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TECHNOLOGY, COMPUTING, AND SIMULATION

The Effect of an Interactive Visual Reminder in an Anesthesia Information Management System on Timeliness of Prophylactic Antibiotic Administration

David B. Wax, MD^*, Yaakov Beilin, MD^*, Matthew Levin, BS, Neil Chadha, MD^*, Marina Krol, PhD^*, and David L. Reich, MD^*

From the Departments of *Anesthesiology, and Obstetrics, Gynecology, and Reproductive Sciences; and Mount Sinai School of Medicine, New York, New York.

Address correspondence and reprint requests to David Wax, MD, Department of Anesthesiology, Mount Sinai School of Medicine, 1 Gustave L. Levy Place, Box 1010, New York, NY 10029. Address e-mail to david.wax{at}mssm.edu.

	Abstract

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BACKGROUND: To reduce the incidence of surgical site infection, preoperative antibiotics should be administered within 60 min before surgical incision. The purpose of this study was to determine whether adding a visual interactive electronic reminder with a message related to antibiotic administration to our anesthesia information management system would increase compliance with prophylactic antibiotic guidelines.

METHODS: We retrospectively studied electronic anesthesia records of ambulatory and day-of-surgery admission surgical cases in which one of our usual prophylactic antibiotics was administered from June 2004 through December 2005, an interval that includes cases both before and after the February 2005 implementation of the new reminder. Compliance was defined as documented antibiotic administration within 60 min before the surgical procedure starting time. Noncompliant cases were divided into those in which dosing was too early or too late.

RESULTS: Compliance for 4987 cases before and 9478 cases after the reminder was implemented increased from 82.4% to 89.1% (P < 0.01). This increase was found both for attending anesthesiologists assisted by a resident or nurse anesthetist (82.9% before vs 89.1% after, P < 0.01) and for attending anesthesiologists working alone (80.1% before vs 89.3% after, P < 0.01). The improvement in compliance was associated with a decrease in the incidence of antibiotics administered too late (i.e., after surgical incision) (15.2% before vs 8.1% after, P < 0.01), but with no significant change in the incidence of antibiotics administered too early (i.e., more than 60 min before skin incision) (2.4% before vs 2.8% after, P = 0.07).

CONCLUSIONS: The implementation of a visual interactive electronic reminder regarding administration of preoperative antibiotics in an anesthesia information management system was associated with a sustained increase in compliance with surgical prophylactic antibiotic administration timing guidelines.

	Introduction

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It has been widely reported that patients receive only about half the preventive care that they require (1,2). An issue of emerging importance in perioperative preventive care is the timeliness of administration of antibiotics for prophylaxis against surgical site infection (SSI), a complication that increases length of stay, cost of care, and mortality (3). Guidelines issued by the Centers for Disease Control and other groups for prevention of SSI call for the administration of preoperative antibiotics within 60 min before surgical incision (4,5). However, suboptimal compliance with guidelines was demonstrated in a United States national multicenter review of data from 2001. In that study, dosing within the recommended 60 min prior to presurgical incision period occurred in 54% of cases (3).

One strategy for improving adherence to clinical guidelines is to use reminders at critical times during patient care. With the growth in use of electronic health records and computer-based physician order-entry, many electronic reminders have been implemented to improve adherence to "best practices" for various patient conditions. Studies of these systems indicate that such reminders significantly increase compliance with clinical guidelines, though the benefits may not be sustained over time (6,7).

We hypothesized that an interactive electronic visual reminder in an anesthesia information management system (AIMS) would increase compliance with the timeliness of prophylactic antibiotic administration.

	METHODS

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In our hospital, the decision of what (if any) prophylactic antibiotics to administer to ambulatory and day-of-surgery admission surgical patients is made preoperatively through a discussion between each patient’s anesthesia and surgery practitioners. The decision is influenced by our hospital’s published antibiotic prophylaxis guidelines regarding choice and timing of preoperative antibiotics. Those guidelines which had been disseminated to the staff before the study period and remained unchanged during the study period. Actual administration of the chosen antibiotic drugs and documentation thereof usually occurs in the operating room and is the responsibility of the anesthesia care team.

