Identifying Nursing Interventions Related To Spinal Fusion Surgery In The Child With Spina Bifida

Sue Leibold MSN, RN, CNS-P, Amy Keefover-Hicks MSN, RN, Carrie Wilson BSN, RN, CPN, Diana Dulworth BSN, RN, CPN, Shelly Collins BSN, RN, Terri Pensabene-Lewis PhD, RN, Ross Talbott BS, RN, CNOR, and Joette Anderson ADN, RN

Abstract

A quality improvement project was conducted in one of the nation's leading pediatric centers for the treatment of orthopedic conditions. The Spina Bifida (SB) program at this facility is one of the largest interdisciplinary care clinics within the United States with over 900 active pediatric patients. Patients with SB can present with progressive spinal deformities (i.e., scoliosis and kyphosis). Treatment of these conditions in this population is complicated by lack of sensation below the lesion level, neurogenic bowel and bladder, and decreased mobility. At one time it was believed that all patients with SB who underwent spine surgery would encounter complications, such as post-operative infections, skin breakdown, and re-hospitalization. The purpose of this project was twofold: to determine the incidence of post-operative complications and to identify nursing interventions that may positively influence outcomes among these children. A nursing task force was formed to conduct a retrospective chart review. Twenty-five patients with SB who had a spinal fusion between 2003 and 2005 were identified, and their charts were reviewed. Variables were examined in these patients, including bladder and bowel incontinence, pressure ulcers, pulmonary function, and nutrition. Results of this project suggest that nursing interventions focusing on continence and prevention of surgical site contamination, as well as increasing parents' engagement in care, are crucial to decreasing complications in this population. In an effort to develop evidence-based nursing practice, a future study is being designed to assess the effectiveness of proposed nursing interventions in decreasing post-operative complications.

Keywords: spina bifida , evidence-based practice , wound infection , nursing interventions , incontinence

INTRODUCTION

Spina Bifida (SB) is a complex neural tube birth defect associated with shunted hydrocephalus, Chiari malformation, and tethered cord. Patients with SB can present with progressive spinal deformities (i.e., scoliosis and kyphosis). Severe spinal deformities can lead to skin breakdown, respiratory insufficiency, poor nutrition, and decreased independence. Treatment of scoliosis in this group is complicated by lack of sensation below the lesion level, neurogenic bowel and bladder, and decreased mobility.

Anterior/posterior spinal fusion with instrumentation is the most common form of intervention for progressive spinal deformities in patients with SB. Inherent difficulties of the surgery in this population include the poor quality of the vertebral/pelvic bone and the thin, scarred skin in the region where the defect was closed. These surgical challenges place patients with SB at increased risk for post-operative complications that include infections, skin breakdown, and re-hospitalization. Efforts to reduce these adverse outcomes are a clinical priority. Therefore, the purpose of this project was twofold: to determine the incidence of post-operative complications and to identify nursing interventions that may positively influence these outcomes.

LITERATURE REVIEW

Current infection rates of all patients who have undergone spine surgery range from 0.7% to 11.9% (1). Infection rates vary significantly by type of spinal deformity, surgical procedure, and the presence of risk factors prior to and following surgery. Predisposing risk factors among all groups of patients who undergo spinal fusions include the surgical approach, length of surgery, obesity, malnutrition, pulmonary status, and use of prophylactic antibiotics (2,3).

Infection rates following surgery for scoliosis in the neuromuscular population are higher than the overall infection rates for adolescents after idiopathic scoliosis surgery (4). Labbe' et al.(5) reported a wound infection rate of 5.2% in all patients who had undergone instrumentation with a posterior fusion or combined anterior-posterior fusion surgery. Spinal fusions that involve instrumentation into the pelvis may also increase the likelihood of infection due to exposure of the incision site to potential sources of infection (4,6). Patients with scoliosis and myelodysplasia have a nine-fold increase in the rate of surgical site infection compared to patients without myelodysplasia (5). The increased infection rate is due to poor skin condition, decreased mobility after surgery, and urinary or fecal incontinence (5).

