Working Together -Working Together -Appropriate Antibiotic Appropriate Antibiotic

AdministrationAdministration

The Health Network ofTHE CHESTER COUNTY HOSPITAL

About Us……..About Us……..• Acute Care Hospital-221 BedsAcute Care Hospital-221 Beds• Open Heart Surgery and Interventional Open Heart Surgery and Interventional

Cardiology with Electrophysiology Cardiology with Electrophysiology ServicesServices

• Heart Surgery program affiliated with Heart Surgery program affiliated with Cleveland ClinicCleveland Clinic

• Level III NICU and Pediatric Unit with Level III NICU and Pediatric Unit with Children’s Hospital of Philadelphia Children’s Hospital of Philadelphia Neonatologists and Pediatricians on site Neonatologists and Pediatricians on site 24/724/7

• Oncology Program affiliated with Oncology Program affiliated with University of Pennsylvania Cancer CenterUniversity of Pennsylvania Cancer Center

• Beta Site for Siemens EMR and CPOEBeta Site for Siemens EMR and CPOE

Surgical Antibiotic Surgical Antibiotic BeginningBeginning

• In September 2002, QIP performed In September 2002, QIP performed baseline data abstraction at PA baseline data abstraction at PA hospitals:hospitals:

• Our Hospital sample:Our Hospital sample:– N=18 casesN=18 cases

• Small sample size, but a Small sample size, but a beginning………beginning………

QIP Baseline ReportQIP Baseline Report

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A b x w i t h i n o n e h o u r A p p r o p r i a t e A b x D / C ' d w i t h i n 2 4 h r s

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Continuing the JourneyContinuing the Journey• Joined QIP Surgical Infection Prevention Joined QIP Surgical Infection Prevention

Collaborative in June 2003 Collaborative in June 2003 • Advised to trial process with small patient Advised to trial process with small patient

population to begin improvement processespopulation to begin improvement processes• Focused on antibiotic usage :Focused on antibiotic usage :

– TimingTiming– AppropriatenessAppropriateness– DiscontinuationDiscontinuation

• Goal was to achieve 100% compliance with Goal was to achieve 100% compliance with antibiotic usageantibiotic usage

Surgical Infection Surgical Infection Prevention TeamPrevention Team

• Orthopedic SurgeonOrthopedic Surgeon• General SurgeonGeneral Surgeon• Cardiac SurgeonCardiac Surgeon• MicrobiologistMicrobiologist• Infection Control PractitionerInfection Control Practitioner• Nursing Director of ORNursing Director of OR• Quality Staff (2)Quality Staff (2)• OR Staff NurseOR Staff Nurse• PharmacistPharmacist

First StepFirst Step

• Presented information and Presented information and recommendations to recommendations to department of department of surgery surgery – Majority feared delay in flow of patients Majority feared delay in flow of patients

from pre-op area to ORfrom pre-op area to OR– Concerned antibiotic levels would be Concerned antibiotic levels would be

inadequate at time of incisioninadequate at time of incision– Wanted antibiotic administered in Wanted antibiotic administered in

ambulatory care to observe for adverse ambulatory care to observe for adverse reactionsreactions

– For inpatients, wanted antibiotic given 45 For inpatients, wanted antibiotic given 45 minutes pre-op and prior to transportminutes pre-op and prior to transport

Second StepSecond Step

• Met with Met with department of anesthesiadepartment of anesthesia to gain their support for to gain their support for administering the antibioticadministering the antibiotic

• Major reluctance at first, but bought Major reluctance at first, but bought in soon after in soon after

• Holding nurse assigned to coordinate Holding nurse assigned to coordinate flow of patientsflow of patients

• Dept of Surgery assigned urologist to Dept of Surgery assigned urologist to be the liaison to our teambe the liaison to our team

Small StepsSmall Steps

• We selected antibiotic usage for We selected antibiotic usage for Hip, Hip, KneeKnee and and Bowel ResectionBowel Resection patients patients

• Specific Indicators:Specific Indicators:– Prophylactic Antibiotic Within 1 Hour Prophylactic Antibiotic Within 1 Hour

Prior To IncisionPrior To Incision– Appropriate Antibiotic Selection for Appropriate Antibiotic Selection for

Surgical PatientsSurgical Patients– Discontinuation of Antibiotics Within 24 Discontinuation of Antibiotics Within 24

Hours After Surgery End TimeHours After Surgery End Time

Surgeon Buy-InSurgeon Buy-In

• General surgeons and orthopedic General surgeons and orthopedic surgeonssurgeons agreed to the trial agreed to the trial

• Two homogeneous groupsTwo homogeneous groups• Generally focused on good patient Generally focused on good patient

outcomesoutcomes• Known to adopt changes more easily Known to adopt changes more easily

than somethan some

Being Well-PreparedBeing Well-Prepared

• Prior to beginning of trial:Prior to beginning of trial:– Developed form to place in front of each Developed form to place in front of each

chart prior to sending patient to ORchart prior to sending patient to OR• Pre-op antibiotic reminder formPre-op antibiotic reminder form• In large letters, reminded anesthesia to document In large letters, reminded anesthesia to document

time antibiotic given on their anesthesia recordtime antibiotic given on their anesthesia record

