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ECONOMICS, EDUCATION, AND POLICY

A System and Process Redesign to Improve Perioperative Antibiotic Administration

From the Department of Anesthesiology and Division of Healthcare Quality, Baystate Medical Center, Springfield, Massachusetts.

Address correspondence and reprint requests to Neil Roy Connelly, MD, Department of Anesthesiology, Baystate Medical Center, 759 Chestnut Street, Springfield, MA 01199. Address e-mail to neil.roy.connelly{at}bhs.org.

Abstract

Surgical infection is a leading cause of patient injury, mortality, and excess health care costs. As part of a collaborative effort, we instituted three main focuses for perioperative antibiotic administration: appropriate selection of antibiotics, administration of antibiotics within 60 min before incision, and discontinuation of prophylactic antibiotics within 24 h of surgery. Anesthesiologists were identified as the practitioners most likely to accomplish the successful administration of antibiotics within 60 min before incision. Changes were made in ordering, documentation, and antibiotic preparation. Education was provided to all operating room staff at meetings and grand round presentations. Results were prominently displayed, and feedback was provided. The baseline appropriate antibiotic selection was 82% and is now 95% The preintervention administration-incision time was 79 (range, 32–380) min, with 11% within the 60 min before incision. The administration-incision time is currently 19 (range, 0–95) min, and the number within 60 min is 95%. Before the institution of the process, the rate of surgical site infections was 3.8%, and is now approximately 1.4%. We describe our process used to improve antibiotic administration. During this time, the surgical site infection rate has been significantly reduced.

Surgical infection is a leading cause of patient injury, mortality, and excess health care costs. An estimated 2.6% of the nearly 30 million operations performed each year are complicated by surgical infections (1). Each infection can increase the length of hospital stay, the likelihood of an intensive care unit stay, and the incidence of readmission as well as increase the risk of mortality (2). An estimated 40%–60% of surgical infections are thought to be preventable with appropriate interventions (1). On the basis of its demonstrated commitment and track record in performing successful quality improvement projects, Baystate Medical Center was chosen in early 2002 to be the Massachusetts representative in a nationwide quality improvement initiative, the "Collaborative Experience Project: Surgical Infection Prevention," led by the Centers for Medicare & Medicaid Services and the Centers for Disease Control (3). The goal of the collaborative was to optimize the outcomes of patients undergoing surgery by improving the use of evidence-based practices shown to reduce the incidence of surgical infections. Evidence-based practices resulted in three main focuses for antibiotic administration: appropriate selection of antibiotics, administration of antibiotics within 60 min before incision, and discontinuation of prophylactic antibiotics within 24 h of surgery.

The initial surgical populations targeted were cardiac and vascular patients. This was followed a year later with the addition of patients undergoing total joint replacement, abdominal surgery, and gynecological surgery.

METHODS

After evaluation of our existing process incorporating rapid cycle PDSA (plan-do-study-act) techniques, a complete process redesign of the perioperative system was performed. The system was (and is) continuously improved using multiple small tests of change techniques to ensure compliance and improvement of the three processes. Often in quality improvement, using rapid cycle change, multiple interventions are introduced at once or in rapid fashion to improve process and ultimately outcome. The selection of the appropriate prophylactic antibiotics was determined based on Centers for Disease Control guidelines as well as review of the medical literature (4–6). Collaboration with the cardiac and vascular surgeons resulted in a guideline for antibiotic choice. This guideline was then incorporated into the computerized admission order sets of the surgeons. The department of healthcare quality reviewed all charts for appropriateness of selection and a letter was sent or phone call made to the surgeon, if he/she failed to order the correct antibiotic. This was a rare occurrence, as shown by our high compliance to the guideline.