Organisms isolated from postoperative spinal surgery wound infection cultures often are found in the gastrointestinal and urinary tracts (36%) and on the skin (50%) (5). This suggests that poor hygiene practices place patients with SB at a higher risk for developing surgical site infections (7). The Centers for Disease Control (CDC) recognizes that most surgical site infections are associated with skin flora. Pre-operative antiseptic showers significantly reduce skin microbial colony counts (8), which suggests the importance of cleansing the skin to reduce skin flora and secondary contamination from urinary and fecal bacteria (2).

Incontinence has the greatest influence on the development of post-operative spinal would infections in patients with SB (2). When other risk factors were controlled, post-operative incontinence after a posterior surgical approach had approximately an eight times greater risk of causing infection in the surgical site (2). Due to poor innervation of the urinary system, almost all patients with SB have urinary differences, including sphincter dysfunction, bladder hypertonia, and/or urinary retention that can lead to incontinence, infections, and possible renal damage (9). Even with the use of clean intermittent catheterization, asymptomatic bacteruria may still occur (9). Similarly, almost all patients with SB require a bowel program to achieve bowel continence.

Pressure ulcers are also a post-operative problem encountered in patients with SB. The most significant risk factors for developing pressure ulcers are fecal incontinence, impaired mobility, and malnutrition (10). When all other risk factors were held constant, patients with fecal incontinence were 22 times more likely to develop pressure ulcers (10) than those who were continent. The joint effect of fecal incontinence and impaired mobility increased patients' odds of developing a pressure ulcer to 37.5 (10).

Patients with SB are at greater risk for developing pressure sores due to prolonged pressure in an area with decreased or absent sensation, increased amount of pressure applied to the area, or the length of time that the pressure is being applied (11). Mattress overlays distribute pressure over more body surface area, thus decreasing the intensity of pressure evenly over all body surface areas (12). These overlays effectively lower tissue interface pressure and are associated with lower pressure ulcer incident rates (13). Wheelchair use may further contribute to the risk of developing pressure sores in this vulnerable population. To prevent pressure sores from developing, wheelchair cushions are used to reduce pressure over areas of weight-bearing bony prominences (14). Use of pressure mapping can impact decisions regarding the need for pressure relief wheelchair modifications (15). Pressure mapping identifies the distribution of buttock pressure and is a reliable method to evaluate the effectiveness of the wheelchair cushion (14).

Patients with neuromuscular scoliosis are at risk for decreased lung expansion for reasons such as muscle weakness, decreased flexibility in the thoracic region, and shortened trunk (16). Respiratory insufficiency in this patient population increases their likelihood of rapid desaturation during periods of apnea or hypoventilation, leading to development of post-operative pneumonias (17,18). Brain stem compression from the Chiari II hindbrain anomaly may result in sleep disordered breathing (17,19). Thorough pre-operative assessment that includes pulmonary testing can decrease the risk for postoperative complications (16).

Patients with SB undergoing spine surgery are at risk for poor nutritional status (20). Surgical patients have an increased need for protein and calories due to the additional stressors placed on the body during surgery and decreased intake in the post-operative period (20). Nutritional status can be evaluated through laboratory measurements such as serum albumin, prealbumin, and lymphocyte counts (1). When values indicate poor nutritional status, there is a correlation with poor wound healing, increased post-operative infections and immune suppression (1,7).

Evidence-based practice research has resulted in improved outcomes for surgical patients. Our review of the literature, however, identified no evidence-based, nursing-researched nursing interventions for patients with SB undergoing spinal fusion. Nursing practice may influence outcomes in patients with SB by concentrating on identified risk factors, specifically urinary and fecal incontinence, reduction of skin flora both pre-operatively and post-operatively, prevention of skin breakdown, improved nutrition for wound healing, and pulmonary assessment, yet this remains untested.

