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ECONOMICS, EDUCATION, AND POLICY

The Role of Anesthesiologists in the Selection and Administration of Perioperative Antibiotics: A Survey of the American Association of Clinical Directors

R. David Warters, MD^*, Peter Szmuk, MD^*, Evan G. Pivalizza, MB, ChB, FFASA^*, Ralf E. Gebhard, MD^*, Jeffrey Katz, MD^*, and Tiberiu Ezri, MD

*Department of Anesthesiology, The University of Texas Medical School at Houston; and Department of Anesthesiology, Wolfson Medical Center, Holon, Israel.

Address correspondence to and reprint requests to R. David Warters, M.D., 6431 Fannin Street, Suite 5.020, Houston TX 77030. Address e-mail to robert.d.warters{at}uth.tmc.edu.

Abstract

The importance of timely administration of antibiotics for prophylaxis of surgical site infections has led to pressure on anesthesiologists to administer antibiotics. We present a survey of members of the American Association of Clinical Directors designed to evaluate the role of the anesthesiologist in the selection and administration of perioperative antibiotics. A 13-question survey was sent via e-mail to all 233 members of the American Association of Clinical Directors. Two requests for survey responses resulted in a response rate of 43%. Based on the responses received, anesthesiologists appear to be integrally involved with the administration, but not selection, of perioperative antibiotics, despite what respondents perceive as inadequate training in antibiotic therapy. Furthermore, perioperative antibiotic therapy in general appears to be poorly monitored, and responsibility for selection and administration of perioperative antibiotics appears to be poorly defined.

Prophylactic antibiotics for prevention of surgical site infections are more effective when administered 30–60 minutes before surgical incision (1). Many institutions, therefore, expect anesthesiologists to assume responsibility for antibiotic administration (2,3). However, anesthesiologists receive little, if any, training in antibiotic therapy during residency or through continuing medical education (3).

In a letter to the editor (4), we described a system in which anesthesiologists assume responsibility for administration of antibiotics to patients who have not received them before arrival in the operating room (OR). With this system, anesthesiologists administer the antibiotics, but drug selection is based on a protocol authored and regularly updated by the institutional infection control committee. This letter provoked a lively dialogue both in the journal (5) and by personal e-mail and resulted in many requests for a copy of the protocol. From this response, there appears to be a lack of unanimity in the manner in which antibiotics are selected and administered in ORs around the nation, prompting us to undertake a survey to evaluate the current national practice.

We present a survey of members of the American Association of Clinical Directors (AACD) designed to evaluate the role of the anesthesiologist in the selection and administration of perioperative antibiotics.

Methods

This survey was based on discussions with a panel of five anesthesiology faculty members from the Department of Anesthesiology at the University of Texas at Houston. Questions were written based on our own experience as well as comments from more than 100 e-mails we received in response to our letter to the editor (5). An e-mail distribution list was obtained from the AACD along with written permission for the use of the e-mail addresses for this survey. Agreement was given in writing that the addresses would be used exclusively for the survey.

An e-mail describing the purpose of the survey was sent to all 233 members of the AACD on the distribution list. The 13-question survey was included as an electronic attachment. The text of the e-mail and questionnaire are included in their entirety as Appendix A.

After completion of the 13 questions, participants were prompted to submit the survey. Survey results were sent to a central data server, and the data were then tabulated using Microsoft Excel. Data are presented as percentages of total responses.

Results

Of the original 233 e-mails sent, 12 were returned as undeliverable, resulting in 221 potential responders. Seventy-two responses were received within 3 weeks of the original request, at which time a second request was sent to those who had not yet responded. An additional 22 responses were received after the second request. Ninety-four responses of 221 amounted to a response rate of 43%. The 94 responses were all from different institutions.

Ninety-three of 94 respondents (99%) were anesthesiologists; one respondent was a surgeon. Seventy-one percent of respondents described their practice setting as a "tertiary hospital," whereas 22% described their practice setting as a "community hospital" and 4% as an "outpatient surgical center," with 2% not responding to this question. Thirty-six percent of respondents described their anesthesia coverage as "resident supervised by anesthesiologist," 26% as "certified registered nurse anesthetist supervised by anesthesiologist," and 14% as "anesthesiologist only." Twenty-four percent of respondents described their anesthesia coverage as a combination of the available choices (Appendix A).

