- Email: [email protected]
Improving Compliance With Prophylactic Antibiotic Administration Guidelines
Improving Compliance With Prophylactic Antibiotic Administration Guidelines Anne White, RN; Todd Schneider
S
urgical 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
© AORN, Inc, 2007
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
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 at a 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. AORN J 85 (January 2007) 173-180. © AORN, Inc, 2007. JANUARY 2007, VOL 85, NO 1 • AORN JOURNAL • 173
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TABLE 1
Quality Measures to Prevent Surgical Site Infections1 Prophylactic antibiotics were administered on time. Appropriate prophylactic antibiotics were selected. Prophylactic antibiotics were discontinued within 24 hours after surgery. Perioperative serum glucose was controlled (ie, was less than 200 mg/dL) among major cardiac surgery patients. Postoperative wound infection was diagnosed during index hospitalization (ie, the admission during which the surgical procedure occurred). Appropriate hair removal was performed. Perioperative normothermia was maintained among colorectal surgical patients. Perioperative serum glucose was controlled (ie, was less than 200 mg/dL) among noncardiac major surgery patients. Major surgery patients who did not undergo planned hypothermia maintained normothermia during the perioperative period. 1. FMQAI—Florida's Medicare Quality Improvement Organization. Surgical Care Improvement Project (SCIP) page 2. Available at: http://www.fmqai.com/Professionals-Providers /hospital/Identified-Participant-Groups/Surgical-Care-Im provement-Project/Surgical-Care-Improvement-Project -Page-2/. Accessed November 7, 2006.
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 na-
174 • AORN JOURNAL
tional guidelines and immediately notifying noncompliant physicians. EXPANSION OF COMPUTERIZED CHARTING. Intraoperative 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. It was necessary to make adaptations to this process for cardiac surgical patients because of longer surgical prep times for these patients in the OR. The ideal time for administering antibiotics to the cardiac surgical patient was determined to be when the anesthesia care provider inserted the pulmonary artery catheter because the initial incision was made approximately 30 minutes after this point. It also was necessary to make process adaptations for patients receiving fluoroquinolone or vancomycin. The national guidelines for administering
White — Schneider
JANUARY 2007, VOL 85, NO 1
A critical step in ensuring staff member compliance with the new interventions was allowing adequate time for staff member education, particularly for educating physicians. fluoroquinolone or vancomycin state that the infusion must be started within 120 minutes before the anticipated time of the initial incision so that the medication is completely infused within 60 minutes before the initial incision is made.25 Preoperative holding area staff members, therefore, were instructed to administer fluoroquinolone or vancomycin when the patient arrived in the preoperative holding area to meet the national guidelines for administering these medications. For cardiac patients who received fluoroquinolone or vancomycin, the infusion was started when the patient departed the preoperative holding area, which allowed approximately one hour for the medication to infuse before the initial incision was made. To meet these strict timelines for antibiotic administration, the antibiotic needed to be easily accessible to preoperative holding area staff members. To mitigate delays related to pharmacy delivery, antibiotics were stored in an automated medication dispensing system in the preoperative holding area, enabling immediate retrieval of antibiotics when needed. APPROPRIATE STANDING ORDERS FOR ANTIBIOTICS. The standing orders were revised to include preoperative antibiotic administration. The revised orders specified antibiotic selection and timing for surgical procedures for which preoperative antibiotics were recommended.23 PREOPERATIVE HOLDING AREA STAFF MEMBER ROLE. Previously, there was no systematic process for ensuring timely antibiotic administration. One procedure change included assigning responsibility to the preoperative holding area staff for ensuring that patients appropriate for preoperative antibiotics (ie, based on national guidelines) had an order for antibiotics (Table 2). If orders were not present when a patient was transferred to the preoperative holding area, a holding area staff member called the physician for an an-
tibiotic order. After obtaining the order, the preoperative holding area staff member retrieved the antibiotic from the automated dispensing system and prepared and hung the antibiotic for administration at the appropriate time.
