APPROPRIATE ADMINISTRATION OF SURGICAL ANTIBIOTIC PROPHYLAXIS FOR INPATIENT CASES

Whitney Aultman, Pharm.D. Candidate 2015; Julie Botsford, Pharm.D.; Samuel Kwaku Osei, M.D. Candidate 2016;
Mike Tiberg, Pharm.D., BCPS (AQ-ID); Christy Joynt, BS; Cynthia Nichols, PhD

STUDY OBJECTIVES
To guide future process improvement efforts related to
surgical antibiotic prophylaxis in the inpatient setting

416 Inpatient Surgeries

BACKGROUND1-3
In 2013, an interdisciplinary process improvement team was
established at Munson Medical Center, a 391 bed teaching
hospital in northern Michigan, with the primary goal of delivering
the correct antibiotic to the correct patient at the right time every
time
The initial effort focused on outpatient surgery, which
constitutes over 90% of the total surgical volume

There are 5 significant inpatient challenges that have already been

identified as potential causes of antibiotic fallout:

Primary Endpoint
Once 85% power requirements
have been met or a difference
between the four categories has
been found

Orthopedic
Cardiothoracic
General
Others

1. No standard inpatient surgery scheduling process

2. Multiple vehicles exist to order preoperative antibiotics
3. Visibility of inpatient surgical cases to inpatient pharmacy
personnel

Exclusion Criteria

Inclusion Criteria
Inpatient surgical cases from January 1,
2014 to August 28, 2014
Inpatient status defined as any
surgery case including emergent,
urgent, bedded, transferred, or directly
admitted

New surgical antibiotic prophylaxis guidelines were published in

2013, updated from previous guidelines published in 1999
The new guidelines presented opportunities to optimize
antibiotic prophylaxis in all types of surgical procedures
The next step in process improvement is to focus on the inpatient
setting
Approximately 70% of inpatient surgeries are from the
combined specialties of orthopedic, cardiothoracic, and
general surgeries

PRELIMINARY RESULTS

METHODS
Retrospective Chart Review

4. Shared domain between operating room pharmacy and

inpatient pharmacy

Outpatients
Inpatients undergoing more than one
surgical procedure
Class A surgical patients defined as life,
limb, and/or sight threatening condition
requiring immediate surgery within one
hour of declaration

5. Time of surgery being scheduled to the actual surgery time is

short
Study Implications

Emphasize areas of inpatient surgery charting and ordering that

need to be addressed
Enhanced antibiotic stewardship
Increased patient safety

Data Collection
Are they on
treatment
antibiotics?

Do they have an Do they have a

antibiotic
history of
allergy?
MRSA?

Does the drug

administered =
the drug
ordered?

What is the
What time
administration
was the
time?
patient in the
OR?

Was the drug

documented as
at the patient
bedside?

Authors of this presentation have nothing to disclose concerning

possible financial or personal relationships with commercial
entities that may have a direct or indirect interest in the subject
matter of this presentation

Was the Antibiotic Ordered Appropriate?

Power analysis using the RMSSE method

104 patients in each group required for 85% power at =0.05
Fisher Exact test to compare the frequency of protocol discrepancy
between the four surgery subgroups

Further post-hoc analysis will be performed to evaluate specific

subgroups of patients who may be at increased risk for antibiotic
discrepancies

Retrospective chart review study design

Several data collectors possible variation in assessment of
fallout

DISCLOSURE

STATISTICAL ANALYSIS

Post-hoc comparative analyses to evaluate for subgroup differences

Missing data will be deleted in pair-wise fashion
Outliers will not be excluded

Study Limitations

REFERENCES
Physician Error

Omission
Duplicate Therapy
Physician Order Entry
Error
Disagreement with
Protocol

Was there Error?

System Error

Case Boarded Without Antibiotic

Selection
Wrong Choice by Anesthesia
Omission by Anesthesia
Dispensed but not Administered
Multiple Dispenses

1. Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical practice guidelines for
antimicrobial prophylaxis in surgery. Am J Health-Syst Pharm. [February 1,
2013]; 70:195-283.
2. Botsford J, Joynt C. Surgical antibiotic prophylaxis update. Powerpoint
presentation of safety update; 2013; Munson Medical Center, Traverse
City, MI.
3. Tiberg M, Botsford J. Update on surgical antimicrobial prophylaxis at
Munson Medical Center. Munson Healthcare Pharmacy & Therapeutics
Newsletter; 2013 July: Vol 18, Issue 7.