Prophylactic Antibiotics in the Instances of Surgical Site Infections - Research Paper Example

 The Use Of Prophylactic Antibiotics To Reduce The Instances Of Surgical Site Infections A Stetler Model Approach ABSTRACT Surgical site infection continues to be a concern for all involved in surgery and post-operative care. In many hospitals great care and staffing are assigned to ensure that infectious outcomes are limited via adequate administration, cross checking, and backup protocols. Through the Stetler Model, we will apply nursing techniques and applications to design a model for a smaller community hospital setting using current research models to write nursing guidelines for surgical antibiotic immunoprophylaxis. We will write a plan for the implementation and evaluation of this plan and its application guidelines. In the interest of covering the trend of electronic health records, the plan will involve the use of newer technologies in maintaining a 100% antibiotic prophylaxis rate. While much has been written concerning which medications to use, when and how, I will take the Stetler Model to use newer technologies to improve upon current problems and provide new ideas to that extent. Phase 1: Introduction and Preparation A great many strides have been made since the advent of antibiotics that have helped cure infection and even prevent them from happening. In surgical care, because the body is being necessarily invaded normal flora can be translated to areas in which they become pathogenic and cause infection and disease (Wells, 2009) . Surgical site infections occur as a result of these bacteria and cause disease in the following manners: Incisional Deep (muscle and fascial layers) Subcutaneous (cellulitis) Organ or Space (Abscess or Meningitis) Further, research conducted by White (2007) shows how despite national recommendation guidelines many hospital surgical teams fail in achieving a 95%+ rate of surgical antibiotic prophylaxis to prevent post-operative infections which can occur as late as 30 days after the procedure (Wells, 2009). The most common soft tissue infectionsare gram positive organisms and are easily treated or prevented, but if allowed to infect areas of the body without prior treatment they can reproduce and cause abscesses, then the chance of damaging infections where organ function is compromised can be adequately controlled using the Stetler model to be implemented here. Appendix 1 will show the replication of the National Research Council Wound Classification. Interest Interest in this topic stems from insight to the needs we have at present to improve some of the antiquated paper systems in place with one that provides for the needs of the patient population, accounting for human error, that will be incurring a surgical procedure and that would be all patients from pediatric to geriatric. The need to limit infection as a complication of an already difficult medical practice is tantamount to improving post-operative infection outcomes where co-morbidities are not common place, but rare and limited. Patient Population and Clinical Settings As mentioned, almost every patient will at one time need a surgical procedure. However, each operation is different and carries risks unique to itself. A colectomy will certainly need different antibiotic treatment than a simple cyst removal or even a transplant operation, however the pre-surgical needs are all the same. Each patient needs to meet with the anesthesiologist, the operating surgeon if they haven't prior to the date, and nursing staff who will be caring for them throughout the process. In each, be it an outpatient facility, hospital, or clinic, appropriate treatments should be administered and proper documentation followed. Validation and Literature Review A complete and thorough review of current literature regarding surgical prophylaxis was performed using Google Scholar for literature review, PubMed, and text sources. Search target parameters included 'surgical prophylaxis error', 'nursing surgery error', 'pre-surgical antibiotics' and 'surgical infection'. After a thorough review, the data seems to suggest that prophylaxis and infection are spotty and that while some systems may have a 90+ rate of compliance, they still have errors concerning which drug should have been administered. A review of the literature gave the following information: Medication prescribing errors were recorded at residency training programs, most of which were not attributable to lack of knowledge (Larsen 2004) Some surgical site infections (SSI) were avoided merely because the incision was clean and no secretions were involved however, 10% did get an infection that was treatable post operatively (Blair 1995) After implementation of new compliance regimens a study in Florida was able to raise complaince from 75% to a baseline of 95% in antibiotic prophylaxis with electronic monitoring included in part of the protocol (White 2007) Multiple component safety intervention in British hospitals found that compliance was already over 90% and that use of increased hand washing and scrubbing was responsible for a decrease in Clostridium difficile and MRSA infection rates (Benning 2011) Literature review also found few studies, if any, that utilized newer technologies in tracking patient care and this is likely due to the new implementation of the technology and few hospitals doing it. The use of paper is slowly going to become a rather antiquated way of entering patient data at bedside, the real issue has been portability, power and battery life, the ability to uplink data in real time, ease of use for those who have not yet become computer competent, and the ability to enter data without heavy training times that pull staff away from the