We initially selected the cardiac surgery and vascular populations because the surgeons performing these procedures had an interest in improving their process of care. When the process interventions to be incorporated were reviewed, targeted surgeons felt their current practice was already aligned to the majority of these processes. Our initial cycle to decrease prophylactic antibiotic administration time increments was focused at having the nursing staff in the preoperative holding area administer the prophylactic antibiotics. We collected data on 30 cases after implementing this intervention and found the times were relatively unchanged. The next cycle was having the anesthesiologist administer the prophylactic antibiotic within 60 min before incision. Building the success for process this included identifying, educating, and supporting an anesthesiologist clinical champion. To simplify the administration process we made the decision to have prophylactic antibiotics for all procedures administered by the anesthesiologist. This included all procedures done in our main operating suites and quickly spread to the other sites. Continuous daily monitoring has been in place since we began the process.

The antibiotic administration was targeted to be administered within 60 min before surgical incision. Before the intervention, antibiotics were frequently administered in the preoperative area or on the nursing unit before the patient being sent to the operating room (OR). Although the antibiotics had been thought to be administered within the 60 min before the incision, case delays and long patient preparation time frequently resulted in antibiotics being administered more than 60 min before incision. Anesthesiologists were identified as the practitioners most likely to administer the antibiotics within this timeframe. To accomplish this, our computerized physician order entry system was revised to eliminate the "administer on-call to OR" orders. Changes were made in OR documentation to prompt and better capture antibiotic administration times. A prompt was placed on the anesthesia record to record the antibiotic administration time. Preoperative nurses prepare the antibiotic in the preoperative holding area for administration by anesthesiologists in the OR. The antibiotics are placed on an IV pole with the IV fluid but are not begun in the preoperative area. Surgical preoperative order sheets were redesigned to simplify antibiotic ordering. The educational process consisted of grand rounds for the Department of Anesthesiology and Surgery, in-services for the OR staff, e-mails, memos, storyboards, and scorecards. The initial Surgical Infection Prevention team consisted of surgeons, OR nurses, Department of Healthcare Quality members, and infectious disease specialists. Anesthesiologists were brought in only after the 60-min measure failed to be achieved. It was realized that the practitioner most likely to administer the antibiotic within the 60-min guideline was the anesthesiologist. We thought that the anesthesiologist should be in control of all medications being administered to patients during and around the time of induction of anesthesia. We thought that having another practitioner administer medications independent of the anesthesiologist could lead to complications. The pharmacy prepared the medications and the preoperative nurse did spike and prime the line. We then attempted to remove as many barriers as possible to make it easy and simple for the anesthesiologist to be successful in meeting the 60-min time. The intraoperative process requires that the circulating nurse verifies that the anesthesiologist has given the initial antibiotic and that intraoperative re-dosing occurs when appropriate. Evidence-based education was provided to all "stakeholders." Real-time results were displayed prominently in the ORs. The results were formally shared with the OR teams at monthly meetings. Because this is a multidisciplinary project requiring teamwork, the OR nurses were assigned the task of reminding the anesthesiologists to administer the antibiotics. Because of this, weekly reviews of the policy and processes were done for the entire OR staff. Improving quality is the responsibility of the team taking care of the patient and not just one specialty. The nurses also noted the time on a "white board" on the OR wall and reminded the anesthesiologist when a re-dose was necessary. There are other stakeholders as well: the surgeon ordering the antibiotic, the pharmacist responsible for preparing the antibiotics and making sure they are available in the preoperative area, the preoperative nurses for spiking and priming the antibiotic tubing, and the anesthesiologists for administering the antibiotic.

Appropriate discontinuation of the prophylactic antibiotics was defined as none administered 24 h after the surgical end time. Pilot surgeons were presented with evidence regarding discontinuing prophylactic antibiotics within 24 h. Memos documenting this evidence were sent after these meetings. The computerized physician order entry system was modified to eliminate antibiotic administration after 24 h. The American Academy of Orthopaedic Surgeons recently endorsed the policy of discontinuing antibiotics within 24 h in an advisory statement; this information was shared with the surgeons (7).

