Implementation of a Plan-Do-Study-Act framework to reduce unindicated surgical antimicrobial prophylaxis

Auto-Substitutions to Optimize Perioperative Antimicrobial Prophylaxis: Pre-Post Intervention Study

BACKGROUND

Appropriate administration of perioperative antibiotics can prevent antimicrobial resistance, adverse drug events, surgical site infections, and increased costs to the health care system for many surgeries in Otolaryngology-Head and Neck Surgery (OHNS).

OBJECTIVE

The objective of the study is to achieve 90% compliance with evidence-based perioperative antibiotic prophylaxis guidelines among elective surgical procedures in OHNS.

METHODS

The pre-intervention group consisted of patients undergoing elective surgical procedures in the 13 months prior to the interventions (September 2019-2020) whereas the post-intervention group comprised patients undergoing elective procedures during the 8 months following the implementation (October 2020-May 2021). The 4 Es of knowledge translation and the Donabedian framework were used to frame the study. Components of the intervention included educational grand rounds and automatic substitutions in electronic health records. In June 2021, a survey of staff and residents assessed the self-reported perception of following evidence-based guidelines.

RESULTS

Compliance with antimicrobial prophylaxis guidelines were evaluated based on agent and dose. The overall compliance improved from 38.8% pre-intervention to 59.0% post-intervention (p < 0.001). Agent compliance did not improve from pre- to post-intervention, that is, 60.7% to 62.8%, respectively, (p = 0.68), whereas dose compliance improved from 39.6% to 89.2% (p < 0.001). Approximately 78.5% of survey respondents felt that they strongly agreed or agreed with always following evidence-based antimicrobial prophylaxis guidelines.

CONCLUSION

Compliance with antimicrobial prophylaxis guidelines improved, primarily due to increased dosing compliance. Future interventions will target agent compliance and selected procedures with lower compliance rates.

LEVEL OF EVIDENCE

3 Laryngoscope, 133:3403-3408, 2023.

Quantifying Procedure-level Prophylaxis Misutilization in Pediatric Surgery: Implications for the Prioritization of Antimicrobial Stewardship Efforts

OBJECTIVE

To quantify procedure-level inappropriate antimicrobial prophylaxis utilization as a strategy to identify high-priority targets for stewardship efforts in pediatric surgery.

BACKGROUND

Little data exist to guide the prioritization of antibiotic stewardship efforts as they relate to prophylaxis utilization in pediatric surgery.

METHODS

This was a retrospective cohort analysis of children undergoing elective surgical procedures at 52 children's hospitals from October 2015 to December 2019 using the Pediatric Health Information System database. Procedure-level compliance with consensus guidelines for prophylaxis utilization was assessed for indication, antimicrobial spectrum, and duration. The relative contribution of each procedure to the overall burden of noncompliant cases was calculated to establish a prioritization framework for stewardship efforts.

RESULTS

A total of 56,845 cases were included with an overall inappropriate utilization rate of 56%. The most common reason for noncompliance was unindicated utilization (43%), followed by prolonged duration (32%) and use of excessively broad-spectrum agents (25%). Procedures with the greatest relative contribution to noncompliant cases included cholecystectomy and repair of inguinal and umbilical hernias for unindicated utilization (63.2% of all cases); small bowel resections, gastrostomy, and colorectal procedures for use of excessively broad-spectrum agents (70.1%) and pectus excavatum repair and procedures involving the small and large bowel for prolonged duration (57.6%). More than half of all noncompliant cases were associated with 5 procedures (cholecystectomy, small bowel procedures, inguinal hernia repair, gastrostomy, and pectus excavatum).

CONCLUSIONS

Cholecystectomy, inguinal hernia repair, and procedures involving the small and large bowel should be considered high-priority targets for antimicrobial stewardship efforts in pediatric surgery.