floors and increase worloads for the personnel who are not in the training classes. Tablet computing has finally begun to address these issues and with the increased use of EHR/EMR becoming the standard with recent legislation, the need to develop these systems within hospitals and clinics will become more critical to maintaining or improving patient care. Comparative Evaluation Medical practice is at a critical juncture with regard to technology and its use. Currently, many small physician practices use software to record data and update patient records to a central server. Programs such as SequelMed among others help doctors, nurses and staff to log information into the system and seen by other computers immediately after a “Save” is registered. However, the use of computerized systems in the hospital setting are still in its primitive states. In most locations, a paper chart is still used to track lab reports, administration of medications, rehabilitation, or vital signs. Information currently available points to the fact that the need to garner immediate information is especially critical in places like ICU wards and post-operative care units. The lag time between the taking of a sample and the laboratory report can be hours especially if the report sits on a desk in a basement or top floor while the information is needed in another floor or wing. So how does this apply to surgical prophylaxis? In short, incorrect medication orders, inadequate lead time from results from laboratories, human error could all be avoided with a more up to date electronic ordering and recording system based in part on portable electronic tablets where updating is immeiate and a system of cross checking and evaluation can virtually eliminate error, inadequate administration, and other problems inherent in a paper system. A recent study by Petty's, et al (2010) showed that electronic reminder systems significantly decreased missed prophylaxis for venous thromboembolism. Collaborative efforts between the pharmceutical department led to a simple electronic reminder (ER) for each patient. The results were clear. Before the implementation of the ER the rate of prophylaxis was ~58%. Following installation of the reminder, the rate shot to ~79%. Any patients not needing prophylaxis or who were taking medications where prophylaxis was unwarranted were inclued in the remaining totals. Another study comparative to the previous above, also showed an increase in prophylaxis when EMR alerts were utilized (Lee 2010). Further, a new program at Jefferson University Hospital in Philadephia showed a greatly reduced rate of medication errors in a new EMR program (web link 2010). From the story the doctor in charge was quoted as saying the following: He said that other doctors have told him “the alert has really helped them do the right thing at the right time.” The feasibility of the design is not simple, but it would be effective. The risks of the systems include a lack of adequate battery life in the bedside units or portable tablets, loss of data due to viral infection of the main servers spread to the mobile units, breakage of the units before data upload complete, loss of electricity prior to adequate battery charge and operator error due to a lack of familiarity with computer systems. IT support would be necessary to maintain the units, keep the enhanced systems bug free, and maintain adequate wireless data flow. Clogging of the system due to server “traffic jams” would delayed information upload/download times and potentially lead to inadequate patient care outcomes. Resources for this would include many things, some of which will be included in the plan to follow, but access to technology and wiring for remote LAN connections on a closed loop without outside access would be required. In conversations with friends, I believe that preventing access to the systems from outside internet access would comply with current HIPPA laws and protect patient records. Cost factors may play a role as well, but at less than $500 per unit, the ability to implement an immediate notification system would show greater positive outcomes, plus lower liability rates for the hospital or facility using it. Lowering post-surgical infection rates would lower post operative costs to the wider systems and increase worker productivity in returning to work faster. Current practices are based on paper based systems which require staff signing off on lab reports, medication orders, new procedure orders or scheduling, and then entered into the computerized system. While the paper is a hard record, the chance of losing a simple sheet can mean the difference in getting a correct antibiotic prophylactically or getting one to which the patient might be allergic. Again, the chances of having a system which flows toward better patient care is enhanced when applied with newer technology. An alert can come up on the screen which reminds the nurse, doctor, resident, or lab tech that the patient is allergic to sulfa drugs or a specific class of drugs. Using a personal code, each person would be responsible for each segment of their position and the system provides for ensuring adequate controls for proper drug administration. Decision to Implement The decision to implement would come from several sources and go through an exhaustive evaluation period. The pharmacy department, Chiefs of the ER, ICU, and Internal Medicine, Infectious Disease chief, and nursing staff dept heads would collaborate to find a system which would be simple, yet effective. The hospital protocol committee would utilize its staff and resources to decide how many units and what software enhancements would need to be made. IT staff would be involved from the start at designing such a system