• Appropriate Operating Room Antibiotic Re-Dosing for General Surgery Patients

      Lock, Kelly M.; Piscotty, Ronald (2020-05)
      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.
    • A Clinical Practice Guideline for Staphylococcus aureus Decolonization in Select Surgical Outpatients

      Celotto, Abigale A. (2017)
      Surgical site infections (SSI) are among the most prevalent types of hospital-acquired infections, causing substantial negative consequences for patients and health care systems, including increased morbidity and mortality rates, and higher costs to hospitals and insurers. Preoperative nasal colonization with Staphylococcus aureus (S. aureus) is an independent risk factor for the development of an SSI. Decolonization bundles that include combined use of nasal S. aureus colonization screening, targeted nasal decolonization, and preoperative Chlorhexidine gluconate (CHG) bathing are an effective means of SSI prevention. The purpose of this DNP scholarly project was to develop and evaluate an institutional clinical practice guideline (CPG) for the decolonization of S. aureus in adult, non-emergent cardiac surgery and total hip and/or knee arthroplasties. This manuscript focuses on the CHG recommendations within the larger decolonization bundle. The setting for this project was an ambulatory, Patient Readiness and Evaluation Center within a tertiary, mid-Atlantic medical center. It was anticipated that the guideline would be evaluated and graded as high quality and be considered reasonable and practical for implementation. Guided by Steven’s Stevens Star Model of Knowledge Transformation, the CPG was developed and evaluated in three phases. Prior to Phase One, a thorough evidence review and first draft of the CPG were completed. Phase One involved introductory meetings with stakeholders while Phases Two and Three were evaluation and revision phases. Two samples& Evaluation (AGREE II) Tool. The second sample consisted of eight end-users who assessed the CPG for applicability and sustainability utilizing the Practitioner Feedback Questionnaire. All six domains within the AGREE II tool scored greater than the targeted 80% agreement. The highest scoring domain was Editorial Independence with 94% agreement, while the lowest scoring domain was Applicability scoring 82% agreement. The final item, Overall Assessment of the Guideline, scored 90% agreement all SMEs stating they would recommend use of the guideline. Components that scored close to 80% were revised before Phase Three commenced. Of the four factors within the Practitioner Feedback Questionnaire, quality scored the highest with 93.75% favorable responses, while applicability of recommendations scored the lowest with 35.5% positive responses. Overall the CPG was found to be of high quality and practical for implementation with all SMEs and end-users stating they would use the CPG if it were implemented at their facility. The overarching goals of the CPG to standardize practice and minimize patient morbidity aligned with the institutional missions to deliver superior health care and discover ways to improve health outcomes. If the CPG were implemented as standard institutional practice, it is anticipated that the number of SSIs, specifically S. aureus infections, would decrease, reducing the targeted medical center’s healthcare costs and improving patient outcomes.
    • Clinical Practice Guideline for the Decolonization of Staphylococcus aureus in Surgical Patients

      Moledina, Ashifa (2016)
      Background: A surgical site infection (SSI) is a post-surgical complication closely linked with increased morbidity and mortality. SSIs are preventable with appropriate care and insurers no longer reimburse for their cost. Chlorhexidine Gluconate (CHG) is an antiseptic agent that is used preoperatively, often within a decolonization bundle, as a safe and cost effective means of decreasing the risk of SSIs. Objective: The purpose of this doctorate of nursing practice (DNP) project is to develop an evidence based, standardized, pre-operative CHG bathing regimen for surgical patients to be utilized in a decolonization clinical practice guideline (CPG) for elective cardiac and hip and knee arthroplasty patients at the targeted pre-op center. Design: Three DNP students developed an evidence based CPG which was evaluated for guideline quality, methodological rigor, and transparency by a group of subject matter experts (SME) (n=7) using the AGREE II tool platform. After incorporating SME feedback, the revised CPG was distributed to a group of end users (n=8) for evaluation of guideline’s quality, applicability and acceptability utilizing the Practitioner Feedback Questionnaire (PFQ). Results: All domains of the AGREE II tool were scored above the 80% benchmark with Editorial Independence scoring the highest at 94% and Applicability scoring the lowest at 82%. The PFQ Applicability scores were also low with only 35.4% favorable responses however 100% of respondents from both groups recommended this CPG for practice at their site Implications: Earlier stakeholders and end user engagement may have increased CPG applicability while decreasing staff’s reluctance to change. The finalized CPG was distributed to the Department of Infection Prevention and Hospital Epidemiology and target site staff for future implementation.
    • Perioperative Glucose Management to Reduce Surgical Site Infections: Clinical Practice Guideline