Prevention of Surgical Site Infections in Neonates and Children: Non-Pharmacological Measures of Prevention

A surgical site infection (SSI) is an infection that occurs in the incision created by an invasive surgical procedure. Although most infections are treatable with antibiotics, SSIs remain a significant cause of morbidity and mortality after surgery and have a significant economic impact on health systems. Preventive measures are essential to decrease the incidence of SSIs and antibiotic abuse, but data in the literature regarding risk factors for SSIs in the pediatric age group are scarce, and current guidelines for the prevention of the risk of developing SSIs are mainly focused on the adult population. This document describes the current knowledge on risk factors for SSIs in neonates and children undergoing surgery and has the purpose of providing guidance to health care professionals for the prevention of SSIs in this population. Our aim is to consider the possible non-pharmacological measures that can be adopted to prevent SSIs. To our knowledge, this is the first study to provide recommendations based on a careful review of the available scientific evidence for the non-pharmacological prevention of SSIs in neonates and children. The specific scenarios developed are intended to guide the healthcare professional in practice to ensure standardized management of the neonatal and pediatric patients, decrease the incidence of SSIs and reduce antibiotic abuse.

Antimicrobial stewardship for surgical antibiotic prophylaxis and surgical site infections: a systematic review

Background Surgical site infections account for 14-17% of all healthcare-associated infections. Antimicrobial stewardship (AMS) are complementary strategies developed to optimize the use of antimicrobials. Aim to evaluate the effectiveness of AMS in promoting adherence to surgical antibiotic prophylaxis protocols in hospitalized patients, reducing surgical site infection rate and cost-benefit ratio. Method This systematic review of randomized clinical trials, non-randomized clinical trials and before and after studies was performed using Pubmed, Cochrane, Web of Science, Scopus, Embase, Google Scholar and ClinicalTrials.gov, in addition to reference lists of included studies. The risk of bias of studies was measured by the ROBINS-I checklist and the quality of the evidence synthesis by GRADE. Results Fourteen before and after design studies were included. In 85.7% of the studies, AMS was effective in increasing adherence to surgical antibiotic prophylaxis protocols and in 28.5%, there was reduction in surgical site infection rate. Three studies evaluated cost-benefit ratio and found a favorable impact. Eight (57%) studies were at risk of moderate bias and six had severe bias. The evaluation of the synthesis of evidence showed quality ranging from low to very low. Conclusion AMS, such as audit, feedback, education, implementation of a protocol, and a computer-assisted decision support methodology, appear to be effective in promoting adherence to surgical antibiotic prophylaxis protocols, reducing surgical site infection rate with a positive economic impact. However, more studies, particularly randomized clinical trials, are needed to improve the level of evidence of available information on AMS in order to favor decision-making.

Implementing PDSA Methodology for Pediatric Appendicitis Increases Care Value for a Tertiary Children's Hospital

Supplemental Digital Content is available in the text.

Introduction:

We used the plan-do-study-act (PDSA) framework to develop and implement an evidence-based clinical practice guideline (CPG) within an urban, tertiary children’s referral center.

Methods:

We developed an evidence-based CPG for appendicitis using iterative PDSA cycles. Similar CPGs from other centers were reviewed and modified for local implementation. Adjuncts included guideline-specific order sets and operative notes in the electronic medical record system. Outcomes included length of stay (LOS), 30-day readmissions, hospital costs, and patient and family experience (PFE) scores. Our team tracked outcome, process, and balancing measures using Statistical Process Charts. Outcome measures were compared over 2 fiscal quarters preimplementation and 3 fiscal quarters postimplementation, using interrupted time series, student t test, and chi-square tests when appropriate.

Results:

LOS for simple (uncomplicated) appendicitis decreased to 0.87 days (interquartile range [IQR] 0.87–0.94 days) from 1.1 days (IQR 0.97–1.42 days). LOS for complicated appendicitis decreased to 4.96 days (IQR 4.95–6.15) from 5.58 days (IQR 5.16–6.09). This reduction equated to an average cost-savings of $1,122/patient. Thirty-day readmission rates have remained unchanged. PFE scores increased across all categories and have remained higher than national benchmarks.

Conclusion:

Development and Implementation of a CPG for pediatric appendicitis using the PDSA framework adds value to care provided within a large tertiary center.