Feedback was given to the surgeons when any case was identified that had inappropriate antibiotic selection or use of antibiotics for more than 24 h. Feedback was given to anesthesiologists whenever a case was identified in which the antibiotics were not given within 60 min before incision. Grand rounds presentations were made for the Departments of Anesthesiology and Surgery every 4 months to review the data and to reinforce the guidelines. Our monthly physician bulletin has contained prophylactic antibiotic information. The use, timing, and discontinuation of prophylactic antibiotics were reviewed on a quarterly basis at the surgery and anesthesia quality improvement meetings.

Surgical site infections were determined based on the National Nosocomial Infection Surveillance System (8). Surgical infections are determined in-house patients with positive culture or clinical report; readmission with positive culture or clinical report; or postdischarge questionnaire (sent to every surgeon with a list of all their cases from the previous month). They review and identify any infections (from incisional to deep wound). Although self-reported, the return rate has consistently been 97%. Cases are then reviewed by the infection control staff as either potentially preventable or nonpreventable. Information is shared with the Committee on Infections as well as the appropriate quality improvement teams. Each surgeon gets a monthly listing of his/her cases and they self-report infections by type: superficial, deep, or organ space.

RESULTS

In all patients, the baseline appropriate antibiotic selection was 82%, and is now 95%. The majority of inappropriate antibiotic selections resulted from a lack of awareness of the appropriate antibiotic.

Our baseline rate in all patients for administering the antibiotic within 60 min before incision was 11%. The preintervention administration-incision time was 79 (range, 32–380) min. After implementation of the strategies to address the timing of administration in cardiac and vascular patients, the first quarterly time improved to 30 (range, 0–110) min, and the number administered within the 60-min time period improved to 91%. In cardiac and vascular patients, the administration-incision time is currently 19 (range, 0–95) min, and the number within 60 min is 95%. In all other patients, the administration-incision time is currently 29 (range, 0–115) min, and the number given within 60 min is currently 97% (Figure 1).

View larger version (12K): [in this window] [in a new window]   Figure 1. The time from antibiotic administration to skin incision. The boxes represent the 25th–75th percentile, and the solid lines represent the median. The extended bars represent the 10th–90th percentiles.

Discontinuing antibiotic therapy within 24 h after surgery originally had been 10% in all patients. One year later, this rate was 92% in cardiac and vascular patients, and the rate is currently 90%. The most recent quarterly rate in all other patients is 70%.

Before the institution of the process, the rate of surgical-site infections was 3.8% in cardiac and vascular patients and 1.8% in all other patients. After institution of these processes, this rate is now (last quarter) 1.4% in all patient groups.

Before the initiation of this process, it was estimated that the charge accrued for a single wound infection at our hospital was $5969; it was also estimated that the average additional hospitalization days were 5.31 per surgical site infection. In 2003 and 2004, there were 177 and 122 respective documented infections. This decrease in 55 infections can be extrapolated to a savings of $328,295 and 292 hospitalization days.

DISCUSSION

Prophylactic antibiotics are administered to reduce the microbial burden so that host defenses are not overwhelmed. It has been estimated that over-use, under-use, and misuse of antibiotics occur in 20%–50% of operations (1). A national survey revealed that an antimicrobial dose was administered to 55.7% of patients within 60 minutes before incision (1). This same survey showed that antimicrobial drugs consistent with published guidelines were administered to 92.6% of the patients and that they were discontinued within 24 hours of surgery end time for only 40.7% of patients (1). We believed that surgical antibiotic administration was a ripe area for improvement at our institution.