IMPLEMENTATION Implementation of these interventions began in October 2004 and was completed in March 2005. Implementation of the interventions was staggered over a fivemonth period to ensure adequate time for staff members to become familiar with the new processes. As individual components of the interventions were implemented, it was necessary to make some adjustments to perioperative processes to improve implementation. For example, a prompt in the intraoperative electronic documentation system reminded the circulating nurse to discuss antibiotics with the physician to make sure antibiotics were ordered so that they could be administered within 60 minutes before the initial incision was made. Initially, there was confusion regarding which patient populations required antibiotic orders. This resulted in some physicians being asked for antibiotic orders when it was not indicated and other physicians not being asked about antibiotics when antibiotics were indicated. To overcome this problem, the names of patients for whom antibiotics were recommended according to national guidelines were highlighted on the OR schedule. With the addition of each new strategy during the implementation phase, perioperative nursing and medical staff members were educated and supported. A critical step in ensuring staff member compliance with the new interventions was allowing adequate time for staff member education. This was particularly evident when educating physicians about the project. Numerous presentations were made to physicians at regular AORN JOURNAL •
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TABLE 2
Antibiotic Recommendations for Select Surgical Procedures1-3 Surgical procedure category Cardiothoracic
Recommended antibiotic prophylaxis
Recommendation for patients with beta-lactam allergy*
• • •
Cefazolin 1 g to 2 g IV Cefuroxime 1.5 g IV Vancomycin** 1 g IV (if high risk for methicillin-resistant Staphylococcus aureus [MRSA])
• •
Vancomycin** 1 g IV Clindamycin 600 mg to 900 mg IV
Esophageal, gastroduodenal, biliary tract (high-risk patients only)
•
Cefazolin 1 g to 2 g IV
•
Colorectal
• •
Ampicillin/sulbactam 1.5 g IV Cefazolin 1 g to 2 g IV plus metronidazole** 0.5 g to 1 g IV
Clindamycin 600 mg to 900 mg IV plus gentamicin** 1.5 mg/kg IV or aztreonam** 1 g to 2 g IV or levofloxacin** 750 mg IV Metronidazole** 0.5 g to 1 g IV plus gentamicin** 1.5 mg/kg IV or levofloxacin** 750 mg IV
Appendectomy, nonperforated
•
Cefazolin 1 g to 2 g IV plus metronidazole** 0.5 g to 1 g IV
Ruptured viscus
•
Cefoxitin 1 g to 2 g IV plus gentamicin** 1.5 mg/kg IV
•
Levofloxacin** 750 mg IV
All procedures
Gastrointestinal
•
Genitourinary High-risk patients only
Gynecologic and Obstetric Abdominal or vaginal hysterectomy
• • •
Ampicillin/sulbactam 1.5 g IV Cefazolin 1 g to 2 g IV Metronidazole 0.5 g to 1 g IV
•
Cesarean section
•
Cefazolin 1 g to 2 g IV (administered after umbilical cord is clamped)
• •
Abortion—first trimester, high risk patients
• •
Aqueous penicillin G** 2 million units IV Doxycycline** 300 mg orally
•
Cefazolin 1 g to 2 g IV
Abortion—second trimester
surgical section meetings to present information and data regarding the implementation strategies for increasing the rates of antibiotic administration within 60 minutes of initial incision and appropriate antibiotic selection. In addition to physicians, administrative, risk management, and nursing staff members attend-
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Clindamycin 600 mg to 900 mg IV plus gentamicin** 1.5 mg/kg IV or aztreonam** 1 g to 2 g IV or levofloxacin** 750 mg IV Clindamycin 600 mg to 900 mg IV Metronidazole** 0.5 g to 1 g IV plus gentamicin** 1.5 mg/kg IV or levofloxacin** 750 mg IV
ed these meetings. A clinical pharmacist also spoke at physician meetings and with individual physicians to discuss appropriate selection and timing of antibiotics. It was essential to bring data about compliance rates with the national guidelines, as well as literature sources for the guidelines, to meetings with the
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TABLE 2
Antibiotic Recommendations for Select Surgical Procedures (continued) Surgical procedure category Head and neck Incisions through oral or pharyngeal mucosa
Recommended antibiotic prophylaxis
• •
Clindamycin 600 mg to 900 mg IV plus gentamicin 1.5 mg/kg IV Cefazolin 1 g to 2 g IV
•
Cefazolin 1 g to 2 g IV
•
Cefazolin 100 mg subconjunctivally
• • • • • •
Recommendation for patients with beta-lactam allergy*
Neurosurgery All procedures
•
Vancomycin** 1 g IV
Cefazolin 1 g to 2 g IV Cefuroxime 1.5 g IV Vancomycin** 1 g IV (if high risk for MRSA)
• •
Vancomycin** 1 g IV Clindamycin 600 mg to 900 mg IV
Cefazolin 1 g to 2 g IV Cefuroxime 1.5 g IV Vancomycin** 1 g IV (if high risk for MRSA)
• •
Vancomycin** 1 g IV Clindamycin 600 mg to 900 mg IV
Ophthalmic All procedures
Orthopedic Hip or knee arthroplasty
Vascular Surgery All procedures
General recommendations
• • • • •
One dose of antibiotic should be administered within 60 minutes before the initial incision is made. Vancomycin and fluoroquinolones (ie, levofloxacin) should be administered within 120 minutes before the initial incision is made so the medications are completely infused within 60 minutes of the initial incision. Readminister antibiotic every 3 hours for prolonged procedures (ie, longer than 4 hours); in cases of major blood loss; or unless contraindicated. Consider higher antimicrobial dose for patients who weigh 80 kg or more. All antibiotics should be discontinued within 24 hours after the procedure.
1. Antimicrobial prophylaxis for surgery. Treat Guidel Med Lett. 2004;2:27-32. 2. Bratzler DW, Houck PM, Surgical Infection Prevention Guidelines Writers Workgroup, et al. Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project. Clin Infect Dis. 2004;38:1706-1715. 3. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999: Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol. 1999;20:250-278. * For patients with beta-lactam allergies, any medication in this column is appropriate for this surgical procedure category. ** These medications should not be readministered in the event of a long procedure or major blood loss.
physicians and anesthesia care providers to ensure their acceptance of and adherence to the changes needed on their part.
