Many hospitals do poorly in presurgical prophylaxis

Most hospitals are not complying with standard guidelines for antibiotic (ABX) prophylaxis before surgery. Barely more than half of patients in a recent study received antibiotics within one hour of the initial incision. Less than half of patients were taken off ABX prophylaxis within 24 hours following surgery. The result is an unknown number of surgical site infections that could have been prevented with more appropriate treatment.

"There have been efforts for years to get healthcare providers more attuned to preventing surgical site infections with proper antibiotic prophylaxis," said Cynthia LaCivita, Pharm.D., director of clinical standards and quality for ASHP. "People are doing an adequate job, but they must focus on the time of administration to get optimal effect."

Current surgical prophylaxis guidelines from ASHP and other organizations call for administration of narrow-spectrum antibiotics within 60 minutes of the first incision for most surgical patients.

Surgeons did a good job of ordering an appropriate antibiotic for 92.6% of surgical patients. But even with the right drug, only 55.7% of patients received ABX prophylaxis in the hour before surgery. And only 40.7% had ABX prophylaxis halted within 24 hours after surgery. The study appeared in February's Archives of Surgery.

"If you want antibiotics started within that vital one-hour window, it takes coordination among every department and every person who has a hand in scheduling and delivering patient care," Bratzler said. "Hospitals have to develop a system to ensure that antibiotics are delivered and stopped at the right time."

Hospitals also need systems to ensure that only the most appropriate antibiotics are used. While more than 92% of patients in the retrospective study received recommended agents, only 78.7% received regimens limited to recommended agents. That suggests a substantial overuse of antibiotics, a major contributor to antibiotic resistance, Bratzler noted. The continuation of prophylactic regimens for longer than 24 hours after surgery for nearly 60% of patients also contributes to the rise of resistant organisms.

Researchers collected the study data as a baseline for the Surgical Infection Prevention (SIP) Project, sponsored by the Centers for Medicare & Medicaid Services and the Centers for Disease Control & Prevention.

In 2002, Medicare Quality Improvement Organizations (QIOs) nationwide began using the baseline data in training programs designed to translate practice guidelines into treatment protocols. The results, Bratzler said, have been highly positive. In California, a group of 26 hospitals improved delivery of antibiotics within one hour of first incision from 73.8% to 84.3%. A group of 16 Colorado hospitals boosted compliance from 62% to 88%.

Individual hospitals reported even better results. Leesburg Regional Medical Center in Florida boosted its one-hour antibiotic administration rate from 19.3% to 92%. In New York, Glen Cove Hospital went from 43% in July 2003 to 100% in early 2004. Mercy Health Center in Oklahoma City tallied 400 major surgeries without a single surgical site infection. That was four times its success rate before a QIO training program on ABX prophylaxis.

"We knew we had to walk the science from the bench to the bedside," said Ronda Pasley-Shaw, R.N., Mercy's manager of epidemiology and occupational health. "We had to standardize orders and make the business case for using specific procedures and specific products. And we had to convince surgeons that we didn't want cookbook medicine, we wanted best practices."

One of the most important steps was taking R.Ph.s to the operating rooms and preop areas. Since pharmacy handles drug distribution, it was pharmacy's job to trim floor stocks back to a short list of approved agents.