      Joseph, Sheilla S.; Gonzalez, Michelle LR; Amos, Veronica Y. (2019-05)
      Background: The association of hyperglycemia during and after surgery has been shown to increase the risk of Surgical Site Infections in multiple surgical specialties. Surgical site infections are a complication that has an annual financial impact of over $3 billion dollars nationally. Patients with poorly controlled glycemic levels are at higher risk for surgical site infections and are commonly predisposed to post-op soft tissue and bone healing complications. Local Problem: A large tertiary medical facility in Maryland requested an updated evidencebased guideline to manage perioperative hyperglycemia to reduce surgical site infections in their adult patient population undergoing elective orthopedic surgeries. A review of the literature revealed current standard of practice recommendations of maintaining glycemic values </= 180 mg/dL demonstrated a stronger link to reducing rates of surgical site infections and other post-op complications. The purpose of this Doctorate of Nursing Practice project was to develop a clinical practice guideline that provided best practice strategies for the management of postoperative hyperglycemia in adult patients undergoing elective orthopedic surgery. Intervention: A clinical practice guideline was developed for this quality improvement project. The project included three Student Nurse Anesthetists as project leaders, and three stakeholders. Stakeholders reviewed and graded the guideline draft using the Appraisal of Guidelines for Research & Evaluation Tool. This tool is an open source appraisal instrument used worldwide to evaluate structure, content and the quality of guidelines. Revisions made to the guideline were based on stakeholder recommendations and the appraisal tool results. Implementation of the project was in the form of a brief formal PowerPoint presentation to the anesthesia department and providers were asked to rate the guideline using the Provider Feedback Questionnaire. The data collected from this questionnaire and the appraisal tool were examined using simple descriptive and correlative statistics. Results were acquired to make final modifications to the guidelines. Results: The overall response to the guideline was favorable. The average percentage scores of the guideline appraisal tool were calculated by domain and showed an overall guideline assessment score of 87%. A total of 23 provider feedback questionnaires were collected; and the most common response was a 3 (Strongly Agree), appearing on 18 out of the 23 survey responses. The overall percentage of respondents’ agreement for the guideline was 79% with a standard deviation of 10%. In total, these results are very promising for continuing to explore the implementation of the guidelines. Conclusion: Perioperative glycemic control of </= 180mg/dL has been demonstrated to reduce the incidence of surgical site infections in adult patients undergoing orthopedic surgery. This clinical practice guideline was developed and implemented specifically for this institution. The guideline found strong support among the end users/stakeholders and both doctors and nurses strongly approved of the guidelines. The results of the provider feedback questionnaire indicated effective and internal reliability in which implementing the Guidelines would result in decreasing the rate of perioperative hyperglycemia and the rates of surgical site infections. Further evaluation of patient outcomes after implementation of the guidelines is recommended to measure continued guideline efficacy.
    • Perioperative Glucose Management to Reduce Surgical Site Infections: Clinical Practice Guideline

