A quality management approach to optimizing delivery and administration of preoperative antibiotics.

OBJECTIVE: To optimize the process for delivering and administering preoperative antibiotics in order to prevent potential adverse patient outcomes. DESIGN: Using a multidisciplinary quality-improvement team, an evaluation of the preoperative medication order and delivery process was conducted. Charts were reviewed by selected time periods, with winter 1994 discharges for orthopedic surgeries (n = 97) and spring 1995 discharges for open heart procedures (n = 50) being used to arrive at baseline data (n = 147). A plan was devised to mainstream the medication-use process so that it would be standardized hospitalwide. A goal of administering preoperative antibiotics within 30 to 60 minutes prior to cut time was established. Following redesign and education, a repeat chart review of orthopedic surgeries (n = 33) and open heart procedures (n = 168) was conducted during April 1997 for discharges from the same diagnosis-related groups to total (n = 201). SETTING: A nearly 1,000-bed tertiary referral center and teaching hospital with three separate campuses. RESULTS: We identified multiple ordering mechanisms, multiple medication sources and delivery sites, multiple administration sites and administering personnel, and other logistical conflicts. Thirty-one percent of cases received antibiotics less than 30 minutes prior to start time, 39% between 30 to 60 minutes, and 30% greater than 60 minutes before start time. Following the multidisciplinary redesign and education, an increase from 39% to 61% receiving preoperative antibiotics between 30 to 60 minutes prior to surgery start time and a decrease from 31% to 18% receiving them in less than 30 minutes was documented. The percentage of patients receiving preoperative antibiotics in 60 minutes or less increased from 70% to 80%. CONCLUSION: A continuous quality-improvement approach that engages all departments involved in patient care is necessary to achieve meaningful change in complicated hospital processes.

The effect of age and everyday exercise on steady-state plasma digoxin concentrations.

Age-related physiologic changes may significantly alter the disposition and pharmacologic characteristics of many drugs. The elderly are the most frequent users of digoxin because of increased prevalence of atrial fibrillation and congestive heart failure. This study was conducted to confirm the decrease in digoxin concentrations during exercise, to determine if age is a factor in this decrease, and to explore the difference between chronologic age and physiologic age. Eighteen men age 50-85 years were treated with digoxin for more than 1 month before enrolling and had serum digoxin concentrations of 0.4-2.0 micrograms/L. They were evaluated during a 3-hour period in the morning (A.M. dose withheld). Blood samples were obtained every 10 minutes during sequential 60-minute periods of rest (phase I), walking (phase II), and rest (phase III). There were no significant differences in mean concentration between phases II and I (p < 0.76), phases III and phase I (p < 0.70), or phases II and III (p < 0.37). The effect of age was positively correlated with the mean concentration of phase II but was not statistically significant (p < 0.62). Statistically significant correlations were seen only between the exercise phase and serum albumin and Mini-Mental Status Examination scores. We conclude that exercise has minimal, if any, clinically relevant effects on plasma digoxin concentrations. Increasing chronologic age has no influence on a decrease in the concentrations with exercise; a younger physiologic age may play a role.

Bacillary angiomatosis in a patient with AIDS.

OBJECTIVE: To report the clinical presentation and response to antimicrobial therapy of presumed bacillary angiomatosis in an AIDS patient. DESIGN: Single case report. SETTING: A 1058-bed, university teaching hospital. PATIENT: 28-year-old HIV-positive man (T4 lymphocyte count < 3/mm3), who was diagnosed with AIDS in 1984. RESULTS: The skin lesions responded promptly to treatment with doxycycline and erythromycin. CONCLUSIONS: Bacillary angiomatosis is an infection that occurs with endstage AIDS. Skin lesions have recognizable characteristics and respond promptly to appropriate antibiotic therapy.