MEASURING PROGRESS To determine whether the interventions had improved compliance rates with preoperative antibiotic adminis-
tration guidelines, staff members at TMH used a pre-experimental staticgroup comparison design26 to compare compliance rates before and after the changes were made in preoperative medication administration processes. The QI project leaders employed a retrospective review of existing databases AORN JOURNAL •
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TABLE 3
Rates of Compliance With National Guidelines for Administering Prophylactic Antibiotics Before and After Implementation of Strategies to Improve Compliance Surgical procedure groups
Compliance before implementation
Compliance after implementation
Change in compliance
Total joints
86%
(n = 56)
97%
(n = 79)
11%
Cardiac surgery
80%
(n = 50)
95%
(n = 41)
15%
Gastric bypass
88%
(n = 16)
92%
(n = 12)
4%
Colon resection
74%
(n = 38)
96%
(n = 26)
22%
Vascular surgery
53%
(n = 45)
87%
(n = 35)
34%
All groups
75% (N = 205) and medical records of patients who underwent surgical procedures before and after the preoperative antibiotic administration process changes were implemented for this project. Following approval by the institutional review board of the health care facility, specially trained staff members reviewed perioperative databases to identify eligible participants among patients who underwent elective surgical procedures between Sept 1, 2004, and Oct 31, 2004, (ie, the pre-implementation group) and between June 1, 2005, and July 31, 2005 (ie, the postimplementation group). The staff members then retrospectively reviewed medical records for the presence of inclusion and exclusion criteria for the QI project. Participants were restricted to patients who underwent one of the following surgical procedures: • total joint replacement (ie, hip, knee, shoulder); • cardiac surgery (ie, coronary artery bypass, cardiac valve repair or replacement); • major vascular surgery; • gastric bypass; or • colon resection. Participants were excluded if they had a contaminated wound classification. A total of 398 participants met the criteria, with 205 participants in the preimplementation group and 193 participants in the postimplementation group. Data on the following variables were
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95% (N = 193)
20%
extracted from participants’ medical records or the hospital databases: • type of surgical procedure, • the physician who performed the procedure, • wound classification, • time of preoperative antibiotic administration, • time of initial incision, • type of antibiotic administered, and • any patient allergies. Data were summarized using descriptive statistics. The project leaders calculated the rates of compliance with the guidelines for administering prophylactic antibiotics within 60 minutes of the initial incision for the two groups (ie, the pre-implementation and postimplementation groups). Time lengths that were within the zero- to 60-minute period before the initial incision were considered compliant, and those occurring outside that recommended period were considered noncompliant.
RESULTS Data from the pre-implementation period of this project validated the results of a previous study24 and anecdotal observations that administration of preoperative antibiotics within the time period identified in national guidelines does not occur for all patients (Table 3). During the baseline period of the project, preoperative antibiotic administration for 25% of patients
White — Schneider
was found not to be in compliance with the national guidelines. Of particular concern was the disparity in compliance rates between different surgical procedure groups, with one subgroup of surgical procedures (ie, vascular procedures) having a compliance rate of only 53%. Compliance rates after implementation increased from an overall preimplementation rate of 75% to an overall postimplementation rate of 95%. The largest improvements in compliance were in the two surgical subgroups with the lowest pre-implementation scores, with compliance rates for vascular procedures increasing from 53% to 87% and compliance rates for colon resection procedures increasing from 74% to 96%. The subgroups that had the least increase in compliance over the project period were the two groups with the highest preimplementation scores; compliance rates for joint replacement procedures increased from 86% to 97% and compliance rates for gastric bypass surgeries increased from 88% to 92%. The project leaders used chi square analysis to determine whether a significant change in compliance scores occurred after the intervention was implemented. They found that all of the increases in compliance rates were statistically significant (P < .05).
PROJECT OUTCOMES This project demonstrated that significant improvements in compliance with national guidelines can occur with implementation of a variety of strategies to change perioperative processes for prophylactic antibiotic administration. Not surprisingly, the largest improvements in compliance rates occurred in those surgical categories with the lowest baseline compliance rates before implementation of the strategies. Other health care facilities also may be able to increase their rates of compliance with prophylactic an-
JANUARY 2007, VOL 85, NO 1
tibiotic administration guidelines by implementing similar changes to their preoperative processes. ❖ Anne White, RN, BSN, CNOR, is the director, main OR at Tallahassee Memorial HealthCare, Tallahassee, Fla. Todd Schneider, BSIE, EIT, is a management engineer and improvement advisor at Tallahassee Memorial HealthCare, Tallahassee, Fla. The authors acknowledge Patricia Folsom, RN, BSN, CNOR, assistant nurse manager, main OR; Natalie Robertson, PharmD, MHA, pharmacy clinical coordinator; and Linda Russell, RN, CNOR, improvement advisor, Tallahassee Memorial Hospital, Tallahassee, Fla, for their contributions to and assistance with this project.