QUALITY IMPROVEMENT CHART REVIEW

A quality improvement project was conducted in one of the nation's leading pediatric centers for the treatment of orthopedic conditions. The SB program at this facility is one of the largest interdisciplinary care clinics within the United States with more than 900 active pediatric patients.

A nursing task force was formed to evaluate outcomes of spinal fusions in patients with SB and report identified changes needed to the Hospital Performance Improvement Committee. A retrospective chart review, developed by the task force, was undertaken by a clinical nurse specialist, a research nurse, the hospital infection control nurse, three nurses from the outpatient clinic, an operating room nurse, and an inpatient nursing team leader. Twenty-five patients with SB who had a spinal fusion between 2003 and 2005 were identified. All 25 charts were reviewed to identify risk factors for infection, skin breakdown, and other adverse outcomes and assess the potential for specific nursing interventions to minimize the incidence of these complications.

FINDINGS

The variables examined in these 25 patients are summarized, and descriptive statistics are reported in Table 1. None of the patients had adverse outcomes resulting in pneumonia or difficulty weaning from the ventilator following surgery. Seven patients (28%) developed wound infections, six patients (24%) developed skin breakdown, and nine patients (36%) were re-hospitalized to treat wound infections or skin breakdown. The length of stay during re-hospitalization ranged from four days to 11 months. Treatment included surgical incision and drainage of the wound, removal of rods in several patients, or advanced wound care treatment.

Inconsistent documentation of nursing care hindered efforts to identify pre- and post-operative risk factors for pressure sores and wound infections. Documentation of pre-operative shower or scrub for nine of the 25 patients was absent. Two of the nine patients developed post-operative wound infections. However, five of the seven patients who developed post-operative wound infections had documented pre-operative shower scrub but did not have documentation of whether the bowel program was completed prior to or after the pre-operative shower. No documentation of the use of a pressure-relieving mattress was found for nine of the 25 patients. Two of the nine patients developed post-operative wound infections. Location of post-operative bowel movement was not documented for 13 of the 25 patients (See Table 2). Two of the thirteen patients developed wound infections. Four of the seven patients who developed a wound infection had a bowel movement in the diaper documented. Following discharge, six children developed skin breakdown and four of those had a bowel movement in the diaper documented.

DEVELOPMENT OF EVIDENCE-BASED PROTOCOL

As a result of the chart review, several changes in nursing interventions for patients with SB undergoing spinal fusion surgery have been recommended. These changes focused on the risk factors identified in the retrospective chart and literature reviews: pre-operative nutritional assessment, pre-operative nutritional assessment, pre-operative pulmonary assessment, skin hygiene, bowel management, urinary incontinence management, and management and pressure relief of bony prominences. Recommendations emphasized early assessment, planning, and family education in protocol development and reemphasized thorough documentation of nursing care.

Pre-operative Nutrition Assessment

Research indicates how important nutrition is for post-operative wound healing (1,7,20). Chart review findings revealed a need for early assessment of nutritional status to allow time for interventions. Based upon evidence, the group developed guidelines for obtaining a CBC, Iron Profile, and Zinc, Prealbumin, and Albumin levels two to six months prior to surgery.

Pre-operative Pulmonary Assessment

Research also indicates the importance of pre-operative pulmonary testing (of patients with SB) (16). Pulmonary function tests will be used to screen patients for unidentified respiratory insufficiency two to six months prior to surgery. Those patients who are found to be at risk for pulmonary complications will be referred to a pulmonologist for further evaluation and intervention as necessary.

Reduction of Skin Flora

For patients with post-operative surgical site infection, the most frequently identified bacteria were those that originated from the bowel (See Table 2). Data suggests that pre- and post-operative bowel management may be one of the most important variables in the prevention of post-operative wound infections. Detailed guidelines for reducing contamination of the proposed surgical site have been developed to be implemented by the family prior to admission and by the staff nurses pre- and post-operatively (See Appendix 1).

