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Improving compliance with prophylactic antibiotic administration guidelines

AORN Journal, Jan, 2007 by Anne White, Todd Schneider

ABSTRACT

* TO REDUCE THE INCIDENCE of surgical site infections, preoperative prophylactic antibiotics should be administered within 60 minutes before the initial incision is made. A recent study and anecdotal observations, however, indicate that rates for compliance with these guidelines are low.

* A QUALITY IMPROVEMENT PROJECT was undertaken ata Florida health care facility to determine if implementing changes in preoperative processes would increase compliance with prophylactic antibiotic administration guidelines.

* AFTER THE STRATEGIES were implemented, compliance rates with the national guidelines for administration of antibiotics within 60 minutes of surgical incision increased from 75% at baseline to 95% postimplementation.

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Surgical site infections (SSIs) are a serious complication of surgery, significantly increasing the morbidity, mortality, length of hospital stay, and costs associated with surgical procedures. (1-9) The risk for SSIs varies depending on the surgical procedure and patient characteristics including age; steroid use; nicotine use; malnutrition; and comorbid conditions, including diabetes and obesity. (10,11)

In an effort to prevent SSIs, health care practitioners employ a variety of interventions, such as using sterile surgical instruments, maintaining a sterile surgical field, ensuring rigorous antiseptic preparation of the incision site, clipping hair at the incision site instead of shaving, and maintaining normothermia. (12-14) In addition, several studies have shown that administering prophylactic parenteral antibiotics immediately before the beginning of the procedure significantly decreases the incidence of postoperative SSIs in selected surgical procedures, (15-18) Appropriate administration of antibiotics also is one of several quality measures identified by the Surgical Care Improvement Project as important processes for health care facilities to implement to prevent SSIs (Table 1).

National guidelines emphasize the importance of timing in prophylactic parenteral antibiotic administration, with recommendations stating that administration should occur within 60 minutes before the initial incision is made. (2,19-23) Despite the widespread dissemination of information about the need to administer prophylactic parenteral antibiotics, a recent study and anecdotal observations indicate that compliance rates with the national guidelines are low. (24) The purpose of this quality improvement (QI) project was to determine whether selected changes in perioperative processes for prophylactic antibiotic administration would improve compliance rates with the guidelines for medication administration to occur within 60 minutes of the initial incision.

CHANGES IN PREOPERATIVE PROCESSES

At Tallahassee Memorial HealthCare (TMH) in Tallahassee, Fla, the SSI improvement team--composed of staff members from the main OR, pharmacy, and infection control and performance improvement departments--decided to address inconsistencies in preoperative antibiotic administration by making changes to preoperative processes. Infection reduction was part of the surgical services strategic plan, which was linked to the hospital's vision to be recognized as a world-class community health care system. In addition, SSI process measures are publicly reported measures by the Centers for Medicare and Medicaid Services. To achieve rapid change, TMH joined the Institute for Healthcare Improvement's Breakthrough Series Collaborative. Staff members implemented strategies designed to improve compliance with prophylactic antibiotic administration within 60 minutes of initial incision, including

* making changes in the electronic documentation of perioperative care;

* changing the preoperative processes for antibiotic administration;

* revising preoperative standing orders for select surgical diagnoses; and

* introducing a preoperative holding area process for screening preoperative antibiotic orders according to national guidelines and immediately notifying noncompliant physicians.

EXPANSION OF COMPUTERIZED CHARTING. Intra-operative electronic documentation was installed one year before this QI project began. These processes were expanded to include prompts regarding prophylactic antibiotics that included antibiotic selection and time of administration. The electronic chart included a question asking if antibiotics had been ordered. The perioperative nurse then charted the timing and antibiotic selection for antibiotic administration.

TIMING OF ANTIBIOTIC ADMINISTRATION, To ensure that prophylactic antibiotics were consistently administered within 60 minutes before the initial incision was made, it was necessary to determine the appropriate time for the health care practitioners to administer them. The appropriate time for administration was determined by observing the average time from when the patient entered the OR to when the initial incision was made, which for all procedures ranged from 20 to 30 minutes. Based on this information, the SSI improvement team determined that the anesthesia care provider should administer the antibiotics immediately before the patient leaves the preoperative holding area. This process change enabled health care practitioners to consistently administer antibiotics within 60 minutes of the initial incision.

Health Care Industry

Improving compliance with prophylactic antibiotic administration guidelines

AORN Journal, Jan, 2007 by Anne White, Todd Schneider

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