On February 9, 2005, an interactive visual reminder for prophylactic antibiotic administration had been activated in the departmental AIMS as part of a performance improvement initiative. After approval by our center’s IRB, we retrospectively reviewed all electronic anesthesia records from June 2004 through December 2005.

During the study period, the AIMS at the authors’ institution (CompuRecord, Philips Medical, Andover, MA) was used in nearly all anesthetizing locations. One feature of the AIMS is a sequential series of event icons that appear on the computer display to facilitate the documentation of timing of critical events, such as anesthetic induction and tracheal intubation (Table 1). For each event icon that is displayed, the clinician can either acknowledge the event to create a time-stamped entry in the record, or skip the event. Clinicians can also create custom AIMS configurations that may suppress the display of certain event icons for some or all procedure types.

The event icon with the wording "Prophylactic Antibiotics Given" was configured to appear between the "Position/Prep Start" and "Procedure/Surgery Start" event icons (Fig. 1). Acknowledgment of the event icon did not enter the actual name, dosage, or timing of the antibiotics in the electronic record, which had to be entered separately.

View larger version (34K): [in this window] [in a new window]   Figure 1. This is a screen capture of the anesthesia information management system with the prophylactic antibiotic administration icon displayed. The reminder icon is indicated by the arrow.

The case inclusion criterion for analysis was administration of one of our center’s commonly used prophylactic antibiotics with documentation of this in the AIMS (including drug and date/time of administration) by the anesthesia practitioner. (Antibiotic drugs included cefazolin, ampicillin, cefotetan, clindamycin, and cefuroxime.) Antibiotics with special procurement or administration requirements and those typically used only in combination with one of the aforementioned drugs were excluded. Inpatient cases were also excluded because of the increased incidence of complex antibiotic requirements that may include dosing on inpatient wards before arrival in the operating suite and because the timing of such doses are not captured in our AIMS.

The data that were extracted for each case included procedure date, timing of antibiotic administration, surgical procedure start time, practitioner identity and classification (i.e., certified registered nurse anesthetist (CRNA), anesthesia housestaff, attending anesthesiologist), and patient admission status (i.e., ambulatory or day-of-surgery admission).

The dataset was divided into two groups representing the periods before (June through December 2004, PRE) and after (March through December 2005, POST) the event icon was implemented. The PRE period was chosen to determine our baseline compliance. A longer POST time period was used compared with the PRE period to determine whether any sustained change occurred after implementation. Cases done during the month immediately before and the month immediately after the new event icon was implemented were excluded to eliminate the short-term effect of any departmental discussions and announcements regarding the configuration changes that may have led to increased attention to the issue of antibiotic timing.

Compliance or noncompliance with the timeliness of prophylactic antibiotic administration was defined as a binary variable. Compliant cases included documentation of the dosing of an antibiotic within 60 min before the procedure/surgery start time. Noncompliant cases were those in which the antibiotics had been given before or after the target interval.

The postimplementation group was further subdivided into those cases in which the event icon was acknowledged [POST POS] or not acknowledged (i.e., skipped or suppressed) [POST NEG].

Statistical analysis was performed with SPSS (SPSS, Chicago, IL). Aggregate data were analyzed using ² to find differences in compliance for our department as a whole between the PRE and POST periods. Compliance of each individual practitioner between the PRE and POST periods was compared using a Wilcoxon’s signed rank test. A P < 0.05 was considered statistically significant.

	RESULTS

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A total of 14,465 cases met the study inclusion criteria, 4987 before the event icon implementation and 9478 after the implementation. Compliance for the entire data set increased from 82.4% to 89.1% (P < 0.01) before and after the event icon implementation, respectively. In the period after event icon implementation, monthly compliance ranged from 84.1% to 91.1%, with no identifiable pattern of improvement or deterioration during that period (Fig. 2). There was no monthly interval after event icon implementation when the compliance rate decreased to the rate preceding implementation. Table 2 shows that the cases in which the event icon was acknowledged (POST POS) had a higher rate of compliance than cases in which it was not acknowledged (POST NEG).

