A multifaceted quality improvement project improves intraoperative redosing of surgical antimicrobial prophylaxis during pediatric surgery.

BACKGROUND: Accurate intraoperative antibiotic redosing contributes to prevention of surgical site infections in pediatric patients. Ensuring compliance with evolving national guidelines of weight-based, intraoperative redosing of antibiotics is challenging to pediatric anesthesiologists. AIMS: Our primary aim was to increase compliance of antibiotic redoses at the appropriate time and appropriate weight-based dose to 70%. Secondary aims included a subset analysis of time compliance and dose compliance individually, and compliance based on order entry method of the first dose (verbal or electronic). METHODS: At a freestanding, academic pediatric hospital, we reviewed surgical cases between May 1, 2014, and October 31, 2017 requiring antibiotic redoses. After an institutional change in cefazolin dosing in May 2015, phased interventions to improve compliance included electronic countermeasures to display previous and next dose timing, an alert 5 minutes prior to next dose, and weight-based dose recommendation (September 2015). Physical countermeasures include badge cards, posting of guidelines, and updates to housestaff manual (September 2015). Statistical process control charts were used to assess overall antibiotic redose compliance, time compliance, and dose compliance. The chi-square test was used to analyze group differences. RESULTS: A total of 3015 antibiotic redoses were administered during 2341 operative cases between May 1, 2014, and October 31, 2017. Mean monthly compliance with redosing was 4.3% (May 2014-April 2015) and 73% (November 2015-October 2017) (P < 0.001). Dose-only compliance increased from 76% to 89% (P < 0.001), and time-only compliance increased from 4.9% to 82% (P < 0.001). After implementation of countermeasures, electronic order entry compared with verbal order was associated with higher dose compliance, 90% vs 86% (P = 0.015). CONCLUSION: This quality improvement project, utilizing electronic and physical interventions, was effective in improving overall prophylactic antibiotic redosing compliance in accordance with institutional redosing guidelines.

A quality improvement initiative to optimize dosing of surgical antimicrobial prophylaxis.

BACKGROUND: The risk of surgical site infections is reduced with appropriate timing and dosing of preoperative antimicrobials. Based on evolving national guidelines, we increased the preoperative dose of cefazolin from 25 to 30 mg·kg-1 . This quality improvement project describes an improvement initiative to develop standard work processes to ensure appropriate dosing. AIMS: The primary aim was to deliver cefazolin 30 mg·kg-1 to at least 90% of indicated patients. The secondary aim was to determine differences between accuracy of cefazolin doses when given as an electronic order compared to a verbal order. METHODS: Data were collected from January 1, 2012 to May 31, 2016. A quality improvement team of perioperative physicians, nurses, and pharmacists implemented a series of interventions including new electronic medical record order sets, personal provider antibiotic dose badges, and utilization of pharmacists to prepare antibiotics to increase compliance with the recommended dose. Process compliance was measured using a statistical process control chart, and dose compliance was measured through electronic analysis of the electronic medical record. Secondary aim data were displayed as percentage of dose compliance. An unpaired t-test was used to determine differences between groups. RESULTS: Between January 1, 2012 and May 31, 2016, cefazolin was administered to 9086 patients. The mean compliance of cefazolin at 30 mg·kg-1 from May 2013 to March 2014 was 40%, which prompted initiation of this project. From April 2014 to May 2016, a series of interventions were deployed. The mean compliance from September 2015 to May 2016 was 93% with significantly reduced variation and no special cause variation, indicating that the process was in control at the target primary aim. There were 649 cefazolin administrations given verbally and 1929 given with an electronic order between October 1, 2014 and May 31, 2016. During this time period, the rate of compliance of administering cefazolin at 30 mg·kg-1 was significantly higher when given after an electronic order than when given verbally, 94% vs 76%. CONCLUSION: This comprehensive quality improvement project improved practitioner compliance with evidence-based preoperative antimicrobial dosing recommendations to reduce the risk of surgical site infections.