The Journal of Bone and Joint Surgery (American). 2008;90:226-232.
doi:10.2106/JBJS.G.00297
© 2008 The Journal of Bone and Joint Surgery, Inc.
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Ensuring Appropriate Timing of Antimicrobial Prophylaxis

Andrew D. Rosenberg, MD1, Daniel Wambold, MD1, Linede Kraemer, RN, MA, CNOR1, Maureen Begley-Keyes, BS, RN, CPHRM, CPHQ1, Scott L. Zuckerman1, Neeraj Singh, BA1, Max M. Cohen, MD2 and Michele V. Bennett, RN, MA, ONC1

1 Department of Anesthesiology (D.W., S.L.Z., and N.S.), NYU Hospital for Joint Diseases, 301 East 17th Street, New York, NY 10003. E-mail address for A.D. Rosenberg: Andrew.Rosenberg{at}med.nyu.edu
2 NYU Hospital Center, 550 First Avenue, New York, NY 10016
Investigation performed at the NYU Hospital for Joint Diseases, New York, NY

Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families 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 authors, or a member of their immediate families, are affiliated or associated.

A commentary is available with the electronic versions of this article, on our web site (www.jbjs.org) and on our quarterly CD-ROM (call our subscription department, at 781-449-9780, to order the CD-ROM).

Background: Delivery of intravenous antibiotic prophylaxis within one hour prior to surgical incision is considered important in helping to decrease the incidence of surgical site infections, but methods to ensure compliance have not been established.

Methods: All patients at our institution are subjected to a surgical "time-out" protocol to prevent wrong-site surgery. During a seven-week period, all patients undergoing spine surgery, total hip arthroplasty, or total knee arthroplasty had another safety initiative, that of ensuring that prophylactic intravenous antibiotics were administered at least one hour prior to incision, "piggybacked" onto our existing time-out verification checklist. In addition, we compared compliance during the study period with compliance during a three-month period prior to institution of this protocol and compliance for eighteen months after institution of this protocol.

Results: The average time (and standard deviation) between the antibiotic administration and the incision was 26 ± 12 minutes for all patients. The protocol was effective in ensuring antibiotic administration at the optimal time to 316 (99.1%) of the 319 patients. Analysis of a group of forty patients who had undergone total hip or knee replacement during the three months prior to the beginning of the study demonstrated a compliance rate of 65%. The difference between this baseline compliance rate and the rate during the study period was significant (p < 0.0001). The compliance rate was 97% for 160 patients who underwent similar procedures during the eighteen months after completion of the study. Independent audits demonstrated continuation of the significantly better compliance with timing of antibiotic prophylaxis for patients undergoing total hip and knee arthroplasty since the implementation of the protocol in our institution.

Conclusions: Piggybacking of verification of prophylactic antibiotic administration onto the wrong-site-surgery time-out protocol is an effective, cost-free, and easy-to-adopt method to ensure compliance with appropriate timing of prophylactic antibiotics.

Level of Evidence: Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.


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Ensuring Appropriate Timing of Antimicrobial Prophylaxis
Devdatta S Neogi, et al.
JBJS Online, 6 Feb 2008 [Full text]