REFERENCES 1. Gaynes RP, Culver DH, Horan TC, Edwards JR, Richards C, Tolson JS. Surgical site infection (SSI) rates in the United States, 1992-1998: the National Nosocomial Infections Surveillance System basic SSI risk index. Clin Infect Dis. 2001;33(suppl 2): S69-S77. 2. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999: Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol. 1999; 20:250-278. 3. Cruse P. Wound infection surveillance. Rev Infect Dis. 1981;3:734-737. 4. Cruse PJ, Foord R. The epidemiology of wound infection: a 10-year prospective study of 62,939 wounds. Surg Clin North Am. 1980;60:27-40. 5. Martone WJ, Jarvis WR, Culver DH, Haley RW. Incidence and nature of endemic and epidemic nosocomial infections. In: Bennett JV, Brachman PS, eds. Hospital Infections. 3rd ed. Boston: Little, Brown and Co; 1992:577-596. 6. Boyce JM, Potter-Bynoe G, Dziobek L. Hospital reimbursement patterns among patients with surgical wound infections following open heart surgery. Infect Control Hosp Epidemiol. 1990;11:89-93. 7. Poulsen KB, Bremmelgaard A, Sorensen AI, Raahave D, Petersen JV. Estimated costs AORN JOURNAL •
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of postoperative wound infections: a casecontrol study of marginal hospital and social security costs. Epidemiol Infect. 1994;113: 283-295. 8. Vegas AA, Jodra VM, Garcia ML. Nosocomial infection in surgery wards: a controlled study of increased duration of hospital stays and direct cost of hospitalization. Eur J Epidemiol. 1993;9:504-510. 9. Albers BA, Patka P, Haarman HJ, Kostense PJ. Cost effectiveness of preventive antibiotic administration for lowering risk of infection by 0.25% [in German]. Unfallchirurg. 1994;97: 625-628. 10. Society of Hospital Epidemiology of America, Association for Practitioners in Infection Control, Centers for Disease Control, Surgical Infection Society. Consensus paper on the surveillance of surgical wound infections. Infect Control Hosp Epidemiol. 1992;13:599-605. 11. Cruse PJ. Surgical wound infection. In: Wonsiewicz MJ, ed. Infectious Diseases. Philadelphia: WB Saunders Co; 1992:758-764. 12. Agency for Healthcare Research and Quality. Prevention of surgical site infections. In: Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Rockville, Md: Agency for Healthcare Research and Quality; 2001:221-243. Also available at: http://www.ahrq.gov/clinic/ptsafety. Accessed November 14, 2006. 13. Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization: study of Wound Infection and Temperature Group. N Engl J Med. 1996;334:1209-1215. 14. Kjonniksen I, Andersen BM, Sondenaa VG, Segadal L. Preoperative hair removal— a systematic literature review. AORN J. 2002;75:928-940. 15. Zanetti G, Giardina R, Platt R. Intraoperative redosing of cefazolin and risk for surgical site infection in cardiac surgery.
Emerg Infect Dis. 2001;7:828-831. 16. Zmora O, Pikarsky AJ, Wexner SD. Bowel preparation for colorectal surgery. Dis Colon Rectum. 2001;44:1537-1549. 17. Boxma H, Broekhuizen T, Patka P, Oosting H. Randomised controlled trial of single-dose antibiotic prophylaxis in surgical treatment of closed fractures: the Dutch Trauma Trial. Lancet. 1996;347:1133-1137. 18. Barker FG II. Efficacy of prophylactic antibiotic therapy in spinal surgery: a metaanalysis. Neurosurgery. 2002;51:391-400. 19. Classen DC, Evans RS, Pestotnik SL, Horn SD, Menlove RL, Burke JP. The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection. N Engl J Med. 1992;326:281-286. 20. Dellinger EP, Gross PA, Barrett TL, et al. Quality standard for antimicrobial prophylaxis in surgical procedures. Infect Control Hosp Epidemiol. 1994;15:182-188. 21. Antimicrobial prophylaxis for surgery. Treat Guidel Med Lett. 2004;2:27-32. 22. Butts JD, Wolford ET. Timing of perioperative antibiotic administration. AORN J. 1997;65:109-115. 23. Bratzler DW, Houck PM, Surgical Infection Prevention Guidelines Writers Workgroup, et al. Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project. Clin Infect Dis. 2004;38:1706-1715. 24. Bratzler DW, Houck PM, Richards C, et al. Use of antimicrobial prophylaxis for major surgery: baseline results from the National Surgical Infection Prevention Project. Arch Surg. 2005;140:174-182. 25. Burlingame B. OR fire extinguishers; classifying wounds and minor procedures; antibiotic infusion time; mopping after minor procedures [Clinical Issues]. AORN J. 2006;83:1384-1393. 26. Campbell DT, Stanley JC. Experimental and Quasi-Experimental Designs for Research. Chicago: R McNally; 1963:12-13.
Grants Available to Attend 2007 Congress in Orlando
T
he AORN Foundation is offering grants for nursing students, staff nurses, and OR managers to attend AORN’s 54th Congress in Orlando, March 11-15, 2007. Funding for these grants is made possible by a generous donation from the Integra Foundation. The deadline to apply for a grant is Feb 9, 2007,
180 • AORN JOURNAL
and all applications must be mailed to the AORN Foundation office. Winners of 2006 Congress grants are not eligible to apply for 2007 Congress grants. For more information and to obtain an application, please visit the AORN Foundation web site at http:// www.aorn.org/foundation/grants.asp.