View larger version (41K): [in this window] [in a new window]   Figure 2. The graph demonstrates the average compliance of all anesthesiologists with prophylactic antibiotic administration timing guidelines. The arrow indicates the month of implementation of the electronic reminder in the electronic anesthesia record. The months of January and February, 2005 are included in this graph, but were excluded from the data analysis.

When the analysis was limited to those cases in which an attending anesthesiologist was assisted by house staff or a CRNA, the increase in compliance remained significant (82.9% of 4131 cases vs 89.1% of 8022 cases, before and after event icon implementation, respectively, P < 0.01). Similarly, when the analysis was limited to only cases in which an attending anesthesiologist worked without assistance, the increase in compliance was similar (80.1% of 856 cases vs 89.3% of 1456 cases, before and after event icon implementation, P < 0.01).

In a comparison of individual compliance rates, we found 35 attending anesthesiologists who performed at least five PRE and POST POS cases unassisted by a resident or CRNA. The median compliance rates were 83% and 100% before and after implementation, respectively (P < 0.01). Compliance increased for 80% of practitioners, declined for 9%, and remained unchanged for 11% after the event icon was added and displayed.

The frequency of noncompliance due to late antibiotic administration decreased from 15.2% to 8.1% before and after event icon implementation, respectively (P < 0.01). In those late-administration cases, we did not detect a change in the mean difference between the surgery start time and antibiotic administration before and after event icon implementation (19 min vs 20 min, respectively, P = 0.85). There was a small upward trend that was not statistically significant in the frequency of cases that were noncompliant due to early antibiotic administration that was not statistically significant (2.4% vs 2.8%, P = 0.07).

	DISCUSSION

Top Abstract Introduction METHODS RESULTS DISCUSSION REFERENCES

 
Our analysis demonstrates an increase in compliance with antibiotic administration guidelines associated with the implementation of an interactive visual reminder in an AIMS. This new reminder was configured to appear just before a preexisting reminder designed to document the starting time of the surgical procedure. The large majority of the improvement was related to a reduction in the percentage of cases in which the antibiotics were administered after skin incision. Further analysis demonstrated that the majority of practitioners’ clinical practice improved, and that the presence of an assistant (i.e., resident or CRNA) did not affect the efficacy of the reminder. Because our AIMS had been implemented several years in advance of the study, the configuration change had no associated costs related to configuration, training, or other support.

We further analyzed the effect of the event icon in cases in which antibiotics were administered too early. The reminder could have had a paradoxical negative impact on compliance by prompting clinicians to administer antibiotics too early relative to surgical incision time (i.e., as soon as the reminder was displayed). We hoped to mitigate this potential problem by configuring the antibiotic reminder to appear after the "Patient Prep Start" event but before the "Procedure Start" event. We did not see a significant increase in premature antibiotic administration, suggesting that the current configuration of the event reminder is probably optimally timed in the perioperative process. The persistence of some premature administration seems to relate to longer than expected patient preparation times.

We also analyzed the effect of the event icon in cases in which antibiotics were administered too late. We considered that the reminder might at least reduce the delay after skin incision before antibiotics were ultimately given (albeit late), but that effect was not seen. We have no way of determining to what extent late antibiotic administration was related to surgeons requesting delayed administration (e.g., to facilitate surgical wound cultures) but the frequency of such requests is not thought to have changed between the study periods. Therefore, we have added additional documentation to our AIMS to encourage documentation of planned delays in antibiotic administration.

It was problematic analyzing cases in which the event reminder was not acknowledged (POST NEG). In those cases, it is possible that the event key was not displayed because of a custom (clinician-specific) AIMS configuration that suppressed it, or that it was displayed but skipped over by the practitioners involved. A survey of the attendings with high rates of unacknowledged event reminders indicated that custom configurations (that often predated the event reminder inclusion in the standard departmental AIMS case templates) seemed to be the most important factor. The other major reason is that some practitioners felt it was redundant to document both the event reminder and administration of the drug itself. Our 6.7% increase in compliance for the entire department includes these POST NEG cases. If we consider only POST POS cases in which the reminder was acknowledged and therefore definitely displayed, the absolute compliance rate improved by 11%. This is further evidence of the efficacy of the reminder when used as intended.