Responses to our questions pertaining to current practice are presented in Table 1. Eighty-three percent of respondents indicated that surgeons are responsible for antibiotic selection, whereas 13.8% indicated that antibiotic selection is based on an institutional protocol. Only 1.1% responded that antibiotic selection is up to the anesthesiologist. One respondent indicated that responsibility for selection is not well-defined, and one indicated that it is the joint responsibility of the surgeon and anesthesiologist. Fifty-two percent of respondents noted that anesthesiologists are responsible for antibiotic administration, whereas only 3.2% indicated that antibiotic administration is the responsibility of the surgeon. Thirty percent of respondents indicated antibiotic administration is the responsibility of a preoperative nurse, 1.1% indicated the OR nurse, and 9.6% indicated that responsibility for administration is not clearly defined. One respondent skipped the question, two said the responsibility for antibiotic administration is drug-specific, and one indicated that administration is by protocol.

We also inquired about who assumes responsibility for antibiotic administration if a patient reaches the OR without receiving preoperative antibiotics. In this scenario, 77.7% of responders indicated responsibility falls to the anesthesiologist, 9.6% indicated the surgeon, 3.2% indicated the OR nurse, and 6.4% indicated that responsibility is not clearly defined. One wrote "Anesthesiologist/Registered Nurse," another "doctor on call" and another skipped the question.

When asked who was responsible for confirmation of antibiotic administration before skin incision, 33% noted that this is not clearly defined. Thirty percent indicated that this is the responsibility of the anesthesiologist, 20.2% indicated the surgeon, 9.6% indicated the OR nurse, and 5.3% indicated a team "time out" or "huddle." One respondent skipped the question.

When asked, "What percentage of your patients receives antibiotics before skin incision?" 17% noted that this was unknown. Seven-point-five percent of respondents indicated 100% of patients received antibiotics before skin incision, 33% indicated 90%, 17% indicated 80%, 5.3% indicated 70%, 12.8% indicated 60%, and 7.5% indicated <50%.

In the event of a prolonged surgical procedure, 73.4% of respondents noted that the anesthesiologist is responsible for administration of intraoperative antibiotics, whereas 13.8% indicated the surgeon and 2.1% indicated the OR nurse as the responsible party. Nine-point-six percent of respondents indicated that the responsibility for intraoperative redosing of antibiotics was not clearly defined. One respondent skipped the question.

Responses to our questions pertaining to training of anesthesiologists in the selection and administration of antibiotics are presented in Table 2. Eighty-two percent of respondents indicated that anesthesiologists do not receive adequate training in antibiotic selection, whereas 16% indicated they do receive adequate training. In contrast, 73.4% indicated anesthesiologists do receive adequate training in antibiotic administration, whereas 25.5% indicated they do not receive adequate training. Fifty-eight-point-five percent of respondents believe that antibiotic selection should be a part of anesthesiology resident training, whereas 39.4% believe that it should not be included. In contrast, 92.6% of respondents believe antibiotic administration should be included in anesthesiology resident training, whereas just 6.4% believe it should not be included.

Discussion

The efficacy of antibiotics for the prevention of infections at surgical sites is highly dependent on the timing of administration (1). It is important that therapeutic levels be present at the time of surgical incision and throughout the surgery (1,6). The importance of timely administration of antibiotics for prophylaxis of surgical site infections has led to pressure on anesthesiologists to administer antibiotics (1,7). The purpose of this survey was to examine the current role anesthesiologists play in the selection and administration of perioperative antibiotics.

Responses to the question regarding responsibility for selection of perioperative antibiotics demonstrate surprising unanimity in the anesthesia community, identifying the surgeon as the responsible physician in most cases. It appears from the data that involvement of anesthesiologists with the selection of perioperative antibiotics is quite rare.

Responsibility for antibiotic administration is far more varied; more than half of respondents identified the anesthesiologist as primarily responsible for antibiotic administration, approximately one third identified the preoperative nurse, and only 3% identified the surgeon. Fully 9.6% indicate that this is not clearly defined at their institution. If a patient reaches the OR without having received preoperative antibiotics, then responsibility for antibiotic administration is again assumed by the anesthesiologist in most cases. Likewise, in the event of a prolonged surgical procedure, the anesthesiologist is typically responsible for administration of additional intraoperative antibiotics. These data clearly demonstrate that, in the majority of institutions responding to this survey, the surgeon dictates antibiotic selection and the anesthesiologist assumes responsibility for administration. This arrangement results in an unusual medicolegal situation in which one physician is essentially following an order issued by another. Liability for an adverse drug reaction could be controversial if medical documentation or institutional policy does not clearly delineate responsibility for selection and administration.