S
urgical 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
© AORN, Inc, 2007
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
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 at a 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. AORN J 85 (January 2007) 173-180. © AORN, Inc, 2007. JANUARY 2007, VOL 85, NO 1 • AORN JOURNAL • 173
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JANUARY 2007, VOL 85, NO 1
TABLE 1
Quality Measures to Prevent Surgical Site Infections1 Prophylactic antibiotics were administered on time. Appropriate prophylactic antibiotics were selected. Prophylactic antibiotics were discontinued within 24 hours after surgery. Perioperative serum glucose was controlled (ie, was less than 200 mg/dL) among major cardiac surgery patients. Postoperative wound infection was diagnosed during index hospitalization (ie, the admission during which the surgical procedure occurred). Appropriate hair removal was performed. Perioperative normothermia was maintained among colorectal surgical patients. Perioperative serum glucose was controlled (ie, was less than 200 mg/dL) among noncardiac major surgery patients. Major surgery patients who did not undergo planned hypothermia maintained normothermia during the perioperative period. 1. FMQAI—Florida's Medicare Quality Improvement Organization. Surgical Care Improvement Project (SCIP) page 2. Available at: http://www.fmqai.com/Professionals-Providers /hospital/Identified-Participant-Groups/Surgical-Care-Im provement-Project/Surgical-Care-Improvement-Project -Page-2/. Accessed November 7, 2006.
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 na-
174 • AORN JOURNAL
tional guidelines and immediately notifying noncompliant physicians. EXPANSION OF COMPUTERIZED CHARTING. Intraoperative 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. It was necessary to make adaptations to this process for cardiac surgical patients because of longer surgical prep times for these patients in the OR. The ideal time for administering antibiotics to the cardiac surgical patient was determined to be when the anesthesia care provider inserted the pulmonary artery catheter because the initial incision was made approximately 30 minutes after this point. It also was necessary to make process adaptations for patients receiving fluoroquinolone or vancomycin. The national guidelines for administering
White — Schneider
JANUARY 2007, VOL 85, NO 1
A critical step in ensuring staff member compliance with the new interventions was allowing adequate time for staff member education, particularly for educating physicians. fluoroquinolone or vancomycin state that the infusion must be started within 120 minutes before the anticipated time of the initial incision so that the medication is completely infused within 60 minutes before the initial incision is made.25 Preoperative holding area staff members, therefore, were instructed to administer fluoroquinolone or vancomycin when the patient arrived in the preoperative holding area to meet the national guidelines for administering these medications. For cardiac patients who received fluoroquinolone or vancomycin, the infusion was started when the patient departed the preoperative holding area, which allowed approximately one hour for the medication to infuse before the initial incision was made. To meet these strict timelines for antibiotic administration, the antibiotic needed to be easily accessible to preoperative holding area staff members. To mitigate delays related to pharmacy delivery, antibiotics were stored in an automated medication dispensing system in the preoperative holding area, enabling immediate retrieval of antibiotics when needed. APPROPRIATE STANDING ORDERS FOR ANTIBIOTICS. The standing orders were revised to include preoperative antibiotic administration. The revised orders specified antibiotic selection and timing for surgical procedures for which preoperative antibiotics were recommended.23 PREOPERATIVE HOLDING AREA STAFF MEMBER ROLE. Previously, there was no systematic process for ensuring timely antibiotic administration. One procedure change included assigning responsibility to the preoperative holding area staff for ensuring that patients appropriate for preoperative antibiotics (ie, based on national guidelines) had an order for antibiotics (Table 2). If orders were not present when a patient was transferred to the preoperative holding area, a holding area staff member called the physician for an an-
tibiotic order. After obtaining the order, the preoperative holding area staff member retrieved the antibiotic from the automated dispensing system and prepared and hung the antibiotic for administration at the appropriate time.
