Frontline Pharmacist

Frontline Pharmacist

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Multidisciplinary approach to optimizing as a measure to help prevent unneces-
sary antimicrobial resistance.
antibiotic prophylaxis of surgical-site Our institution is a 178-bed progres-
sive community hospital that provides
infections about 6000 surgeries per year. Laparo-
scopic cholecystectomies, knee arthros-

S urgical-site infections (SSIs) are a

common cause of nosocomial in-
fections. More than 2% of surgical pa-
choices of antimicrobial agents and the
timing and number of doses for spe-
cific surgical procedures.
tients in the United States will develop Even with guidelines for antimicro-
an SSI, with at least 50% of those pa- bial prophylaxis, several studies have
tients more likely to spend time in an demonstrated that the potential still
intensive care unit.1 The efficacy of an- exists for improving the care of surgi-
timicrobial prophylaxis in reducing the cal patients. In 2002, the Centers for
incidence of SSIs has been well estab- Medicare and Medicaid Services and
lished for many surgical procedures. the Centers for Disease Control and
However, antimicrobial use must be Prevention implemented the National
weighed against the risks of use, which Surgical Infection Prevention Project.
include the potential for adverse drug Through this collaboration and the re-
reactions, emergence of bacterial re- view of the available evidence, experts
sistance, and cost. Several organiza- in infection control, epidemiology,
tions, including the American Society and surgical-infection prevention (the
of Health-System Pharmacists, Surgical Infection Prevention Guide-
have published guide- line Writers Workgroup) three core
lines2 that out- measures for surveillance and qual-
line the ity improvement were recommended.1
The three measures are (1) initiating
prophylactic antimicrobials within
1 hour of surgical incision (2 hours
for vancomycin), (2) choosing anti-
microbials according to published
guidelines, and (3) discontinuing
antimicrobial prophylaxis with-
in 24 hours after surgery. The
focus on timing and selection
was on the basis of the poten-
tial of these measures to reduce
SSIs. The limit on duration was chosen
The Frontline Pharmacist column gives staff pharmacists an opportunity to share their experi-
ences and pertinent lessons related to day-to-day practice. Topics include workplace innovations,
cooperating with peers, communicating with other professionals, dealing with management,
handling technical issues related to pharmacy practice, and supervising technicians. Readers are
invited to submit manuscripts, ideas, and comments to AJHP, 7272 Wisconsin Avenue, Bethesda,
MD 20814 (301-664-8601 or ajhp@ashp.org).
copies, and laparoscopic herniorrha-
phies are the most common procedures.
A baseline measurement demonstrated
that our percentage of compliance with
antimicrobial agent administration
within 1 hour of surgery, choice of an-
timicrobial agent, and discontinuation
of antimicrobial prophylaxis within
24 hours were 71%, 100%, and 43%,
respectively. We formed a multidisci-
plinary team to address how we would
improve compliance with these mea-
sures and improve patient care. Physi-
cians from the surgery department and
representatives from hospital adminis-
tration, nursing, infection control, and
pharmacy discussed what changes to
make to our prescribing, dispensing,
and administration practices to achieve
100% compliance.
Initiating prophylactic antimicrobi-
als within one hour of surgical incision.
We realized that our prescriber-order-
entry process, in which written phy-
sician orders were faxed to the phar-
macy, was not going to guarantee rapid
administration. The process would
require confirming the patient’s lack
of allergies to the drug and any con-
traindications, processing the order,
and dispensing and delivering the an-
timicrobial in enough time for a nurse
to infuse the dose and have the patient
brought to the operating room. Several
changes were implemented to improve
efficiency. Preprinted surgical order
forms were revised and made avail-
able in more locations for prescribers.
When possible, orders were written the
Continued on page 2314