• Placed laminated signs about timing, Placed laminated signs about timing, appropriateness, and discontinuation of appropriateness, and discontinuation of antibiotics every place we could find a antibiotics every place we could find a bare spot!bare spot!– Educate, educate, educate - all stakeholdersEducate, educate, educate - all stakeholders

Walking in Their ShoesWalking in Their Shoes

• Spent a day in the OR observing and Spent a day in the OR observing and documenting antibiotic documenting antibiotic administration processesadministration processes

• Found wide variation Found wide variation • Validated that standardization was Validated that standardization was

important to good care and important to good care and outcomesoutcomes

Trial Begun-Glitches Trial Begun-Glitches HappenHappen

• August 2003August 2003• Hips, Knees and Bowel Resection Hips, Knees and Bowel Resection

patientspatients• Glitches HappenGlitches Happen

– Documentation issues with anesthesia-Documentation issues with anesthesia-old form-old habitsold form-old habits

– Some inpatients administered antibiotic Some inpatients administered antibiotic prior to transport (as before)prior to transport (as before)

– Re-educatedRe-educated

P r e - o p S u r g i c a l A n t i b i o t i c s G i v e n W i t h i n O n e H o u r P r i o r t o I n c i s i o nH i p s , K n e e R e p l a c e m e n t a n d B o w e l R e s e c t i o n P a t i e n t s

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Spread Just HappenedSpread Just Happened

• Slowly but surely, anesthesia adopted Slowly but surely, anesthesia adopted process of antibiotic administration for process of antibiotic administration for all surgeriesall surgeries

• Did not discuss with all surgeons prior Did not discuss with all surgeons prior to this change-it just happened!to this change-it just happened!

• No disgruntled surgeons showed up at No disgruntled surgeons showed up at my door my door

• In fact, were okay with change-they In fact, were okay with change-they saw no adverse effect from changessaw no adverse effect from changes

Current StatusCurrent Status

• Process for timing, appropriateness Process for timing, appropriateness and discontinuation being and discontinuation being maintainedmaintained

• Certain surgical specialties are late Certain surgical specialties are late adoptersadopters

• SIP data being submitted for Public SIP data being submitted for Public Reporting and JCAHO Reporting and JCAHO

S u r g ic a l I n f e c t io n P r e v e n t io n M e a s u r e s

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A n t i b i o t i c U s a g e t o P r e v e n t S u r g i c a l S i t e I n f e c t i o n s

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Maintaining the GainMaintaining the Gain

• In top 10% Nationally for In top 10% Nationally for administering antibiotic within one administering antibiotic within one hour prior to incisionhour prior to incision

• Better than PA rate for Better than PA rate for discontinuation of antibioticdiscontinuation of antibiotic

• There is not comparative data for There is not comparative data for recommended antibiotic measurerecommended antibiotic measure

What didn’t work?What didn’t work?• Trying to take on too much for Trying to take on too much for

beginning a large process changebeginning a large process change– Physician approachPhysician approach– Patient populationsPatient populations

• Assuming that one strong education Assuming that one strong education effort is all that is neededeffort is all that is needed

• When antibiotic is given in holding When antibiotic is given in holding area before patient is wheeled into area before patient is wheeled into OR, abx timing is can be delayedOR, abx timing is can be delayed– Solution: Roll the clamp when you roll Solution: Roll the clamp when you roll

the wheels!the wheels!

What has workedWhat has worked• Using small population of patients to Using small population of patients to

beginbegin• Written form for antibiotic reminderWritten form for antibiotic reminder• Collaborating with other hospitalsCollaborating with other hospitals• Engaging anesthesia and OR staffEngaging anesthesia and OR staff• During OR pause, asking about antibioticDuring OR pause, asking about antibiotic• Adding documentation about antibiotic Adding documentation about antibiotic

on OR nursing formon OR nursing form• Putting the antibiotic on pre-op and post-Putting the antibiotic on pre-op and post-

op surgical order sets (so it is op surgical order sets (so it is discontinued within 24 hrs.)discontinued within 24 hrs.)

What else has worked?What else has worked?• Drilling down any charts that fall out for Drilling down any charts that fall out for

physician and specialtyphysician and specialty• Giving feedback to the physicians Giving feedback to the physicians

individually and at medical section and individually and at medical section and committee meetings, including governing committee meetings, including governing board meetingsboard meetings

• Forming a Surgical Infection Prevention Forming a Surgical Infection Prevention taskforce that meets monthly to review taskforce that meets monthly to review data and work on insulin protocol and data and work on insulin protocol and hypothermiahypothermia

• This taskforce presents progress at This taskforce presents progress at Patient Safey and quality meetings and Patient Safey and quality meetings and board committee on a quarterly basisboard committee on a quarterly basis

Problems we still face…Problems we still face…

• Physicians are not documenting reason Physicians are not documenting reason for continuing antibiotic-prophylaxis vs for continuing antibiotic-prophylaxis vs treatmenttreatment

• Unasyn was given for bowel resections, Unasyn was given for bowel resections, but not approved until July 1, 06 but not approved until July 1, 06 dischargesdischarges

• Certain surgical specialties are locked Certain surgical specialties are locked into old theoriesinto old theories

• Final data broken down into Final data broken down into specialties…........specialties…........

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