IMPLEMENTATION Implementation of these interventions began in October 2004 and was completed in March 2005. Implementation of the interventions was staggered over a fivemonth period to ensure adequate time for staff members to become familiar with the new processes. As individual components of the interventions were implemented, it was necessary to make some adjustments to perioperative processes to improve implementation. For example, a prompt in the intraoperative electronic documentation system reminded the circulating nurse to discuss antibiotics with the physician to make sure antibiotics were ordered so that they could be administered within 60 minutes before the initial incision was made. Initially, there was confusion regarding which patient populations required antibiotic orders. This resulted in some physicians being asked for antibiotic orders when it was not indicated and other physicians not being asked about antibiotics when antibiotics were indicated. To overcome this problem, the names of patients for whom antibiotics were recommended according to national guidelines were highlighted on the OR schedule. With the addition of each new strategy during the implementation phase, perioperative nursing and medical staff members were educated and supported. A critical step in ensuring staff member compliance with the new interventions was allowing adequate time for staff member education. This was particularly evident when educating physicians about the project. Numerous presentations were made to physicians at regular AORN JOURNAL •
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JANUARY 2007, VOL 85, NO 1
TABLE 2
Antibiotic Recommendations for Select Surgical Procedures1-3 Surgical procedure category Cardiothoracic
Recommended antibiotic prophylaxis
Recommendation for patients with beta-lactam allergy*
• • •
Cefazolin 1 g to 2 g IV Cefuroxime 1.5 g IV Vancomycin** 1 g IV (if high risk for methicillin-resistant Staphylococcus aureus [MRSA])
• •
Vancomycin** 1 g IV Clindamycin 600 mg to 900 mg IV
Esophageal, gastroduodenal, biliary tract (high-risk patients only)
•
Cefazolin 1 g to 2 g IV
•
Colorectal
• •
Ampicillin/sulbactam 1.5 g IV Cefazolin 1 g to 2 g IV plus metronidazole** 0.5 g to 1 g IV
Clindamycin 600 mg to 900 mg IV plus gentamicin** 1.5 mg/kg IV or aztreonam** 1 g to 2 g IV or levofloxacin** 750 mg IV Metronidazole** 0.5 g to 1 g IV plus gentamicin** 1.5 mg/kg IV or levofloxacin** 750 mg IV
Appendectomy, nonperforated
•
Cefazolin 1 g to 2 g IV plus metronidazole** 0.5 g to 1 g IV
Ruptured viscus
•
Cefoxitin 1 g to 2 g IV plus gentamicin** 1.5 mg/kg IV
•
Levofloxacin** 750 mg IV
All procedures
Gastrointestinal
•
Genitourinary High-risk patients only
Gynecologic and Obstetric Abdominal or vaginal hysterectomy
• • •
Ampicillin/sulbactam 1.5 g IV Cefazolin 1 g to 2 g IV Metronidazole 0.5 g to 1 g IV
•
Cesarean section
•
Cefazolin 1 g to 2 g IV (administered after umbilical cord is clamped)
• •
Abortion—first trimester, high risk patients
• •
Aqueous penicillin G** 2 million units IV Doxycycline** 300 mg orally
•
Cefazolin 1 g to 2 g IV
Abortion—second trimester
surgical section meetings to present information and data regarding the implementation strategies for increasing the rates of antibiotic administration within 60 minutes of initial incision and appropriate antibiotic selection. In addition to physicians, administrative, risk management, and nursing staff members attend-
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Clindamycin 600 mg to 900 mg IV plus gentamicin** 1.5 mg/kg IV or aztreonam** 1 g to 2 g IV or levofloxacin** 750 mg IV Clindamycin 600 mg to 900 mg IV Metronidazole** 0.5 g to 1 g IV plus gentamicin** 1.5 mg/kg IV or levofloxacin** 750 mg IV
ed these meetings. A clinical pharmacist also spoke at physician meetings and with individual physicians to discuss appropriate selection and timing of antibiotics. It was essential to bring data about compliance rates with the national guidelines, as well as literature sources for the guidelines, to meetings with the
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TABLE 2
Antibiotic Recommendations for Select Surgical Procedures (continued) Surgical procedure category Head and neck Incisions through oral or pharyngeal mucosa
Recommended antibiotic prophylaxis
• •
Clindamycin 600 mg to 900 mg IV plus gentamicin 1.5 mg/kg IV Cefazolin 1 g to 2 g IV
•
Cefazolin 1 g to 2 g IV
•
Cefazolin 100 mg subconjunctivally
• • • • • •
Recommendation for patients with beta-lactam allergy*
Neurosurgery All procedures
•
Vancomycin** 1 g IV
Cefazolin 1 g to 2 g IV Cefuroxime 1.5 g IV Vancomycin** 1 g IV (if high risk for MRSA)
• •
Vancomycin** 1 g IV Clindamycin 600 mg to 900 mg IV
Cefazolin 1 g to 2 g IV Cefuroxime 1.5 g IV Vancomycin** 1 g IV (if high risk for MRSA)
• •
Vancomycin** 1 g IV Clindamycin 600 mg to 900 mg IV
Ophthalmic All procedures
Orthopedic Hip or knee arthroplasty
Vascular Surgery All procedures
General recommendations
• • • • •
One dose of antibiotic should be administered within 60 minutes before the initial incision is made. Vancomycin and fluoroquinolones (ie, levofloxacin) should be administered within 120 minutes before the initial incision is made so the medications are completely infused within 60 minutes of the initial incision. Readminister antibiotic every 3 hours for prolonged procedures (ie, longer than 4 hours); in cases of major blood loss; or unless contraindicated. Consider higher antimicrobial dose for patients who weigh 80 kg or more. All antibiotics should be discontinued within 24 hours after the procedure.
1. Antimicrobial prophylaxis for surgery. Treat Guidel Med Lett. 2004;2:27-32. 2. Bratzler DW, Houck PM, Surgical Infection Prevention Guidelines Writers Workgroup, et al. Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project. Clin Infect Dis. 2004;38:1706-1715. 3. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999: Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol. 1999;20:250-278. * For patients with beta-lactam allergies, any medication in this column is appropriate for this surgical procedure category. ** These medications should not be readministered in the event of a long procedure or major blood loss.
physicians and anesthesia care providers to ensure their acceptance of and adherence to the changes needed on their part.