The task force identified the importance of completing the pre-operative shower after the bowel program, thus reducing the chance of fecal bacteria being introduced to the surgical site. The majority of patients with SB have a two-part bowel program. Oral medication, such as Senna, is taken at a scheduled time every day and is followed by an enema or suppository six hours later to stimulate evacuation. To reduce the bacterial exposure on the proposed operative site, bowel programs should be completed on the toilet, not in a diaper. The schedule may be adjusted to complete the bowel program earlier in the day to allow sufficient time for completion prior to the pre-operative scrub and shower.

After the pre-operative shower scrub, an IV is started in order to administer a prophylactic IV antibiotic the evening before surgery. It is theorized that using a prophylactic antibiotic will sterilize the urine. One hour after the IV antibiotic is administered, an indwelling urinary catheter is placed using sterile technique to keep the scrubbed surgical site clean and dry. The indwelling urinary catheter will remain post-operatively until the patient resumes daytime clean intermittent catheterization. For up to three weeks postoperatively, an indwelling urinary catheter may be placed during hours of sleep if the patient is prone to nighttime incontinence. The indwelling urinary catheter is used to prevent transport of urinary tract bacteria and skin flora to the surgical site both pre- and post-operatively.

The bowel program is reinstated by the fourth postoperative day in an effort to prevent post-operative constipation and incontinence. Defecation on the toilet, rather than in a diaper or on a bedpan, will help to prevent fecal bacteria contamination of the surgical incision.

Prevention of Pressure Sores

Patients with SB are at high risk for developing pressure sores. Therefore, these patients are placed on a pressure-relieving mattress overlay immediately after surgery. Correction of the spinal deformity changes the patients' weight distribution, resulting in alterations in the patients' pressure points. Since patients get up to a chair once or twice on post-operative day one, pressure mapping is completed with the first sitting event. Pressure mapping identifies changes in pressure points and determines the need for modifications of the patients' wheelchair. Pressure mapping is repeated after modifications are made to the wheelchair to assure appropriate pressure relief given the patients' new body habitus.

Patient Education Forms

The chart review revealed that families' understanding and participation in our efforts to decrease complications was crucial. A patient education handout was developed to explain to families the importance of their participation in preparing for surgery, as well as pre- and post-operative nursing interventions and the necessity of each intervention to decrease skin bacteria prior to surgery. Families are responsible for assuring that the patient completes a daily bowel program on the toilet and daily bathing with an antibacterial soap at least one week prior to surgery. Families who are included in the planning process and who understand the importance of the interventions are more likely to implement them as instructed.

Pre-operative Checklist

Once a patient becomes a candidate for spinal surgery, an appointment is made for the patient to meet with the interdisciplinary team. At that time, the patient's pulmonary and nutritional status, skin integrity, continence, and the discharge planning needs are evaluated. The SB Pre-operative Spine Surgery checklist was created to provide guidance for this evaluation. The checklist identifies potential risk factors, which are then used to formulate individual interventions for the patient's plan of care.

Admission Orders

To promote consistent treatment among physicians and ensure that all necessary orders are included, an admission order template was developed. Orders are further individualized to provide specific timing of nursing and interdisciplinary interventions. Timing and order of procedures is important to decrease the bacterial colony counts of the patients' skin.

Spinal Fusion Monitoring Tool

A tool was developed to monitor patient care and documentation for the recommended nursing interventions. Patients will be monitored for one year post-operatively throughout all clinic visits and any re-hospitalizations for care. This audit will provide a means to evaluate the effectiveness of the recommended nursing interventions in preventing complications and improving outcomes.

Staff Education

Staff education was provided to present the results of this chart review, communicate the rationale for specific nursing interventions, and emphasize the importance of thorough documentation in the development of evidence-based practice. Education was provided through inpatient staff meetings, development of a DVD educational program, and poster presentation.

LIMITATIONS

These results must be interpreted with caution since this was a retrospective chart review of a sample that may be too small to detect significant differences. Charts were divided among the task force members and reviewed independently using a tool developed by task force consensus. When documentation was unclear, additional task force members reviewed the chart to reconcile any discrepancy. The lack of inter-rater reliability for chart review completion may be another significant limitation. In future studies, a method to ensure inter-rater reliability will be implemented.

