Editor’s Note:

This text was abstracted from Whitman G, Cowell V, Parris K, et al. Prophylactic antibiotic use: hardwiring of physician behavior, not education, leads to compliance. J Am Coll Surg 2008 Jul;207(1):88-94. The article described a successful program at Temple University Hospital.

Introducing certain forcing functions can help improve physician behavior associated with use of prophylactic antibiotics in preventing surgical site infections, according to the results of a study undertaken at Temple University Hospital. The study addressed correct selection, appropriate timing of administration, and appropriate postoperative ces-sation of antibiotics.

The authors reviewed prophylactic antibiotic administration documented in the charts of more than 1,600 patients cared for between March 2005 and March 2007. Three patient variables were noted: (1) prophylactic antimicrobial regimen consistent with published guidelines, (2) parenteral antimicrobial prophylaxis initiated within one hour before incision, and (3) prophylactic antimicrobials discontinued within 24 hours after the procedure. The authors then devised processes to improve compliance (beyond educating residents and faculty). The processes were as follows:

Appropriate selection. Department-specific preoperative order forms were developed that limited choices to appropriate antibiotic prophylaxis selection (i.e., only prophylactic antibiotics recommended by the national Surgical Care Improvement Project). Compliance with appropriate selection increased from 76% to 91%.

Preoperative timing of administration. The practice of administering preoperative antibiotics within one hour before the procedure has previously been demonstrated to lower wound infection rates by as much as 80%. In response to variances in timing of initial dose, responsibility for confirming antibiotic administration during the time-out was assigned to the anesthesiologist (i.e., according to hospital policy, the time-out occurs in the operating suite before the patient is draped and in the presence of the surgeon, anesthesiologist, and nursing staff). Confirmation of antibiotic administration became part of the time-out checklist, and the time of administration and choice of antibiotic were documented. Compliance with timing of administration increased from 55% to 95%.

Postoperative cessation. To prevent further dose of prescribed antibiotics being administered more than 24 hours after the procedure (resulting from an order similar to the following: “antibiotic IV now and q 8 hours x 3 doses”), a postoperative path-way was implemented in the facility’s electronic medical record. If the pathway is used, the order for postoperative antibiotics limits administration to 16 hours from the initial dose. With the use of this pathway, compliance with postoperative cessation of antibiotics increased from 60% to 86%.Limitations of the study included that study design did not allow for a control group and that physician awareness of importance of correct administration of prophylactic antibiotics may have increased during the study period.