Are preoperative antibiotics administered preoperatively?

Ideally antibiotics should be administered preoperatively within 2 hours of skin incision to ensure adequate tissue concentrations, especially when a vascular prosthesis is used. The quality of patient outcomes may be adversely affected when key processes, by degrees, fail to meet patient care objectives. This study was designed to incorporate the concepts of total quality management to determine how effectively this goal was achieved, and, after review of those measured results, what process improvements could be instituted to meet the established requirements for the administration of antibiotics. The study was then repeated on a yearly basis to determine what effect these improvement measures had on antibiotic administration. Three time periods were established for determining when antibiotics were administered. The "early" period was more than 2 hr preoperatively. "Preoperative" was from 2 hr before surgery until the time of incision and "perioperative" was after the time of incision. Group 1 consisted of the first 100 patients undergoing vascular procedures in 1992. After the data were collected, a multidisciplinary team of nurses, pharmacists, and surgeons was assembled to determine the step by step desired process flow from order received to actual medication administration. The team then reviewed each step of the process to identify variations relative to data obtained. An action plan was developed to implement the agreed upon improvement plan. After improvements were implemented, groups 2, 3, 4, and 5 consisted of the first 100 vascular procedures of 1993, 1994, 1995, and 1996. Group 1 had only 26% of antibiotics administered during the preoperative period and 74% during the perioperative period. Problems identified were: surgeons ordered the antibiotics when the patient was in the operating room, cefamandole and vancomycin required at least 1 hr to infuse, nurses were not aware of the need for preoperative infusion, and the pharmacy did not supply the antibiotics in a timely fashion. Educational inservices were held for all parties involved, and cefazolin was used in place of cefamandole because it could be given as a bolus. Results were: group 1, early, 0%; preoperative, 26%; perioperative, 74%; P = N/A; group 2, early, 0%, preoperative, 90%; perioperative, 10%; group 3, early, 7%; preoperative, 93%; perioperative, 0%; group 4, early 0%; preoperative, 100%; perioperative, 0%; and group 5, early, 0%; preoperative, 100%; perioperative, 0%; P = 0.0001 for groups 2-5 (versus group 1). It was surprising how often antibiotics were administered incorrectly in a busy vascular practice. By focusing on the process of care delivery, a continuous quality improvement team implemented simple changes that resulted in significant improvements. We are now conducting a study to determine what effect these process improvements had on our infection rate.