MEASURING PROGRESS To determine whether the interventions had improved compliance rates with preoperative antibiotic adminis-
tration guidelines, staff members at TMH used a pre-experimental staticgroup comparison design26 to compare compliance rates before and after the changes were made in preoperative medication administration processes. The QI project leaders employed a retrospective review of existing databases AORN JOURNAL •
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TABLE 3
Rates of Compliance With National Guidelines for Administering Prophylactic Antibiotics Before and After Implementation of Strategies to Improve Compliance Surgical procedure groups
Compliance before implementation
Compliance after implementation
Change in compliance
Total joints
86%
(n = 56)
97%
(n = 79)
11%
Cardiac surgery
80%
(n = 50)
95%
(n = 41)
15%
Gastric bypass
88%
(n = 16)
92%
(n = 12)
4%
Colon resection
74%
(n = 38)
96%
(n = 26)
22%
Vascular surgery
53%
(n = 45)
87%
(n = 35)
34%
All groups
75% (N = 205) and medical records of patients who underwent surgical procedures before and after the preoperative antibiotic administration process changes were implemented for this project. Following approval by the institutional review board of the health care facility, specially trained staff members reviewed perioperative databases to identify eligible participants among patients who underwent elective surgical procedures between Sept 1, 2004, and Oct 31, 2004, (ie, the pre-implementation group) and between June 1, 2005, and July 31, 2005 (ie, the postimplementation group). The staff members then retrospectively reviewed medical records for the presence of inclusion and exclusion criteria for the QI project. Participants were restricted to patients who underwent one of the following surgical procedures: • total joint replacement (ie, hip, knee, shoulder); • cardiac surgery (ie, coronary artery bypass, cardiac valve repair or replacement); • major vascular surgery; • gastric bypass; or • colon resection. Participants were excluded if they had a contaminated wound classification. A total of 398 participants met the criteria, with 205 participants in the preimplementation group and 193 participants in the postimplementation group. Data on the following variables were
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95% (N = 193)
20%
extracted from participants’ medical records or the hospital databases: • type of surgical procedure, • the physician who performed the procedure, • wound classification, • time of preoperative antibiotic administration, • time of initial incision, • type of antibiotic administered, and • any patient allergies. Data were summarized using descriptive statistics. The project leaders calculated the rates of compliance with the guidelines for administering prophylactic antibiotics within 60 minutes of the initial incision for the two groups (ie, the pre-implementation and postimplementation groups). Time lengths that were within the zero- to 60-minute period before the initial incision were considered compliant, and those occurring outside that recommended period were considered noncompliant.
RESULTS Data from the pre-implementation period of this project validated the results of a previous study24 and anecdotal observations that administration of preoperative antibiotics within the time period identified in national guidelines does not occur for all patients (Table 3). During the baseline period of the project, preoperative antibiotic administration for 25% of patients
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was found not to be in compliance with the national guidelines. Of particular concern was the disparity in compliance rates between different surgical procedure groups, with one subgroup of surgical procedures (ie, vascular procedures) having a compliance rate of only 53%. Compliance rates after implementation increased from an overall preimplementation rate of 75% to an overall postimplementation rate of 95%. The largest improvements in compliance were in the two surgical subgroups with the lowest pre-implementation scores, with compliance rates for vascular procedures increasing from 53% to 87% and compliance rates for colon resection procedures increasing from 74% to 96%. The subgroups that had the least increase in compliance over the project period were the two groups with the highest preimplementation scores; compliance rates for joint replacement procedures increased from 86% to 97% and compliance rates for gastric bypass surgeries increased from 88% to 92%. The project leaders used chi square analysis to determine whether a significant change in compliance scores occurred after the intervention was implemented. They found that all of the increases in compliance rates were statistically significant (P < .05).
PROJECT OUTCOMES This project demonstrated that significant improvements in compliance with national guidelines can occur with implementation of a variety of strategies to change perioperative processes for prophylactic antibiotic administration. Not surprisingly, the largest improvements in compliance rates occurred in those surgical categories with the lowest baseline compliance rates before implementation of the strategies. Other health care facilities also may be able to increase their rates of compliance with prophylactic an-
JANUARY 2007, VOL 85, NO 1
tibiotic administration guidelines by implementing similar changes to their preoperative processes. ❖ Anne White, RN, BSN, CNOR, is the director, main OR at Tallahassee Memorial HealthCare, Tallahassee, Fla. Todd Schneider, BSIE, EIT, is a management engineer and improvement advisor at Tallahassee Memorial HealthCare, Tallahassee, Fla. The authors acknowledge Patricia Folsom, RN, BSN, CNOR, assistant nurse manager, main OR; Natalie Robertson, PharmD, MHA, pharmacy clinical coordinator; and Linda Russell, RN, CNOR, improvement advisor, Tallahassee Memorial Hospital, Tallahassee, Fla, for their contributions to and assistance with this project.
