Appropriate Operating Room Antibiotic Re-Dosing for General Surgery Patients

Abstract

Problem & Purpose: Antibiotic prophylaxis is a necessary measure aimed at decreasing the number of perioperative infections. Surgical antibiotic prophylaxis is defined as the use of antibiotics to prevent infections at the surgical site (Khan, 2018). Such infections result in roughly $3.5 to $8 billion dollars in yearly costs, in addition to longer hospital stays for patients (Heuer, Kossick, Riley and Hewer, 2017). For patients, who are in long surgical procedures, it is recommended that they receive appropriate re-dosing of antibiotics throughout the remainder of the case. The most common antibiotic used for surgical prophylaxis is Cefazolin. Current Surgical Care Improvement Guidelines (SCIP), recommend re-dosing of Cefazolin every four hours while in surgery or if blood loss is greater than 1500mL (Heuer, Kossick, Riley and Hewer, 2017). Methods: A retrospective quality improvement project was conducted at a large academic teaching institution in Baltimore, Maryland. Data was obtained from a three-month period of time and focused on inpatient general surgery patients that underwent surgical procedures longer than 4 hours in length. Descriptive statistics were used to evaluate the data gathered. Interviews were conducted with staff Certified Registered Nurse Anesthetists and Pharmacists to obtain qualitative data about their perception of barriers towards re-dosing of antibiotics. Interviews also focused on strategies for improvement of re-dosing at the appropriate times. Results: From August to November 2019 there were a total of 243 general surgery cases. Of those cases, 25% (n=61) received antibiotics that did not require re-dosing. A total of 74.5% (n=182) of patients received Cefazolin for antibiotic prophylaxis. Of those 182 patients, 4.3% (n=8) did not receive proper antibiotic re-dosing during the procedure. Also, 2 of those 8 patients had surgical procedures that ended a few minutes past what is considered the “4-hour mark”. SCIP guidelines state that re-dosing of intra-operative Cefazolin should occur every 4 hours (Heuer, Kossick, Riley and Hewer, 2017). Interviews with staff members showed that further prompts within the documentation system, continued chart audits, peer comparison and ongoing education would be beneficial to increasing compliance with antibiotic re-dosing. Conclusion: Continued education, changes to the documentation system, peer comparison and continued staff education all have the potential to increase compliance with re-dosing of intraoperative antibiotics. Implementation of these strategies and follow-up data collection are the next steps in this initiative. Data collection after implementation of these strategies should focus on the number of patients that received appropriate prophylaxis dosing and the measures that were in place to ensure compliance. A comparison with the data collected for this project would be beneficial in measuring the effectiveness of the proposed strategies.