We excluded inpatients (who frequently receive complex antibiotic regimens at our center), and cases in which unusual antibiotics were administered because their special procurement or administration requirements might affect timing of doses. We limited the study in this fashion to assure a surgical patient sample that was relatively consistent with respect to use of standard prophylactic antibiotic dosing that would be administered by an anesthesiologist. Cases in which there was no antibiotic administration documented were also excluded, because this was only an analysis of dose timing in accordance with guidelines. Analysis of appropriateness of antibiotic use or nonuse was not a goal of our study because our AIMS does not store sufficient information about each patient and procedure to make a determination of what antibiotics (if any) were indicated for all cases.

As a retrospective study, the existence of other confounding factors cannot be excluded. For example, continuing education, changing practice patterns, changing patient or procedure mix, and performance review and feedback may have influenced practitioner behavior.

Surgical antibiotic prophylaxis is a standard of care. The Surgical Care Improvement Project mandate to publicly report surgical antibiotic selection/timeliness and pay-for-performance initiatives by payers are compelling reasons for anesthesiologists to improve antibiotic administration compliance (8). Accrediting organizations and competitive forces in the marketplace are further factors that will motivate hospitals to work with anesthesiologists to have the highest possible rates of compliance. We did not compare actual SSI rates between the study periods because only administrative data are readily available, and such data are unreliable (9). We believe that maximizing antibiotic compliance rates has now become an important intrinsic goal for anesthesia providers, because the Surgical Care Improvement Project directly targets processes rather than outcomes in its performance measures.

There are no definitive data regarding the medicolegal impact of reminders that are programmed into electronic medical recordkeeping systems. Considering that establishing a legal claim of physician malpractice requires that violation of a standard of care be tied (by expert opinion) to an injury, electronic reminders would be expected to reduce such exposure overall by decreasing the incidence of deviations from standards of care. Our findings provide further evidence to support the survey results (10) that suggest electronic records have beneficial effects for practitioners in malpractice actions, although there is a report of a case in which inappropriate attestation of attending presence in an AIMS was problematic (11).

Our 89.1% overall compliance rate is well above the national published average of 75% from the same period in 2005 (12). To further improve compliance, we have begun to send antibiotic compliance "report cards" to practitioners with poor performance. We are also working to ensure that the new reminder is included in practitioner-customized configurations to help realize the greater potential for improvement seen in the POST POS group. To prevent premature dosing, we have encouraged staff to delay antibiotic administration until anesthesia preparation (e.g., line placement) has been completed. We have also added a special field to our AIMS case information to allow practitioners to identify cases in which there was an intentional deviation from guidelines, because the inability to identify and exclude such cases may contribute to decreasing calculated compliance rates. Some of our faculty members have advocated adding surgical antibiotic prophylaxis to the surgical "time out(s)" before skin incision.

Other investigators have found that the positive effects of electronic reminders tend to diminish over time (7). In contrast, we observed that the increase in compliance with antibiotic administration guidelines was sustained during a 10-mo period. Our study also differs in that it involved anesthesia practitioners and was specific to antibiotic administration. O’Reilly et al. reported an increase from 70% to 92% compliance with antibiotic timing guidelines during a 1-yr period as a result of several interventions to improve compliance (13). One of the interventions was a reminder item in a case-based "script" in their AIMS, and others were educational programs and electronic mail performance reporting. Our study investigated the changes in compliance before and after the implementation of an electronic AIMS reminder alone.

In conclusion, we found that the implementation of an interactive electronic reminder regarding administration of surgical infection prophylaxis in an AIMS was associated with an increase in compliance with prophylactic antibiotic administration guidelines. This increase was sustained during the study period.

	Footnotes

 
Accepted for publication February 26, 2007.

	REFERENCES

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