the rate of deep SSIs. Secondary measures included aerobic colony counts (ACC) in the OR and safety events associated with fogging.

Results: Pre- (n=150) and post- (n=175) fogging groups were similar in sex, body mass index, spine pathology classification, estimated blood loss, and OR time. The pre-fogging cohort was older (15.0 vs 14.2 years, p=0.021) with a higher mean American Society of Anesthesiologists score (2.6 vs 2.4, p=0.016). ACCs in the ORs decreased 89% immediately after HPF. Deep SSI incidence decreased from 6.7% pre-fogging to 1.1% post-fogging (p=0.007, OR =6.18). A centerline shift was observed on a process control P-chart, and a T-chart showed >238 days between events after fogging implementation, versus 38 days prior to implementation. There were no fogging-related safety events, room unavailability, room delays, or unverified fogging by chemical or biological controls.

Conclusion(s): A bi-weekly HPF program was associated with a statistically significant six-fold reduction in pediatric deep spine SSI incidence, from 6.7% to 1.1%. OR environmental pathogen levels decreased 89% immediately after fogging. The intervention proved feasible, with no fogging-related safety events, room availability issues, or unverified fogging.

T-Chart Showing Days-Between Spinal Fusion SSIs
Time-between-events T-chart demonstrating both the date of each SSI occurrence with the associated time since the previous SSI occurrence and the average time-between events. The solid blue line with diamond data points indicates the days since previous deep spine SSI. The dotted blue line with an arrow indicates the ongoing days from the last spine SSI to the end of the study period, indicated by an asterisk to show that there was not an SSI on December 31, 2024. The solid red line indicates the average time in days-between events. The dotted red lines indicate the control limits. Abbreviations found in figure and title: SSI = surgical site infection.