MikeLigalig.com

Hospital Improves Antibiotic Protocol by "Hardwiring" Docs
At Temple, Compliance Is Mandatory; System Can Work at Other Hospitals, Say Researchers

Two years ago, patients treated in the surgical wards at Temple University Hospital had about a 50% to 70% chance of receiving the correct antibiotic, having it administered within an hour of surgery and being taken off the drug in a timely fashion.

Not great odds, but nothing out of the ordinary. About average for a large urban hospital.

Today, Temple University Hospital boasts one of the most effective antibiotic administration programs in the country—more than 90% of patients receive an appropriate antibiotic within one hour of surgery, and more than 85% are taken off antibiotics in a timely fashion.

“It involved a lot of work, but we managed to substantially improve physician behavior regarding antibiotic prophylaxis,” said Glenn Whitman, MD, a former professor of surgery at Temple University School of Medicine, Philadelphia, at the 2007 Clinical Congress at the American College of Surgeons.

Temple’s feat is the end result of a two-year effort by the hospital’s surgical leadership to bring the program in line with the best practices laid out by the Joint Commission (formerly JCAHO) and the Surgical Care Improvement Project. Beginning in March 2005, they studied the hospital’s statistics on the administration of prophylactic antibiotics and designed, then redesigned, policies to make the appropriate procedures stick. The surgical department heads tried multiple approaches, most with lackluster results. In the end, one tactic brought results—“hardwiring” physicians—in other words, giving surgeons a well-laid-out protocol that mandated every step in the administration of antibiotics.

Other centers that are struggling to improve the administration of prophylactic antibiotics can learn from Temple’s experience, said Steven C. Stain, MD, Neil Lempert Professor and Chair of Surgery, Albany Medical College, Albany, N.Y.

“The data speaks for itself. Hardwiring works,” he said. “This is a very good way to encourage noncompliant physicians to adapt things that lead to better-quality care.”

In 2005, Temple, like many U.S. hospitals, struggled to meet the guidelines for the use of prophylactic antibiotics that the Joint Commission and the National Surgical Infection Prevention Project had recommended. An internal hospital analysis revealed that nearly 25% of surgical patients treated at the hospital in March 2005 received prophylactic antibiotics that were not specialty-specific. Almost half of the patients (45%) did not receive prophylaxis within an hour of surgery, and 40% were not taken off the antibiotics within an appropriate time frame.

Dr. Whitman, who has since moved to Jefferson Medical College, Philadelphia, and other surgical department chairs started to study the hospital’s statistics on antibiotic use on a month-by-month basis. In the spring of 2005, they handed staff an advisory from the National Surgical Infection Prevention Project as a guideline for choosing the right antibiotic. However, they saw few improvements during the following months. So the surgical leadership ramped up the program, and on Jan. 1, 2006, they drew up a new surgical scheduling order, required for all cases, that listed the specialty-specific antibiotic directly on the physician order form. Surgeons had to mark the form even if they did not want any antibiotic given.

The result? By June 2007, 91% of patients were getting an appropriate antibiotic, up 15% from a year and a half earlier (P<0.001).

The department chairs had more trouble coming up with a strategy that would ensure that patients received their antibiotics within an hour before incision, or two hours before if they were receiving vancomycin or a fluoroquinolone. First, the chairs mandated that physician antibiotic orders be available to preadmission testing. More patients ended up receiving timely antibiotics, but the results were inconsistent. So, the surgical heads called for all patients to receive their antibiotic in the preparation area before they were taken to the operating room. Again, the results were inconsistent. Finally, the surgical heads enlisted help from the head of the Department of Anesthesia, who agreed that anesthesia would assume responsibility for administering prophylactic antibiotics in the operating room suite itself during the universal time-out. By June 2007, 95% of surgical patients received prophylactic antibiotics within an appropriate time frame, up 40% from March 2005.

The surgical department also turned to electronic protocols to get patients off antibiotics within an appropriate time frame. They initially tried an educational campaign directed at physicians and residents, but that brought about few changes between spring 2005 and fall 2006. In September 2006, the hospital changed the electronic medical record to include a separate pathway for ordering prophylactic antibiotics. When residents or attending surgeons chose an antibiotic from the list, the order to give the antibiotic was automatically created, with the timing of discontinuation predetermined in the order. Compliance improved from 60% to 86% (P<0.001).

Doctors are more likely to comply with changes when they are forced to do so, said Dr. Whitman. The surgeons were often “emotional” about adapting to standardized procedures but became more agreeable when they recognized that the new policies improved the quality of care.

“The more rigorously we designed processes to eliminate individual physician variability, the more successful we’ve been in improving and standardizing the care we are giving,” said Dr. Whitman.

Temple’s program could be replicated at hospitals across the country, including smaller rural centers, said Dr. Stain. As hospitals adopt more protocols for procedures, measures for the administration of prophylactic antibiotics can be easily included, he said. Surgical centers have to take time to develop antibiotic protocols that can be implemented for all procedures, not just high-volume ones that are more likely to have specific protocols.

“This is absolutely the way things are going. As we shift more and more to electronic medical records, we’ll have more opportunities to protocolize things,” said Dr. Stain.

Appropriately administered antibiotics are critical to prevent surgical site infections, which extend hospital length of stay by an average of 11 days and are associated with a twofold to threefold increase in postoperative mortality (Infect Control Hosp Epidemiol 1999;20: 725-730; J Am Coll Surg 2004; 199:531-537).

Linkback: https://tubagbohol.mikeligalig.com/index.php?topic=7595.0