Improving Appropriate Use of Prophylactic Antibiotics
Abstract & Commentary
By Frank W. Ling, MD, Clinical Professor, Dept. of Obstetrics and Gynecology, Vanderbilt University School of Medicine, Nashville. Dr. Ling reports no financial relationship to this field of study. This article originally appeared in the September 2008 issue of OB/GYN Alert. It was edited by Leon Speroff, MD, and peer reviewed by Catherine LeClair, MD. Dr. Speroff is Professor of Obstetrics and Gynecology, Oregon Health and Science University, Portland, and Dr. LeClair is Assistant Professor, Obstetrics and Gynecology, Oregon Health and Sciences University; both report no financial relationships relevant to this field of study.
Synopsis: In spite of institutional education regarding appropriate use of prophylactic antibiotics, compliance was achieved only when hospital protocols that mandated specific antibiotic use were implemented.
Source: Whitman G, et al. Prophylactic antibiotic use: hardwiring of physician behavior, not education, leads to compliance. J Am Coll Surg. 2008;207:88-94.
Between March, 2005 and June 2007, 1622 consecutive patient charts at Temple University Hospital were reviewed to determine whether prophylactic antibiotics were used appropriately with regard to antibiotic choice, timing of administration, and postoperative cessation of antibiotics. Although not all the procedures were gynecologic, both vaginal and abdominal hysterectomy were included in the totals. Compliance with the evidence-based prophylactic antibiotic regimens improved only after surgeons were "forced" to use specific orders and procedures were implemented that took away the individual's ability to choose inappropriate medications and/or the timing of administration and/or cessation of prophylactic antibiotics.
In the case of antibiotic selection, each surgical chair was asked to develop a protocol, but because of poor compliance, the hospital implemented a surgical scheduling order form in which only appropriate antibiotics were listed. For vaginal and abdominal hysterectomy, the choices were cefotetan, cefazolin, cefoxitin, or ampicillin-sulbactam. For patients with a b-lactam allergy, the choices were either clindamycin combined with gentamicin or a fluoroquinolone or clindamycin monotherapy.
Compliance with timing of administration of prophylactic antibiotics was only 55% after education of the staff. Initial attempts to correct this low rate included mandating of administration before the patient left the pre-operative holding area. This led to compliance of 78%, but some patients were receiving their antibiotics more than an hour before incision. The final step that achieved the highest compliance was having the anesthesiologist take responsibility for administering the medicine in the operating room during the surgical "time-out," thus leading to a 95% compliance rate.
The cessation of prophylactic antibiotics was also variable, often dependent upon residents who wrote orders that led to administration of antibiotics long after the appropriate duration of time. The mechanism that achieved the greatest success was implementing a pathway in the electronic medical record which, if selected, did not allow prophylactic antibiotics to be given more than 16 hours after the initial dose. This led to a compliance rate of 86%, up from 60%.
Commentary
To all of you who went into medicine so that you could be the one making all the decisions and being totally independent from people constantly looking over your shoulders, I apologize. This study adds to the growing body of literature that tells us that, if we're going to do the best thing for patients, we're going to have to accept that we physicians need guidance. In this study, done at a university teaching hospital, physicians did not respond to educational efforts and were compelled to use appropriate antibiotic protocols. We all know the significance of surgical site infections, both clinically to individual patients as well as financially to our health care system. We know that prophylactic antibiotics reduce morbidity and cost. These investigators help us understand how to implement what research has taught us.
I challenge each reader to look at what mechanisms, if any, exist at your respective hospital(s) to implement evidence-based medicine. You can start small and grow it. Here's an article to start with. Are the orders for prophylactic antibiotics pre-printed to make sure that every patient undergoing hysterectomy gets the right medicine at the right time? What about orders for prevention of deep vein thrombosis? What about prophylactic antibiotics for cesarean deliveries? If your hospital doesn't have standardized protocols, then it's likely that it is not doing everything that it can to maximize compliance with the evidence. It's not that anyone is deliberately not doing what the literature finds, but it's difficult for everyone to remember to do everything on every patient.
Let's all put our egos on hold and welcome any and every helpful way to give our patients the best care possible. This was a very insightful article, if for no other reason than the way the authors describe how they evolved their approaches to gain maximum compliance. Good reading. I encourage you to bring it to the attention of your hospital administrators.
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