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Administer Antibiotics Right on Time
How to infuse your pre-op antibiotic protocol with precision.
Georgianne Bauer
Publish Date: March 17, 2008   |  Tags:   Infection Prevention

Do your patients receive pre-op antibiotics when they should? And by this, I'm referring to the standard definition of having patients receive the agents within 60 minutes of the first incision (or within 120 minutes for vancomycin).

If you haven't taken the time to find out, then the odds are it's less often than you think. As anyone who works in the surgical setting knows, there are a lot of activities involved in preparing a patient for surgery. All it takes is one delay to keep the patient from receiving his antibiotics at the right time.

When we randomly reviewed 300 charts a couple years ago, we found that our patients were getting their antibiotics when they should only about 48 percent of the time. We vowed to improve this number and reduce our surgical site infections. Our average compliance rate now exceeds 90 percent. Read on to find out how we did it.

Why don't patients get antibiotics on time?
We began by asking why we failed to administer antibiotics within 60 minutes of incision time more than half the time. Two culprits emerged.

First, some cases started later than planned. Our aim was to administer pre-op antibiotics in the holding area, but this proved to be a problem when cases didn't start on time due to variables we couldn't easily prevent: late-arriving physicians, backed-up anesthesia personnel, cases lasting longer than scheduled and lengthy preparation procedures.

Second, we didn't have designated personnel administering the antibiotics. In some cases, anesthesia personnel administered the medication and in others an OR nurse did. Also, we didn't routinely document the time we started the antibiotics.

Our Quality Improvement Process

To improve our infection control program one measure at a time, we used the FOCUS-PDCA model created by the Hospital Corporation of America. Each letter represents a step you should take to improve your overall quality:

F ??"

Find a process to improve. At our facility, we started with timely antibiotic administration.

O ??"

Organize the team. We used an interdepartmental group to get different perspectives.

C ??"

Clarify how the process works. We looked at how preoperative antibiotics were administered in the OR.

U ??"

Understand and analyze the data. After reviewing the charts, it was clear that more than 50 percent of our patients weren't receiving antibiotics in a timely manner.

S ??"

Select an initiative. We revised our protocols and designated responsibilities to the OR nurses.

P ??"

Plan how to implement the changes and how to monitor the results. We changed how the antibiotics were set up and instructed the OR nurses to administer them once patients and physicians were in the OR, and document the time given.

D ??"

Do it. We initiated the process in February 2006.

C ??"

Check the results. Each month we review 100 records from patients who received preoperative antibiotics.

A ??"

Act by either keeping your planned course of action or choosing another option. Since this worked well for us, there was no need to change. But we're still working on overcoming the remaining obstacles in our problem areas.

— Georgianne Bauer, RN, MSN

Smoothing out the system
After we identified the barriers keeping us from appropriately administering antibiotics, we began looking for solutions. Obviously we couldn't guarantee every case would start on time, but we could rethink how we administered pre-operative antibiotics to make sure we delivered them in the timeliest manner possible.

The first step was to make it easier to administer the antibiotics. We queried some hospitals in the area and asked about their administration processes. One told us that they hung the antibiotic in the pre-op area but waited to start the infusion until the patient entered the OR. We decided to try this idea at our facility.

We also decided to designate responsibility to the OR nurses for the administration and documentation of antibiotics. The circulating nurse reviews the patient's chart for the antibiotic orders and any antibiotic allergies. Once the patient is in the OR and the surgeon has arrived, she starts the antibiotic. It only takes a couple of minutes for the antibiotics to circulate through the patient's system, so starting too soon wasn't a concern.

To improve our documentation, we revised the OR record and added a line that reads: "Pre-op ATB [the name of the antibiotic] started @ [the time it was started] by [the nurse's initials]." Our nurses were compliant with that step in large part because it didn't add to their workload.

Striving for perfection
We have yet to reach a 100 percent effectiveness rate, but since we initiated this protocol our monthly rates are consistently in the 90s or high 80s. We're still actively monitoring this process and identifying the outliers, such as the cases where the positioning takes too long or the physician is later than we had planned.

How well this translates into a clinical benefit is harder to quantify. This is a part of our facility's participation in the Surgical Care Improvement Project, which means it's done along with such techniques as clipping patients' hair instead of shaving, making sure patients have normal body temperatures after procedures, giving perioperative beta blockers to patients who are already on them, monitoring glucose levels and taking steps towards preventing DVT. So while it's hard to say how well antibiotic protocols have helped by themselves, all of these together have kept the SSI rate very low throughout our facility.

The Quickest Route to SSI Prevention

According to the Institute for Healthcare Improvement, the best pre-operative antibiotic practices for the prevention of surgical site infections are:

  • Ensuring the entire dose is fully infused no more than 60 minutes before the incision, although for vancomycin this should be 120 minutes due to its longer infusion time. Research associates higher surgical-site infection rates with longer periods of time after the 60-minute mark.
  • Administering the dose through rapid infusion so the start time of the dose is close to the end time.
  • If the patient will have a cuff near the surgical site, ensuring the dose is fully infused before inflating the cuff so all the antibiotic will reach the surgical site.
  • Adjusting the dose for patient weight. Overweight patients may need higher doses to reach the same therapeutic level.
  • Redosing the patient if the surgery site is open for four hours or longer.

Source: Griffin, FA. Best Practice Protocols: Preventing Surgical Site Infections. Nursing Management. 2005:36:20-26.