Surgical Antimicrobial Prophylaxis Improves Through Teamwork

[September 1, 2009, AJHP News]

Cheryl A. Thompson

BETHESDA, MD 12 August 2009—Teamwork and careful examination of all the steps in administering antimicrobials to surgery patients has helped St. Luke’s Episcopal Hospital in Houston achieve a 90% or better performance rate on three national process-of-care measures.

The hospital audits itself every month, said Stephen Michaud, clinical coordinator of cardiology and cardiovascular surgery.

Michaud is the pharmacist who has been part of the team striving for high rates on measures in the Surgical Care Improvement Project (SCIP).

Annual performance rates on the measures are part of Web-based public reports from the Center for Medicare and Medicaid Services (CMS).

A recent monthly audit showed that nearly all patients in the sample had received antimicrobial prophylaxis in the hour preceding the first incision, Michaud said.

Who’s where when? Michaud declined to state his hospital’s performance rates before the team started its work.

But Chief Executive Officer David C. Pate, speaking at the American Hospital Association’s Leadership Summit in San Francisco on July 24, revealed that the performance rate for appropriate antimicrobial timing had improved by 25%.

Pate credited the improvement to application of the management methods known as "lean."

Michaud said lean management aims to eliminate waste in a process—wasteful steps, wasteful movements, and wasteful activity—so as to reach the goal in the most efficient manner.

To identify waste, he said, team members "first get the 20,000-foot view and then descend and get a closer view."

The SCIP team, which Michaud joined a year ago and consists of supervisors and frontline workers from inside and outside the operating rooms (ORs), mapped the complete process of how a surgery patient receives antimicrobial prophylaxis.

Michaud said the team then examined each step in the process to identify factors preventing the timely administration of antimicrobials.

"We had to look at how the patient comes through, who they interact with, and what it takes to get them to the next stage," he said.

The issue of antimicrobial timing came down to the health care worker who has control of the surgery patient in the hour preceding incision: the OR nurse or the anesthesia provider.

Michaud said the team taught the anesthesia providers, a group under contract to the hospital, about the process-of-care measure.

"The endgame from CMS, if you will, is to publicly report this data," he said. "And our feeling is if our data isn’t good, people aren’t going to elect to have surgeries here. They don’t elect to have surgeries here, we can’t support 50 ORs."

Michaud said the anesthesia providers "responded very well" to the request to "own" the timing of antimicrobial prophylaxis.

Sticker method. While Michaud’s contribution to improvement of prophylaxis timing was from the 20,000-foot level, his work on SCIP infection measure 3 has been much closer.

The measure pertains to discontinuation of prophylactic antimicrobials within 48 hours after the end of cardiac surgery and 24 hours after any other surgery.

"The biggest problem was pharmacists not knowing when the surgical end time was," Michaud said.

That information resides in the medical chart, but OR notes in the chart are not scanned for transmission to the pharmacy, unlike postoperative orders, he said.

The longtime solution had been for pharmacists to estimate the surgical end time.

However, with SCIP infection measure 3, every minute counts, Michaud said.

He proposed that someone affix a sticker to the postoperative orders and write down the time at which surgery ended.

The idea was accepted.

Now, Michaud said, the postanesthesia care unit (PACU) nurse who reviews a patient’s OR notes and inserts them in the medical chart also affixes a sticker labeled Surgical End Time to the postoperative orders and fills it out before scanning the orders for transmission to the pharmacy.

The hospital’s monthly performance rate for this process-of-care measure is now 90–96%, he said.

By knowing the time at which surgery ended, Michaud said, a pharmacist can determine whether the last surgeon-ordered antimicrobial dose will be given within the SCIP-stipulated window. If the pharmacist foresees the last dose being given after the 24- or 48-hour window, he or she will adjust the time of the first postoperative dose so that the full prophylactic regimen finishes in time.

Michaud said his idea arose from the goal of having an easy, standard way to communicate information and put it in a place sure to reach pharmacists.

Ensuring consistent participation by the PACU nurses, he said, "took some training and auditing" over a couple months by their supervisor, who is a member of the SCIP team.

"There’s always pushback when there’s more work to be done," Michaud said, "but the feeling was they could either put the sticker on or a floor nurse had to scan another document from another part of the chart. So that was the conundrum."

But the number of patients per nurse is lower in PACU than on a nursing floor. In addition, Michaud said, the stickers are kept next to the document scanner in PACU, the nurses there have to scan the postoperative orders anyway, and the PACU nurses are more familiar with the content of OR notes than the floor nurses are.

He said pharmacists have complained about missing stickers two or three times a quarter since his idea was put into action in late 2008.

The right drug. SCIP provides lists of appropriate prophylactic antimicrobials, grouped by type of surgery, and updates those lists twice a year, giving hospitals half a year to adapt.

Michaud said pharmacy works to ensure that the prophylactic antimicrobials given to surgery patients are on those lists.

Before the application of lean management methods, the hospital lacked standarized orders for each of the surgical services, he said. Each surgeon ordered whatever antimicrobial he or she wanted, perhaps keeping in mind the recommendations from the chief of surgery.

Michaud said the hospital just finished developing its "first iteration" of standardized preoperative order sets specific to each surgery service line. The order sets "guide" the surgeons to select the appropriate antimicrobials, he said.

When SCIP releases its update in October, Michaud said, the pharmacy will systematically review the antimicrobials in the order sets in preparation for March implementation.