The PDSA system is a useful institutional practice for initiating change (9). This system evaluates a problem and develops an institutional change. The results of this change are then evaluated on a continuing basis, and further changes are implemented as necessary. The hallmark of such a system was to focus on improvements in an incremental fashion (e.g., only cardiac and vascular surgery), with a varying focus of the intervention (the initial focus was timing of the administration). Different aspects of the intervention can be the subject of focus as the process is continuing (discontinuation of the antibiotic within 24 hours is the current area of focus). The use of rapid-cycle PDSA, along with effective communication and other quality improvement techniques can improve the performance of evidence-based practices known to decrease rates of surgical infection. Although passive communication tools (mailings, bulletins, articles) by themselves have not been shown to result in changes in practice, providing clinicians with the rationale, evidence, and information, supporting the desired changes can work effectively for realizing the desired goals. We had outlined our goal (to decrease surgical infections), provided clinicians with rationale (mailings, grand rounds), developed a process (with continuing adjustments), implemented our plan, and have monitored and shared data since our initial participation.

One of the methods that was successful for facilitating appropriate discontinuation of antibiotics was the policy statement of the American College of Orthopaedic Surgeons (7). Our orthopedic surgery program is continually compared with other programs by an outside consulting firm. Although the policy statement was not directly responsible for the improvement in discontinuation rates, it did become one of the criteria used for evaluating joint replacement programs (i.e., discontinuation of antibiotics within 24 hours). Once discontinuation of antibiotics became incorporated into the rating of our surgical program, our surgeons realized that their program’s rating is judged by their compliance with this discontinuation. The feedback from this evaluative process has probably been the main reason for improvement in the number of patients who have their prophylactic antibiotics discontinued within 24 hours.

Despite review with the involved parties and review of the literature (4–6,10), the selection of the appropriate antibiotic remains <100%. In any system, there is resistance to change. It is important to continue the processes that have led to improvement and to continue the feedback process on a timely basis. Part of the reason for the rate remaining <100% is the inclusion of an increased number of surgical services in the most recent evaluation period. Continued feedback and review of the guidelines will ideally improve this rate.

It has been shown that preincision prophylactic administration of antibiotics is more beneficial that postincision administration (11). Furthermore, it has been shown that the preincision timing is important in that a prolonged administration-incision time is not more effective than shorter intervals (11). The reason for the timing of administration within 60 minutes of incision comes from both research as well as expert opinion (10–12).

Prolonged antibiotic prophylaxis is associated with risks, such as an increased risk of Clostridium difficile infection, development of resistant organisms, increased risk of drug reactions, and increased costs (13–19). If these risks were countered by a decreased incidence of surgical wound infections, they would perhaps be justified. However, most studies have confirmed equivalent efficacy of a shorter course of antibiotics (13–19). Thus, although it is unlikely to decrease the incidence of perioperative surgical site infections, avoiding unnecessary prophylactic antibiotics should be considered an important goal.

The main objective of this process was to decrease the morbidity associated with postoperative infection in surgical patients. Surgical site infections account for more than 10% of all hospital-acquired infections. Surgical infections occur in more than 1 million cases per year in the United States (1). Surgical infections result in prolonged length of hospital stay and an average additional cost of approximately $3000. The mortality rate in these patients is approximately twice that of noninfected patients (2). It has been estimated that 40%–60% of these infections are preventable. Our process is associated with potential institutional savings of more than $300,000 annually, while improving patient care. The focus of our intervention has dealt primarily with prophylactic antibiotic administration. This is only one specific area for decreasing surgical infections. Antisepsis, surgical technique, patient temperature maintenance, glucose control, and using clippers and avoiding razors are some of the additional techniques that may also play a role in decreasing surgical site infections. The infection project continues at our hospital. The infection program will be expanded to include some of these other techniques aside from antibiotic administration and will be expanded to other patient populations. The reduction in surgical site infections at our institution can be attributed in part to the changes in the process of antibiotic administration.

We have described our process to decrease these infections. There has been a significant effort involved in achieving improved prophylactic antibiotic administration. During this time, the surgical-site infection rate has decreased 63% in cardiac and vascular patients and 22% in all other patients. Although a more consistent approach to administration of prophylactic antibiotics may not fully account for this decrease, we believe these changes have resulted in a decrease in infections. The system changes need administrative and clinician support to be effective and need multidisciplinary involvement for success.

Footnotes

Accepted for publication March 14, 2006.

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