Pressure from our institutional infection control committee to take responsibility for perioperative antibiotics led to much debate in our department as to what role we were willing to assume. Although most were comfortable with the actual administration of antibiotics, many felt we were not qualified to make the antibiotic selection. Furthermore, in our experience, although many surgeons appear to have more knowledge about antibiotic prophylaxis than anesthesiologists, they are not always confident about drug selection, particularly in complex cases. At our institution, a solution was reached in which the infection control committee provides a protocol for antibiotic selection for prophylaxis of surgical site infections (4). This protocol specifies antibiotic choice and dose by procedure, including specific patient considerations. It also includes alternatives in the event of allergy to the first-line drug. The protocol is condensed onto laminated cards that are attached to our anesthesia machines. The infection control committee is responsible for intermittently updating the antibiotic protocol.

Although the data clearly indicate that anesthesiologists around the country are widely involved in the administration of perioperative antibiotics, anesthesia resident training in this area appears to be unsatisfactory. Eighty-two percent of respondents indicated that anesthesiologists do not receive adequate training in antibiotic selection, and 25.5% indicated that anesthesiologists do not receive adequate training in antibiotic administration. Cheng et al. (3) interviewed residents at one institution in 1992 and concluded that training was inadequate. However, there are few objective data to determine the extent of training provided to anesthesiologists about antibiotic therapy during residency or through continuing medical education. It is noteworthy that 58.5% of respondents felt antibiotic selection should be part of resident training and fully 92.6% of respondents felt antibiotic administration should be part of resident training. This is consistent with Cheng et al. (3), who argued for greater emphasis on training anesthesiology residents in the use of antibiotics. We believe that antibiotic administration should be part of anesthesiology resident training as well as continuing medical education for anesthesiologists. However, in our opinion, the rapid evolution of antibiotic therapy and regional differences in epidemiology make it difficult for anesthesiologists to maintain adequate knowledge to safely select optimal antibiotics.

The administration of antibiotics before skin incision is accepted as the standard of care for prevention of postoperative wound infections (1), yet only 7.5% of respondents indicate 100% of their patients receive antibiotics before surgical incision (Table 1). Furthermore, 17% of respondents cannot say how many of their patients receive antibiotics before skin incision, and a third of respondents indicate responsibility for confirmation of antibiotic administration before skin incision is not clearly defined in their institutions. It would appear from these data that, although anesthesiologists are integrally involved with antibiotic administration, the administration of perioperative antibiotics is often poorly monitored and roles are often not clearly defined. Two studies (8,9) presented at the 2004 annual meeting of the American Society of Anesthesiologists demonstrated that having anesthesiologists assume responsibility for administration of antibiotic prophylaxis improves the timely administration of these vital medications.

The evaluation of current medical practice is extraordinarily difficult. Although we believe a survey is the single best method, the inherent weaknesses of surveys must be acknowledged and the results interpreted with caution. Potential limitations of surveys involve sample population and nonresponse bias (10). We chose the AACD membership as a convenient source of physicians with interest and knowledge in OR management, but the responses do not necessarily reflect the general national practice. Even within the AACD, the results may be skewed by nonresponse bias. Therefore, we have been circumspect with our conclusions, especially with respect to implications for national practice.

Based on the responses received from AACD members, anesthesiologists appear to be integrally involved with the administration, but not the selection, of preoperative antibiotics, despite what respondents perceive as inadequate training in antibiotic therapy. Furthermore, perioperative antibiotic therapy in general appears to be poorly monitored and responsibility for selection and administration of perioperative antibiotics appear to be poorly defined. We believe the intimate involvement of anesthesiologists in the care of patients immediately before surgical incision will inevitably lead to involvement of anesthesiologists in the administration of perioperative antibiotics. However, responsibility for selection and administration should be clearly delineated and monitored to consistently provide our patients with optimal antibiotic coverage and to avoid confusing medical-legal situations.

A special thanks to Theresa Le, Director, Management Operations II, for her expert technical assistance.

Appendix A

Dear Colleagues,

The role of anesthesiologists in the selection and administration of preoperative and intraoperative antibiotics has been periodically discussed in the literature but remains controversial. In a recent letter to the editor, we described a system in which anesthesiologists assume responsibility for administration of antibiotics to patients who have not received antibiotics before coming to the OR (Anesthesiology 2003;99:515–6). In this system, anesthesiologists administer the antibiotics, but drug selection is based on a protocol authored and regularly updated by the institutional infection control committee.