REFERENCES 1. Gaynes RP, Culver DH, Horan TC, Edwards JR, Richards C, Tolson JS. Surgical site infection (SSI) rates in the United States, 1992-1998: the National Nosocomial Infections Surveillance System basic SSI risk index. Clin Infect Dis. 2001;33(suppl 2): S69-S77. 2. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999: Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol. 1999; 20:250-278. 3. Cruse P. Wound infection surveillance. Rev Infect Dis. 1981;3:734-737. 4. Cruse PJ, Foord R. The epidemiology of wound infection: a 10-year prospective study of 62,939 wounds. Surg Clin North Am. 1980;60:27-40. 5. Martone WJ, Jarvis WR, Culver DH, Haley RW. Incidence and nature of endemic and epidemic nosocomial infections. In: Bennett JV, Brachman PS, eds. Hospital Infections. 3rd ed. Boston: Little, Brown and Co; 1992:577-596. 6. Boyce JM, Potter-Bynoe G, Dziobek L. Hospital reimbursement patterns among patients with surgical wound infections following open heart surgery. Infect Control Hosp Epidemiol. 1990;11:89-93. 7. Poulsen KB, Bremmelgaard A, Sorensen AI, Raahave D, Petersen JV. Estimated costs AORN JOURNAL •
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of postoperative wound infections: a casecontrol study of marginal hospital and social security costs. Epidemiol Infect. 1994;113: 283-295. 8. Vegas AA, Jodra VM, Garcia ML. Nosocomial infection in surgery wards: a controlled study of increased duration of hospital stays and direct cost of hospitalization. Eur J Epidemiol. 1993;9:504-510. 9. Albers BA, Patka P, Haarman HJ, Kostense PJ. Cost effectiveness of preventive antibiotic administration for lowering risk of infection by 0.25% [in German]. Unfallchirurg. 1994;97: 625-628. 10. Society of Hospital Epidemiology of America, Association for Practitioners in Infection Control, Centers for Disease Control, Surgical Infection Society. Consensus paper on the surveillance of surgical wound infections. Infect Control Hosp Epidemiol. 1992;13:599-605. 11. Cruse PJ. Surgical wound infection. In: Wonsiewicz MJ, ed. Infectious Diseases. Philadelphia: WB Saunders Co; 1992:758-764. 12. Agency for Healthcare Research and Quality. Prevention of surgical site infections. In: Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Rockville, Md: Agency for Healthcare Research and Quality; 2001:221-243. Also available at: http://www.ahrq.gov/clinic/ptsafety. Accessed November 14, 2006. 13. Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization: study of Wound Infection and Temperature Group. N Engl J Med. 1996;334:1209-1215. 14. Kjonniksen I, Andersen BM, Sondenaa VG, Segadal L. Preoperative hair removal— a systematic literature review. AORN J. 2002;75:928-940. 15. Zanetti G, Giardina R, Platt R. Intraoperative redosing of cefazolin and risk for surgical site infection in cardiac surgery.
Emerg Infect Dis. 2001;7:828-831. 16. Zmora O, Pikarsky AJ, Wexner SD. Bowel preparation for colorectal surgery. Dis Colon Rectum. 2001;44:1537-1549. 17. Boxma H, Broekhuizen T, Patka P, Oosting H. Randomised controlled trial of single-dose antibiotic prophylaxis in surgical treatment of closed fractures: the Dutch Trauma Trial. Lancet. 1996;347:1133-1137. 18. Barker FG II. Efficacy of prophylactic antibiotic therapy in spinal surgery: a metaanalysis. Neurosurgery. 2002;51:391-400. 19. Classen DC, Evans RS, Pestotnik SL, Horn SD, Menlove RL, Burke JP. The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection. N Engl J Med. 1992;326:281-286. 20. Dellinger EP, Gross PA, Barrett TL, et al. Quality standard for antimicrobial prophylaxis in surgical procedures. Infect Control Hosp Epidemiol. 1994;15:182-188. 21. Antimicrobial prophylaxis for surgery. Treat Guidel Med Lett. 2004;2:27-32. 22. Butts JD, Wolford ET. Timing of perioperative antibiotic administration. AORN J. 1997;65:109-115. 23. Bratzler DW, Houck PM, Surgical Infection Prevention Guidelines Writers Workgroup, et al. Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project. Clin Infect Dis. 2004;38:1706-1715. 24. Bratzler DW, Houck PM, Richards C, et al. Use of antimicrobial prophylaxis for major surgery: baseline results from the National Surgical Infection Prevention Project. Arch Surg. 2005;140:174-182. 25. Burlingame B. OR fire extinguishers; classifying wounds and minor procedures; antibiotic infusion time; mopping after minor procedures [Clinical Issues]. AORN J. 2006;83:1384-1393. 26. Campbell DT, Stanley JC. Experimental and Quasi-Experimental Designs for Research. Chicago: R McNally; 1963:12-13.
Grants Available to Attend 2007 Congress in Orlando
T
he AORN Foundation is offering grants for nursing students, staff nurses, and OR managers to attend AORN’s 54th Congress in Orlando, March 11-15, 2007. Funding for these grants is made possible by a generous donation from the Integra Foundation. The deadline to apply for a grant is Feb 9, 2007,
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and all applications must be mailed to the AORN Foundation office. Winners of 2006 Congress grants are not eligible to apply for 2007 Congress grants. For more information and to obtain an application, please visit the AORN Foundation web site at http:// www.aorn.org/foundation/grants.asp.