NM-283
A clinical informatics approach to improving redosing of surgical antimicrobial prophylaxis during pediatric surgery
Colletti A, Wang E, Caruso T
Stanford University, Lucile Packard Children's Hospital, Stanford, CA, USA
Timely redosing of antibiotics during pediatric surgery is important for prevention of surgical site infections (SSIs). Tissue delivery relies on maintaining a therapeutic plasma level of a drug by redosing at antibiotic-specified intervals and clearance. However, redosing guidelines are frequently revised by expert societies such as the Infectious Disease Society of America (IDSA), leading to national challenges to reliably adjusting practice habits. The aim of this project was to standardize intraoperative antibiotic redosing guidelines by leveraging preexisting standard work of surgeons, pharmacists, and anesthesiologists and utilizing the electronic medical record.
This project was initiated by an interdisciplinary quality improvement team at a 311 bed, freestanding academic pediatric hospital. By utilizing lean methodology, including an A3 project plan, countermeasures were developed to improve redosing compliance. First, we shifted the initial preoperative antibiotic order from verbal (surgeon to anesthesiologist) to electronic (surgeon electronic order entry [EOE]). The EOE provided nationally recommended antibiotic guidelines, increasing the likelihood of appropriate dose and selection of the preoperative antibiotic. The preoperative antibiotic order was filled by the pharmacist instead of the anesthesiologist, and then delivered to the OR. Subsequent intraoperative redoses were prepared and administered by the anesthesiologist. An electronic reminder was incorporated into the electronic anesthesia record to continuously display the time of the next antibiotic redose. An additional electronic best practice alert was incorporated into the anesthesia record which provided a pop-up display 5 minutes prior to the time of redose. Antibiotic redose guideline badge cards were distributed to anesthesia providers. We reviewed intraoperative redosing of antibiotics to determine efficacy of these interventions.
Of 17,736 surgeries at our institution between 5/2014 and 10/2017, 2,685 (15%) required antibiotic redosing and were included in this analysis. As represented by the center line (CL) on a statistical process control (SPC) chart, the baseline mean redose compliance was 18%. Shortly after the EOE and electronic redose reminders in 10/2014, a new CL was established at 57%. A second break occurred in 9/2015, which corresponds to badge card distribution, and compliance has remained near the CL of 88% since.
Timely prophylactic antibiotic dosing is a focus in patient safety efforts to reduce SSIs. However, competing tasks often demand a pediatric anesthesiologist’s attention during a procedure, and subsequent antibiotic doses may be administered at the wrong dose, wrong time, or not at all, as evidenced by our baseline redose compliance of 18%. Although other published studies have demonstrated the efficacy of electronic based redosing reminders, the addition of the primary preoperative dose being fulfilled by the pharmacist leads to subsequent increases in the accuracy of the redose.
This quality improvement initiative leveraged clinical informatics to effectively disseminate evolving antibiotic guidelines across surgical specialties as demonstrated by a sustained redosing compliance near 90%.
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