This letter provoked a lively dialogue both in the journal (Anesthesiology 2004;101:259–60) and by personal e-mail and resulted in many requests for a copy of the protocol. From the response, there appears to be a lack of unanimity in the way antibiotics are selected and administered in ORs around the nation. We are interested in documenting the current national practice and therefore ask you to participate in this brief survey of AACD members. To proceed, please click on the link below. Thank you!!

R. David Warters

Professor and Vice-Chairman for Clinical Operations

Department of Anesthesiology

The University of Texas Medical School at Houston

Please answer the following questions regarding preoperative and intraoperative antibiotic selection and administration at your institution:

1) Who is responsible for preoperative antibiotic selection?

a) Surgeon

b) Anesthesiologist

c) Institutional protocol

d) Other _____________

e) Not clearly defined

2) Who is primarily responsible for preoperative antibiotic administration?

a) Preoperative nurse (DSU or floor)

b) OR nurse

c) Anesthesiologist

d) Surgeon

e) Other _______________

f) Not clearly defined

3) If a patient reaches the OR without having received preoperative antibiotics, who then assumes responsibility for antibiotic administration?

a) OR nurse

b) Anesthesiologist

c) Surgeon

d) Other ___________

e) Not clearly defined

4) Who is responsible for confirmation of antibiotic administration before skin incision?

a) OR nurse

b) Anesthesiologist

c) Surgeon

d) Other _____________

e) Not clearly defined

5) What percentage of your patients receives antibiotics before skin incision?

a) <50%

b) 60%

c) 70%

d) 80%

e) 90%

f) 100%

g) unknown, don't reliably track

6) In the event of a prolonged surgical procedure, who is responsible for administration of intraoperative antibiotics?

a) OR nurse

b) Anesthesiologist

c) Surgeon

d) Other

e) Not clearly defined

7) In your experience, do anesthesiologists receive adequate training in antibiotic selection?

a) Yes

b) No

8) In your experience, do anesthesiologists receive adequate training in antibiotic administration?

a) Yes

b) No

9) Should antibiotic selection be part of anesthesiology resident training?

a) Yes

b) No

10) Should antibiotic administration be part of anesthesiology resident training?

a) Yes

b) No

11) Which of the following best describes your practice setting?

a) Outpatient surgical center

b) Community hospital

c) Tertiary hospital

12) Which of the following best describes your OR coverage?

a) Anesthesiologist only

b) CRNA supervised by anesthesiologist

c) Resident supervised by anesthesiologist

d) Other _____________

13) Which of the following best describes you?

a) Anesthesiologist

b) Surgeon

c) Nurse

d) Administrator

e) Other ________

We are grateful to the AACD for providing us with member e-mail addresses for this survey.

Thank you for your input!!!

Footnotes

Supported in full by the Department of Anesthesiology at the University of Texas Medical School at Houston.

Accepted for publication October 5, 2005.

References

1. Matuschka PR, Cheadle WG, Burke JD, Garrison RN. A new standard of care: Administration of preoperative antibiotics in the operating room. Am Surg 1997;63:500–3.[Web of Science][Medline]
2. Cheng EY, Nimphius N, Hennen CR. Antibiotic therapy and the anesthesiologist. J Clin Anesth 1995;7:425–39.[Medline]
3. Cheng EY, Nimphius N, Hennen CR. Training in antibiotic administration. Anesth Analg 1992;74:619–20.[Free Full Text]
4. Warters RD, Szmuk P, Pivalizza EG, et al. Preoperative antibiotic prophylaxis: the role of the anesthesiologist. Anesthesiology 2003;99:515–6.[Medline]
5. Warters RD, Szmuk P, Pivalizza EG, et al. Anesthesiologists and perioperative antibiotic prophylaxis [letter]. Anesthesiology 2004;101:260.[Medline]
6. Classen DC, Evans RS, Pestotnik SL, et al. The timing of prophylactic administration of antibiotics and the risk of surgical-site infection. N Engl J Med 1992;326:281–6.[Abstract]
7. Silver A, Eichorn A, Kral J, et al. Timeliness and use of antibiotic prophylaxis in selected inpatient surgical procedures. The Antibiotic Prophylaxis Study Group. Am J Surg 1996;171:548–52.[Web of Science][Medline]
8. Brown M, Conway W, Horvath B, et al. Anesthesiologist as change agent for the prevention of surgical site infections [abstract]. Anesthesiology 2004;101:A1387.
9. Brown M, Conway W, Jordan J, et al. Surgical site infection prevention—improved guideline compliance through OR process improvement [abstract]. Anesthesiology 2004;101:A1388.
10. Burmeister LF. Principles of successful sample surveys. Anesthesiology 2003;99:1251–2.[Web of Science][Medline]

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