Assertive R.Ph. action can improve infection control

The Medicare quality improvement organization (QIO) IPRO in Lake Success, N.Y., has contacted 22 hospitals in downstate New York to learn what the facilities have been doing to reduce their rate of surgical site infections. It found that assertive action by health-system pharmacists has enhanced patient safety by improving the timeliness of antibiotic prophylaxis.

"Many of these hospitals had approaches that could be used by any U.S. hospital," said Charles E. Stimler, M.D., the IPRO medical officer who is leading the QIO's New York Surgical Infection Prevention Collaborative project. According to the Centers for Medicare & Medicaid Services, surgical site infections occur in 2% to 5% of clean extra-abdominal surgeries and up to 20% of intra-abdominal surgeries across the country each year.

IPRO's information collection efforts focused on enhancing implementation of guidelines circulated this year by Medicare's National Surgical Infection Prevention Project. The SIP guidelines set three basic patient safety standards: professional guidelines should be followed in the choice and administration of antibiotic prophylaxis, antibiotics should be administered generally no more than an hour before surgery, and they should be discontinued not longer than 24 hours after surgery.

"We looked at the way antibiotics other than cefazolin were being administered in our operating rooms," said John Carson, R.Ph., M.S., a clinical pharmacist and antimicrobial management specialist at St. Peter's. Cefazolin accounts for about 75% of the presurgical administrations at St. Peter's, and it is administered by attending anesthesiologists. "We found there was no set way our anesthesiologists could determine whether other antibiotics had been given," he said.

This was particularly troublesome for pre-op antibiotics that had to be administered slowly. That could mean that missed doses resulted in no administration of prophylaxis antibiotic. "It was often not economically feasible to wait," said Carson. So working with a clinical nurse specialist, he developed a set of solutions, including a redundancy, that enhanced patient safety.

First all antibiotic administrations were noted on a patient chart. Second, whenever surgeons booked a surgical suite, they'd identify what antibiotics were being prescribed, especially noting which should be given before a patient was brought into the suite, for drugs that required prolonged infusion. Third, all prescribed antibiotic administrations were added to a pre-op checklist to be examined and checked off by an anesthesiologist before the first surgical cut. And fourth, as a redundancy, antibiotic administrations were marked off on a checklist in the surgery suite. "We created a baseline checklist at the start of the year and rechecked our results in March," said Carson. "There was quite an improvement in administration. In fact, virtually no doses were missed."

The experience at Victory is equally instructive, especially regarding the timely administration of prophylactic antibiotics and infusion guidelines. "We began examining our pre-op prophylaxis procedures in 1995 and found that only about 75% were within a two-hour timeframe, and that just wasn't good enough," said Richard Williams, Pharm.D., Victory's pharmacy director. "A big problem was that many surgeries go into the theater and wait more than two hours for any number of reasons."

Solutions were achieved as the result of a series of meetings between the hospital R.Ph.s and operating nurses. "We all had the same goal," said Williams, "for infusion to occur as close to the first cut as possible." The first step was the decision to begin antibiotic infusion when a patient came into a surgical suite instead of when called for surgery.