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TECHNOLOGY, COMPUTING, AND SIMULATION

An Anesthesia Information System Designed to Provide Physician-Specific Feedback Improves Timely Administration of Prophylactic Antibiotics

Michael O’Reilly, MD, MS^*, AkkeNeel Talsma, PhD, RN, Sharon VanRiper, MS, RN, Sachin Kheterpal, MD^*, and Richard Burney, MD

From the *Department of Anesthesiology, Office of Clinical Affairs, Corporate Quality Improvement, Department of Surgery, University of Michigan Health System, Ann Arbor, Michigan.

Address correspondence and reprint requests to: Michael O’Reilly, MD, Department of Anesthesiology, University of Michigan Health Systems, 1500 E Medical Center Dr., Room UH1H247, Ann Arbor, MI 48109-0048. Address e-mail to oreilly{at}umich.edu.

	Abstract

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Surgical site infections are a frequent cause of morbidity and mortality and add significantly to the cost of care. One component of the national Surgical Infection Prevention (SIP) program is to ensure timely administration of prophylactic antibiotics, a key factor to reduce postoperative infection. Our anesthesia department decided to assume the responsibility for timing and administration of antibiotic prophylaxis and we initiated a multitiered approach to remind the anesthesiologist to administer the prophylactic antibiotics. We used our anesthesia clinical information system to implement practice guidelines for timely antibiotic administration and to generate reports from the database to provide specific feedback to individual care providers with the goal of ensuring that patients receive antibiotic prophylaxis within 1 h of incision. Before the initiation of this project, 69% of eligible patients received antibiotics within 60 min of the incision. After the program began, there was a steady increase in compliance to 92% 1 yr later. Provider-specific feedback increases compliance with practice guidelines related to timely administration of prophylactic antibiotics. Anesthesia information systems hold promise for implementing and monitoring new practice guidelines and the anesthesiologist may play a key role in influencing surgical outcomes by ensuring appropriate therapy that may not be directly related to anesthesia care.

	Introduction

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Surgical site infections are a frequent cause of morbidity and mortality and add significantly to the cost of care (1). Although it is well established that timely and appropriate administration of prophylactic antibiotics reduces the rate of surgical site infections, ensuring proper administration of antibiotics before surgery continues to be a difficult challenge. To accelerate compliance with accepted guidelines for antibiotic prophylaxis, the Centers for Medicare & Medicaid Services (CMS) and the Centers for Disease Control and Prevention have established a national healthcare quality improvement project, called the Surgical Infection Prevention (SIP) program, to reduce the rate of postoperative infection. There are three components to the SIP program. The first involves the timing of administration of prophylactic antibiotics; the second, the selection of an appropriate drug; the third, the discontinuation of prophylactic antibiotics within 24 h. This nationwide program, which is administered through state-based, CMS-funded Quality Improvement Organizations and endorsed by many private insurers as well, is intended to bring about transformational change in surgical care that will reduce the incidence of preventable surgical site infections. In this paper, we focus only on that part of the SIP program that ensures timely and appropriate administration of preoperative antibiotics (2).

Transformational change involves innovative rethinking of how patient care can be delivered. The anesthesiologist is not ordinarily considered the person primarily responsible for antibiotic prophylaxis for surgical patients. However, given his/her intimate involvement in planning for surgical procedures, proximity to the surgical incision and interest in the best possible surgical outcomes, the anesthesiologist may play a key role in assuring that prophylactic antibiotic administration is handled properly.

In undertaking the SIP project at our large, academic medical center, we decided to accept the responsibility for timing and administration of antibiotic prophylaxis by our anesthesia staff. Since antibiotics are not directly related to anesthesia care, remembering to give them may be a problem. We therefore initiated a multitiered approach to remind the anesthesiologist to administer the prophylactic antibiotic chosen by the surgeon or determined by written guideline. The purpose of this paper is to describe how we used a clinical information system to implement practice guidelines for timely antibiotic administration and to provide specific feedback to individual care providers with the goal of ensuring that patients receive antibiotic prophylaxis within 1 h of incision.