2312 Am J Health-Syst Pharm—Vol 63 Dec 1, 2006

 Frontline Pharmacist
Continued from page 2312
previous day, which allowed the phar-
macists during the evening and night
shifts to process the orders and have
the antimicrobials available for the next
morning. It was decided to have pro-
phylactic antimicrobials administered
in the holding area rather than in the
patient’s room, which would save time
while the patient was transported. This
change required an adjustment in the
pharmacy technician delivery routes.
All of these process changes required
multidisciplinary communication and
collaboration through multiple phone
calls between nurses and pharmacists
to determine optimal locations for de-
livery on a case-by-case basis, until the
systematic changes were in place. In
addition, communication between ad-
missions and the medical staff was im-
portant to facilitate orders to the phar-
macy on the previous day. Revision of
the preprinted order forms required
input from physicians, nursing, and
the pharmacy and therapeutics com-
mittee. Further review of the changes
led to the suggestion of antimicrobial
administration in the operating room
rather than the holding area.
Choosing antimicrobials according
to published guidelines. Although we
had 100% compliance on this core
measure, we still wanted to implement
some strategies to ensure we continued
to reach our goal. Revisions of the pre-
printed surgical order forms included
antimicrobial choices based on current
guidelines and listed a caveat of a pa-
tient’s allergy for ordering other antimi-
crobials. In addition, prescriber educa-
tion about the guidelines was provided
by the pharmacy department and the
chief medical officer. Forums for edu-
cation included telephone contacts, a
grand rounds presentation, and sharing
our data at medical staff meetings.
Discontinuing antimicrobial pro-
phylaxis within 24 hours after surgery.
Improving this measure was going to
2314 Am J Health-Syst Pharm—Vol 63 Dec 1, 2006
be the most challenging for us, as it re-
quired modifications at multiple levels.
At our institution, the specific times
to record medication administration
by nurses are set by pharmacy, since
we do not have electronic charting of
medications. The recommended time
of medication administration on the
print copy of the nurses’ medication
administration record (MAR) had a
significant effect on when medications
were administered to patients. Sev-
eral solutions were proposed. The re-
vised preprinted surgical order forms
included automatic stop times at 24
hours. To ensure that the MARs had
appropriate stop times, the recovery
room nurses were asked to document
on the surgical order forms the times
for administration of the initial anti-
microbial agent and the surgical end
time, which were faxed to pharmacy.
The antimicrobial order was then en-
tered by the pharmacist with a specific
date and time for the last dose of the
antimicrobial agent to be given. Imple-
menting these measures helped to less-
en the number of system obstacles to
improvement; however, there was still
some inappropriate prescribing. The
infection control coordinator and the
clinical pharmacist gave an inservice
presentation to the department of sur-
gery staff to address the core measures.
About 25% of the surgeons attended
the inservice presentation, and several
more were educated at a subsequent
session. The key educational point was
our review of the published literature,
which established that there was no
clinical benefit to prolonged antimi-
crobial use after surgery. We discussed
the potential for negative consequences
including adverse drug effects, antimi-
crobial resistance, and increased cost.
Implementation of process changes
to improve our performance on the
core measures took multidisciplinary
efforts. Challenges to implementation
were those that occur when trying to
institute any kind of process change.
Continual staff education regarding the
importance of the changes was neces-
sary to help gain understanding of the
new procedures. It is an ongoing process
because new staff members have to be
trained. The third core measure (i.e.,
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antimicrobial discontinuation within
24 hours after surgery) continues to
be a challenge. Sometimes a nonsur-
geon physician on the case may renew
the antimicrobial agent for more days.
In addition, there have been isolated
cases of antimicrobial administration
beyond 24 hours because of incorrect
computer order entry by the pharma-
cist, which resulted in the wrong time
on the nurse’s MAR, or because of late
delivery of medication. Education and
gentle reminders to the staff help mini-
mize these isolated incidents.
One year after baseline, subsequent
review of our percentage compliance
with the measures of initiating anti-
microbials within 1 hour of surgery,
choosing appropriate antimicrobial
agents, and discontinuing the admin-
istration of antimicrobial prophylaxis
within 24 hours were 84%, 96%, and
90.2%, respectively. While we were
pleased to see some improvements, our
multidisciplinary team is continuing to
meet and work toward our goal of 100%
compliance and optimal patient care.
1. Bratzler DW, Houck PM. Antimicrobial
prophylaxis for surgery: an advisory state-
ment from the National Surgical Infection
Prevention Project. Clin Infect Dis. 2004;
38:1706-15.
2. American Society of Health-System Phar-
macists. ASHP therapeutic guidelines on
antimicrobial prophylaxis in surgery. Am J
Health-Syst Pharm. 1999; 56:1839-88.
Jacqueline L. Olin, M.S., Pharm.D., BCPS,
Clinical Associate Professor
Department of Pharmacy Practice and
Administration
Ernest Mario School of Pharmacy
Rutgers, The State University of New Jersey
160 Frelinghuysen Road
Piscataway, NJ 08854-8020
jlolin@rci.rutgers.edu
DOI 10.2146/ajhp060245