Copyright © 2008 by The Journal of Bone and Joint Surgery, Inc.
Commentary & Perspective
Commentary & Perspective by
Robert W. Bucholz, MD*,
University of Texas Southwestern Medical Center, Dallas, Texas
Posted February 2008
This study, conducted by Dr. Andrew Rosenberg et al. at the New
York University School of Medicine, focused on a common problem of institutional
process. Timely administration of preoperative prophylactic antibiotics is
undoubtedly a critical factor contributing to avoidance of sepsis following
total joint arthroplasty. Evidence-based medicine has established that the
administration of antibiotics is most effective if done within one hour prior
to skin incision. Historically, compliance with this optimal timing has been
poor. The Surgical Infection Prevention Project promotes the universal use of a
standardized protocol for correct timing and dosage of prophylactic antibiotics1,
and the Centers for Medicare and Medicaid Services (CMS)
has included preoperative antibiotic usage in its list of performance
guidelines.
The concept of this study was to "piggyback" confirmation
and documentation of preoperative antibiotic administration to the standard
preoperative "time-out." The "time-out" in the operating room was initially
championed by various professional organizations (most notably by the American
Academy of Orthopaedic Surgeons) and is now routine procedure in all operating
rooms.
Over a period of seven weeks, 319 consecutive patients were
enrolled at a single hospital. Prior to skin incision, the official time-out
called by the circulating nurse included querying the anesthesiologist about
the dose and timing of antibiotic administration. Documentation of this
discussion and confirmation of the correct timing of intravenous antibiotics
were recorded on the time-out preoperative verification checklist. The
checklist was incorporated into the medical record. In 99% of the patients,
this protocol was effective, with an average documented time from antibiotic
administration to skin incision of twenty-six minutes. These results were
compared with historical controls culled from medical records at the same
institution three months prior to the study period. Of forty records studied, the
records of only twenty-six patients (65%) showed compliance with the one-hour
preoperative window for antibiotic administration. The study results were also
compared with compliance eighteen months after the study period, when this
time-out protocol had become hospital policy. Compliance remained high at 96.8%.
A major limitation of this study was the lack of a clear
description of the operating-room protocol that had been employed prior to the
study to ensure timely antibiotic administration. A 65% compliance rate is
quite low. Many orthopaedic surgeons will not start the preparation and draping
of their patients until they are assured that the anesthesiologist has administered
the correct antibiotics. It is unknown if the compliance at this institution
has traditionally been so poor. Another problem with the study is that, even
with this protocol for proper antibiotic timing, errors still occur. The nurse
must remember to do the time-out, and the anesthesiologist must be listening. It
would be interesting to see if long-term compliance of greater than 95% can be
sustained at most hospitals that make use of this protocol.
This "systems-based practice" study is useful. The concept
of piggybacking antibiotic administration to the other components of the
time-out makes sense. One national study found that in over 34,000 Medicare
patients, only 50% to 60% received antibiotics one hour or less prior to
incision2. For those of us who believe that proper type, timing, and
dosage of antibiotics in arthroplasty surgery is at least as important as most
design and technique considerations in the surgery, such poor performance
should not be tolerated. Indeed, CMS (through
its pay-for-performance measures) and hospitals (through their quarterly
performance report cards) are trying to change the behavior of the surgeon and the
operating-room staff through administrative mandate. Human error occurs with
frightening frequency, and this simple method to ensure proper antibiotic
administration should be instrumental in minimizing this common oversight in
arthroplasty surgery. Additionally, the verification checklist will assist
hospitals and surgeons in their documentation of pay-for-performance measures.
*The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, is affiliated or associated.
References
1. Bratzler DW; Houck PM; Surgical Infection Prevention Guidelines Writers Workgroup; American Academy of Orthopaedic Surgeons; American Association of Critical Care Nurses; American Association of Nurse Anesthetists; American College of Surgeons; American College of Osteopathic Surgeons; American Geriatrics Society; American Society of Anesthesiologists; American Society of Colon and Rectal Surgeons; American Society of Health-System Pharmacists; American Society of PeriAnesthesia Nurses; Ascension Health; Association of Perioperative Registered Nurses; Association for Professionals in Infection Control and Epidemiology; Infectious Diseases Society of America; Medical Letter; Premier; Society for Healthcare Epidemiology of America; Society of Thoracic Surgeons; Surgical Infection Society. Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project. Clin Infect Dis. 2004;38:1706-15.
2. Bratzler DW, Houck PM, Richards C, Steele L, Dellinger EP, Fry DE, Wright C, Ma A, Carr K, Red L. Use of antimicrobial prophylaxis for major surgery. Arch Surg. 2005;140:174-82.
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