	METHODS

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Over the past 10 yr we have developed a fully automated, computer-based anesthesia/operative documentation system for documentation, quality oversight, and monitoring of anesthetic care at our hospital. The system development was begun with in-house consultants and later acquired by GE Medical Systems, now GE Healthcare. For the present project, we reconfigured our perioperative information system (Centricity®, GE Healthcare, Waukesha, WI) so that anesthesia staff could easily document both when antibiotics were administered and when they were not administered (for cases in which there was no indication for antibiotics).

The computer documentation system uses "case-based defaults" which are, in effect, scripts based on the type of case. Figure 1 shows a screen shot of the case-based default or "script." The script is really the "default" documentation for a particular case; the antibiotic documentation elements were added to all scripts for all cases. The actions to be performed, and therefore documented, appear on the left side of the screen in the order they are expected to occur.

View larger version (29K): [in this window] [in a new window]   Figure 1. A typical "case-based default" showing each action in sequence. Cefazolin is the default antibiotic choice for all scripts since it is most commonly administered.

As anesthesia providers go through their preoperative checklist in the operating room (OR), they are reminded either to administer antibiotic(s) or to ask the surgeon if an antibiotic should be administered. An additional documentation element was added to show specifically when an antibiotic was not administered and the reason why (Fig. 1). This step is necessary to automate a query and a report that includes only those cases where a patient was supposed to receive an antibiotic but did not because it was not indicated, or because the patient was already receiving scheduled antibiotics.

Biweekly queries of the Centricity® database identified those cases in which antibiotics were administered more than 60 min before the incision, after the incision, or not at all. For patients who received vancomycin, the analyses were adjusted to allow for start-time up to 120 min before incision. Hypertext mark-up language (HTML) graphic e-mails were sent to each resident, Certified Registered Nurse-Anesthetist, and faculty member showing data in aggregate as well as showing the performance of individual providers. To protect privacy, providers were identified by a letter code only and each provider was notified of their "code." Separate e-mails were sent to each provider either congratulating them on 100% compliance or indicating which letter code corresponded to their performance indicated on the previous e-mail. Thus, each faculty and staff member received two e-mails, the first showed the overall performance (Appendix A [blue/red bars graph] available online at www.anesthesia-analgesia.org). The second e-mail either identified the number of cases that missed appropriate timing (Appendix B [with A, B, C codes]) or consisted of a congratulatory e-mail sent to all faculty and staff with perfect performance for that week.

The biweekly e-mails were derived from data captured by Centricity®, the anesthesiology clinical information system. An extract was prepared to provide data about all surgical patients, procedures, surgeons, start times, end times, antibiotics given, anesthesiologists and staff, and the OR. The decision was made that timely antibiotics are beneficial to all patients, regardless of whether their surgical procedure was included in the SIP program. The data were made available to the analyst biweekly and, using a Microsoft Excel macro, the time between antibiotics given and incision time was calculated. The assigned codes were: (1) antibiotic given within 60 min of incision, (2) no antibiotic given, (3) antibiotic given more than 60 min before incision (too early), or (4) antibiotic given after incision (too late). Patients who did not receive antibiotics were excluded from the feedback report. All patients who did not receive antibiotics within 60 min of incision were reviewed for quality assurance purposes. Cases with legitimate reasons why antibiotics were not given within 60 min were excluded from the biweekly reporting. For example, a culture was taken or the patient received antibiotics for treatment purposes. The results were prepared to update the graphs and prepare feedback about missed opportunities and the 100% compliance report. The weekly reports contain all eligible cases that took place during that particular week, and the off-week was used to generate the reports.

The e-mails were disseminated by quality assurance staff of the anesthesiology department. In addition, results were posted at highly visible locations throughout the OR, especially ORs that performed below the threshold and staff were reminded on a regular basis during weekly all-staff meetings. A poster summarizing the program and results was strategically placed in the OR scrub area. In addition, the anesthesiology contact sought out staff with multiple or repeated lapses and clarified the program and made suggestions about improvements.

