Hardwiring CABG Pre-Operative Antibiotic Administration

ISSUE: Antimicrobial prophylaxis to prevent the development of surgical site infection (SSI) is widely accepted as one of the cornerstones of quality surgical care. While this recommendation was first advocated in the 1960s, many health care facilities continue to struggle with the timing, selection, and/or discontinuation of antimicrobials. PROJECT: Our 400-bed not-for-profit community medical center recognized an opportunity to incorporate evidence-based practice changes with the objective of decreasing the rate of SSI in the CABG population. After a literature review of interdisciplinary best practices, a multidisciplinary CABG Process Improvement Team was formed in April 2004. While current practices in the management of open heart surgery patients were examined by the team, improvement efforts were focused on four areas: pre-operative skin preparation, antimicrobial prophylaxis (appropriate selection, timing and discontinuation), blood glucose control and wound care management. Change initiatives were proposed and education was completed on the evidence-based practice changes selected. The area which realized the greatest improvement was antimicrobial prophylaxis. This initiative focused on improving timing, selection and discontinuation of antimicrobials and followed current published guidelines for cardiac procedures. These guidelines include administering appropriate antibiotics within 60 minutes of surgical incision time (or within 120 minutes when vancomycin is administered due to B-lactam allergy), and discontinuing antibiotics within 48 hours post-procedure. The processes that were instituted which made this initiative a success included documentation of the antibiotic/dose/time on the greaseboards in the ORs; addition of a stamp at the top of the Anesthesia Record to provide a specific location for documentation; initial weekly review of documentation by management which led to additional documentation on the time-out record by both anesthesia and nursing; assigning oversight and monitoring of the project to one manager; and the Anesthesia Department taking responsibility for administering the antibiotics. RESULTS: Pre-initiative, the mean compliance rate for administration of prophylactic antibiotics within the appropriate time frame was 72% (range 47-94%). The Anesthesia Department and the CVOR have been successful in hardwiring this initiative for the subsequent 18 months since the initiative was introduced, and the mean compliance rate has increased to 99% (range 95-100%), which is a statistically significant improvement (p<0.001). LESSONS LEARNED: A change initiative must be implemented by the people who will own the change - the front-line staff. Securing a champion in the targeted area will allow for daily oversight and validation of the importance of an evidence-based initiative.