      Santiago, Frances; Gonzalez, Michelle L. R.; Amos, Veronica Y. (2019-05)
      Background: The association of hyperglycemia during and after surgery has been shown to increase the risk of surgical site infections in multiple surgical specialties. Patients with poorly controlled blood glucose levels are at higher risk for surgical site infections and are commonly predisposed to post-op soft tissue and bone healing complications. Maintaining blood glucose values < 140 mg/dL demonstrated a stronger link to reducing rates of surgical site infections and other postoperative outcomes. Local Problem: The purpose of this project is to develop a clinical practice guideline that provides clear directions and constitutes best practice strategies for the management of hyperglycemia throughout the perioperative period of adult patients undergoing surgery at a tertiary medical facility in Maryland. This facility identified a rise in the incidence of post-op hyperglycemia with blood glucose levels ≥ 180 mg/dl and an increase in post-op surgical site infections in their patient population. Interventions: This project took place in three phases over a 14-week period. The first phase included recruitment of an expert panel consisting of an anesthesiologist and Certified Registered Nurse Anesthetist. After project buy-in, a draft of the guideline was presented to the panel. They reviewed and graded the guideline draft using the AGREE II Tool. Revisions were made based on the panel’s recommendations and AGREE II results. In phase two, a final meeting was held with the chief anesthesiologist for feedback and approval of the final presentation to the anesthesia providers. In phase three, a brief formal presentation was given to the anesthesia department. Anesthesia providers were asked to rate the guideline using the Provider Feedback Questionnaire. The data collected from the Provider Feedback Questionnaire surveys were analyzed and results were obtained to make final changes to the guideline. Results: The guideline provided clear instructions, produced positive patient outcomes, and was deemed favorable by the anesthesia department. Some providers felt the financial implications would hinder implementation, while others were unsure of changing their practice due to the rigid guidelines. Conclusions: This guideline was successfully developed and implemented at the requesting institution with the support of key stakeholders. Monitoring and managing hyperglycemic blood glucose levels in the perioperative period can decrease the incidence of postoperative surgical site infections.
    • Perioperative Glycemic Control to Reduce Surgical Site Infections: Clinical Practice Guideline

      Labang, Tara M.; Gonzalez, Michelle L.R.; Amos, Veronica Y. (2019-05)
      Background: Surgical site infections are a common postoperative complication that has been identified to be related to perioperative hyperglycemia. During times of stress, including surgical stress and anesthesia, the body responds by increasing levels of glucose to meet metabolic demands and reduces the production of insulin, leading to hyperglycemia. Intraoperative blood glucose monitoring and treatment has been demonstrated to reduce the incidence of hyperglycemic events and reducing the incidence of postoperative complications. Local Problem: A tertiary medical center in Maryland requested an updated, evidence-based clinical practice guideline for perioperative glucose management. This clinical practice guideline will provide an evidence-based approach for the following: intraoperative glycemic control, blood glucose monitoring frequency, intraoperative insulin pump management and insulin administration. Interventions: The purpose of this Doctorate of Nursing Practice project was to develop a clinical practice guideline for perioperative glycemic control to reduce surgical site infections in orthopedic surgical patients. This clinical practice guideline was designed for quality improvement purposes and conducted through a combined effort of three student registered nurse anesthetists as project leaders. Feedback and recommendations of the clinical practice guideline were received by key stakeholders through the utilization of the AGREE II tool. Implementation of the project was done via a PowerPoint presentation of the final clinical practice guideline to the end-users, the anesthesia staff, at the facility during the anesthesia staff meeting. End-users provided feedback of the clinical practice guideline via a Practitioner Feedback Questionnaire and demographic questionnaire to evaluate the clinical practice guideline. Data collected using The Agree II tool and Practitioner Feedback Questionnaire were analyzed using simple descriptive and correlative statistics. Results: The mean overall guideline assessment score of the AGREE II tool results was 87%. Both stakeholders rated the overall quality of the guideline with high quality ratings and indicated “yes” to recommending this guideline for use. Descriptive statistics were calculated for the sample of anesthesia providers (n = 23) who completed a Practitioner Feedback Questionnaire. Demographic data revealed that of the 23 respondents, six were anesthesiologists (26%), 16 were certified registered nurse anesthetists (70%), and one student registered nurse anesthetist (4%). Analysis of the Practitioner Feedback Questionnaire results support this clinical practice guideline. The average total percentage of agreement was 80.5% (SD=0.12); indicating the acceptability and usability of this clinical practice guideline by the anesthesia providers at this institution. Conclusions: Perioperative glycemic control has been shown to decrease surgical site infections rates. Recent evidence-based research demonstrates that a target glucose level of <180 mg/dL is effective in reducing surgical site infections, as well as reducing the risk of intraoperative hypoglycemic events. This clinical practice guideline was developed and successfully implemented specifically for this institution as requested to meet the needs of this anesthesia department. Sustainability and spread of the clinical practice guideline will be dependent on the institution.