	RESULTS

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Before the initiation of this project, manual chart review showed that 69% of eligible patients with SIP-related procedures received antibiotics within 60 min of the incision. Our first automated analysis showed that 70% of all surgical patients received their antibiotics within 60 min of incision (Fig. 2). Over a 1-yr period, there was a steady increase in compliance to about 92% (Fig. 2). Evaluation of the improvement was based on a t-test between the first and last shown measurement. The monthly sample contains all surgical cases of two biweekly samples, approximately 560 cases per month. Further analysis revealed that certain ORs were less compliant than others and that the apparent poor compliance in these rooms was related to the types of surgery being performed there. For example, patients undergoing coronary bypass graft surgery were less likely to receive prophylactic antibiotics in a timely manner than those undergoing some other procedure, in part because of the long interval required for setup and anesthetic induction between the time the patient enters the room and the time of surgical incision. We observed the same pattern in other ORs in which complex cases were done that required extensive positioning or other preparation. This was particularly true for some neurosurgical and orthopedic procedures.

View larger version (28K): [in this window] [in a new window]   Figure 2. Compliance with the timely administration of antibiotics gradually increased to about 92%.

On the basis of these observations, anesthesia providers were instructed to begin antibiotic administration, except for vancomycin, at the time the surgical skin preparation was begun, rather than when the patient entered the room. In conjunction with this decision, we moved the antibiotic script item further down on the script to a location in the timeline just before surgical incision (Fig. 1). While we did not specifically measure the impact of these two changes, we believe they have had a positive impact of approximately 3% on the timeliness of antibiotic administration. These changes were implemented late April 2004.

	DISCUSSION

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Surgical site infections are relatively common, occurring in 2%–5% of clean operations and in up to 20% of abdominal procedures (3–7). Patients with infections spend more time in the hospital and incur increased costs (1). They are also more likely to be admitted to an intensive care unit, more likely to be readmitted to the hospital after discharge, and more likely to die (1).

Antimicrobial prophylaxis is most effective when administered before the surgical incision. The optimal time to administer preoperative antibiotics appears to be 30–60 min before incision, or within 2 h of incision if vancomycin is administered (8,9). Before the beginning of this SIP project in our hospital, prophylactic antibiotics were administered by a nurse in the preoperative holding area. An examination of our performance showed that compliance with accepted guidelines was poor. We found inconsistencies and unexplained variations in all three components of the SIP project.

Previous studies showed that work process reengineering that improves compliance within established guidelines decreased the morbidity associated with surgical site infections (10). We hypothesized that the most efficient and practical way to ensure timely administration of preoperative antibiotics was for the anesthesiologist to take responsibility for administering them. While antibiotic administration is not directly related to anesthesia care, as an IV medication, it is under the control of the anesthesiologist in the OR. Physicians have historically resisted adoption of practice guidelines and quality improvement efforts (11,12). The challenge was to change the expected behavior of the anesthesia staff; so they accepted this new role as part of their normal duties in the OR.

At the beginning of the program, we gave detailed explanations to surgeons, nursing staff, and anesthesia staff regarding the nature and severity of the problem we faced; that is, poor compliance with antibiotic guidelines. Citing the old adage, "every system is perfectly designed to achieve the results it gets," we pointed out that the old way of doing things was not likely to lead to the kind of improvement that was needed and being called for by CMS and others. We emphasized the importance of solving this problem from the point of view of the hospital system, in which anesthesia, nursing, and surgical personnel work in partnership to improve care. We then explained why we wished to try an experiment in which anesthesia staff would be responsible for the timely administration of antibiotics selected by the surgeons according to accepted guidelines. Using the department of anesthesiology’s clinical information system, we developed and instituted guidelines that were incorporated into scripts to remind the anesthesiologists to administer antibiotics. The database was regularly queried and reports generated to provide specific feedback to individuals regarding the timeliness of antibiotic administration.