FUTURE DIRECTION

Upon completion of this quality improvement project, the group will move forward with a formal prospective research study to assess the effectiveness of the evidence-based nursing intervention protocol in decreasing post-operative complications. Following IRB approval, 25 patients with SB undergoing spinal fusion surgery will be enrolled in the study. Our goal is to establish evidence-based nursing practice aimed at decreasing post-operative complications in patients with Spina Bifida who are undergoing spinal fusion surgery. We hope our process provides a model for other nurses to develop similar interventions that will benefit their patient population.

Table 1. Chart Review 2003-2005 of Spina Bifida Post Spinal Fusion

	Data	Results
Number of Patients	25
Male/Female	11/14
Average Age	11.53 yrs. Range 8-16 yrs.
Average Length of Stay	10 days Range 5-31 days
Wound Infections	7/25 (28%)
Skin Breakdown*	6/25 (24%)
Rehospitalizations +	9/25 (36%)
Surgery Type: • Anterior/Posterior • Posterior • Kyphectomy	20/25 (80%) 1/25 (4%) 4/25 (16%)	5/20 (25%) developed wound infections No wound infections 2/4 (50%) developed wound infections
Nutrition Assessment	15/25 (60%) had nutrition labs	5/15 (33%) developed wounds • 1/5 (20%) had abnormal pre-operative nutrition labs
UTI prophylaxis: • Bactrim • Furadantin NO UTI prophylaxis	8/25 (32%) • 5/8 (62.5 %) • 3/8 (37.5%) 17/25 (68%)	No wound infections 1/8 (12.5%) developed wound infections 6/17 (35%) developed wound infections
Pressure Relief Bed ROHO Egg Crate No documentation of pressure relief mattress	1/25 (4%) 14/25 (56%) 1/25 (4%) 9/25 (36%)	Developed skin breakdown 1/14 (7%) developed both wound infection & skin breakdown; 3/14 (21%) developed wound infection; 3/14 (21%) developed skin breakdown 1/1 (100%) Developed wound infection & skin breakdown 2/9 (22%) developed wound infections

* All occurred 2 weeks to 6 months after discharge
+ For treatment of infection or treatment of the skin breakdown

Table 2. Adverse Outcomes

Wound Infections by Organisms
Organism (Several of the wounds grew more than 1 organism)	Suspected Source	Potential Contributing Care Factors
1 MRSA 1 MRSE 3 Staph aureus 1 Staph epidermidis	Skin Organisms	11/25 had post-op shower and 2 developed wound infections from a skin organism; 7/25 had documentation of incontinence at night and 1 developed a wound infection from a skin organism
2 Pseudomonas 1 E.coli 1 Proteus 1 Enterobacter	Bowel/Bladder Organisms	12/25 (48%) had post-op bowel movement in diaper • 4/7 (57%) wound infections had post-op bowel movement in diaper; • 2/7 post-op wound infections had NO documentation of where bowel movements occurred
Skin Breakdown (Occurred after discharge, 2 weeks to 6 months after surgery)		6/25 (24%) had skin breakdown • 4/6 (66%) had post-op bowel movement in diaper; • 2/6 had NO documentation of where bowel movement occurred

ACKNOWLEDGEMENT

The authors would like to thank: Renee Manworren MS, RN, BC, CNS for her assistance with the preparation of this manuscript; and to Karl E. Rathjen MD, B. Stephens Richards MD, and Richard R. Adams MD for reviewing this manuscript as the staff physicians for the Spina Bifida patients at Texas Scottish Rite Hospital for Children, and Rich Browne for statistical analysis.

Each author certifies that he or she has no commercial associations that might pose a conflict of interest in connection with the submitted article. Funds were not received in support of this work. The manuscript submitted does not contain information about medical device(s)/drug(s).