There are a number of important elements that must be incorporated into the design of a system that provides specific feedback to individual providers. We thought it important, for example, that providers be able to view their own performance relative to others in a blinded fashion. Every e-mail sent to individual providers specifically stated that the purpose of the project was to create awareness among anesthesia care providers about the importance of appropriate timing of prophylactic antibiotics. Other than receiving e-mails, there were no punitive or other actions taken based on an individual’s performance. However, repeated presentations at weekly staff meetings, discussions among staff, and the presence of performance materials throughout the OR increased staff awareness.

We are not the only large hospital to conclude that the anesthesiologist plays a critical role in prophylactic antibiotic administration. Henry Ford Hospital in Detroit, MI also initiated a program to have anesthesiologists assume responsibility for prophylactic antibiotic administration. At the time they started their project, 58% of eligible patients received antibiotics on time. They found, as did we, that prolonged surgical positioning and preparation affected timely administration of antibiotics. After they initiated their program to have antibiotics administered in the OR, compliance went to 89%.¹

Pexton and Young (13) reported on their efforts using a Six-Sigma and change management methodology to improve timeliness of antibiotic administration. Before their project, 14% of patients received their antibiotics on time; afterward the rate went to 88%.

While we have made a significant improvement in our rates of timely antibiotic administration, we still have not achieved the desired level of compliance, which should be >99%. We are currently looking into remaining variations and inconsistencies in our system and studying new changes to bring about continued improvement in performance.

Timely administration of antibiotics is just the first in a series of proposed modifications in surgical work processes to reduce morbidity and cost. Research shows there are other areas in which systematic improvement may be achieved, including intraoperative glucose control, temperature control, ß-blockade in high-risk cardiac patients undergoing noncardiac surgery, and prevention of perioperative venous thrombosis and embolism. We anticipate applying the same guideline-based provider-specific feedback methodology to the implementation of these new practice guidelines as well.

In summary, surgical site infections are a significant source of morbidity and mortality. Provider-specific feedback increases compliance with practice guidelines related to timely administration of prophylactic antibiotics. We hope that additional changes will result in 100% compliance. Anesthesia information systems hold promise for implementing and monitoring new practice guidelines.

	ACKNOWLEDGMENTS

 
The authors thank Vanessa Griswold and Nathan Kirkpatrick for their help in producing reports and e-mails and Tory Lacca for her help with preparation of the manuscript. A special thanks to John Vandervest for producing the query reports and to Shubangi Gumate for producing the SAS reports.

	Footnotes

 
¹Douglas E. at Henry Ford Health System in Detroit: Surgical Site Infection Prevention Championed by Anesthesiologists. Anesthesiology News, February, 2005;31:2.

This article has supplementary material on the Web site: www.anesthesia-analgesia.org.

Accepted for publication June 15, 2006.

This paper describes the use of an Anesthesia Information System, Centricity, manufactured by GE Healthcare Information Technologies. The Department of Anesthesiology at the University of Michigan is the development site for this software. The University of Michigan, The Department of Anesthesiology, or any of its employees receive no compensation for this work. However, one author (Dr. O’Reilly) has received honoraria for speaking on behalf of this product. In addition, Dr. O’Reilly receives support from GE Healthcare for research to develop multiparameter alarm systems.

	REFERENCES

Top Abstract Introduction METHODS RESULTS DISCUSSION REFERENCES

 

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2. Bratzler DW, Houck PM. Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project. Am J Surg 2005;189:395–404.[Web of Science][Medline]
3. Delgado-Rodriguez M, Sillero-Arenas M, Medina-Cuadros M, Martinez-Gallego G. Nosocomial infections in surgical patients: comparison of two measures of intrinsic patient risk. Infect Control Hosp Epidemiol 1997;18:19–23.[Web of Science][Medline]
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7. Auerbach AD. Prevention of surgical site infections. In: Making health care safer: a critical analysis of patient safety practices (Online). Available at: http://www.ahrq.org/clinic/ptsafety/pdf/ptsafety.pdf. Last accessed July 20, 2001.
8. Gyssens IC. Preventing postoperative infections: current treatment recommendations. Drugs 1999;57:175–85.[Web of Science][Medline]
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