or enhancing the current one to suit the new protocols. Protection of the data would be paramount due to compliance with new HIPPA rules and regulations. A Virtual Protected Network would allow for such protection and would log each registrant to the system as a unique entry. So, when the log recorded the order from the pharmacy to retrieve the antibiotic treatment, a separate log entry would be required for pickup and delivery, and finally administration. Nurses, being adults, can learn the system with appropriate hands on seminar-style learning strategies. Tablet computing is simple and easy to learn. Entering data with ease will be a new experience. Logging vitals and reporting will be updated in real time and the nursing staff will find the new process to be functional and a decrease in time spent entering chart data instead of caring for patients. Productivity will also be increased as a result of the new technology implementation. Lastly, patient care will be significantly affected as fewer mistakes will be made and less missed administrations of medications. The final decisions would be made on dependant on platform, cost, and viability. Increasing patient baseline prophylaxis would be the goal, while at the same time, completely upgrading hospital reporting tools. The current platform offerings are few, but are already being seen as effective. The iPad platform already has a tool called Nimble (be-nimble.com). This reporting tool allows the clinician to access patient data on the fly from wherever they are be it the hospital or clinic. Tools for Android based tablets are reported to be in the works, but none are in practice at the moment. Physicians seem to be gravitating to the iPad platform due to its abundance of software. The real key for the new system implementation is cross platform compatibility with whatever system is in place at the time of the final decision and its ramifications on operations and cost containment. Final acceptance would be need from all parties involved. Proposed Protocol The productivity of each unit involved in pre-operative procedures will be enhanced by the ability to simultaneously perform pre-op tasks and record them in digital format without replicating information with the tablet units. Therefore, beginning from the scheduled surgical procedure, as soon as the time slot is accorded the patient, a simple screen will appear at check-in to reestablish patient health records. Since the records will have been entered from a prior doctors visit, a review of them will suffice. The attending nurse will check the appropriate boxes for any co-morbidities that could interfere or need to delay the procedure due to error. Overlooking a patients blood glucose levels, liver function tests and the like could complicate an already dangerous procedure leading to infection or compromised recovery, also leading to infection. Prior to arrival, the physicians orders for all medications will have been received. The pharmacy will have had them prepared and then enter the digital EMR log which will be transmitted to the appropriate floor stations and to the portable tablets. An alert will signal that the medications are available and to be administered. Using a personal code the nurse or other staff will enter that they have received the order and have taken it. Until the order is administered and the nurse administers the appropriate medications an alert will flash until that person signs off on it and shows that the drug was given. Further, once done, the treating physician will also be given a unit to review all pre-op orders and sign off on their administration. Appendix 2 will provide for a complete breakdown of the process and the design profile. Plan For Evaluation Evaluation of the proposed phrophylaxis protocol will be conducted by the same personnel who over saw its installation. The IT department will, after a given time, report on any data corruption issues, violation of the patient records (attempted hacking), and data improvements to the streams needed for amooth information transfer. The appropriate physician department heads will report on ease of use, any information pertaining to patient infection rates, the ability to retrieve data and information without delay from all departments concerned, and ease of compliance. The nursing staff heads will be able to report on any increase in prophylactic applications and medicine administration. Further, the data will be compiled into a comprehensive report to be presented to the hospital administration so that the final results can be submitted for publication. Total compliance with antibiotic administration records will be kept and compared to prior evidence and data. The complete data will necessarily include many other factors and the yield for better patient outcomes can be completely evaluated even if the baseline for antibiotic prophylaxis is above 90% and the increase is minimal, the resultant data from other areas can lead to decreased patient costs. Hospital costs and over-runs in other areas not seen before can also be evaluated because everthing is immediately reported. Mistakes in drug administration can also be avoided with alerts for allergy conflicts, drug contraindications, and more. Should a patient have an infection, lab reports would be available as soon as possible as to gram species, type, and genus. Immediate administration of a new antibiotic for infections typical to that hospital will available in shorter time frames. Alerts to the physicians tablet can be sent with an immediate reply needed to eliminate the alert window. Even hospitalists on staff can benefit as they will no longer need to be present but can order a medication without being on the floor at the moment and can order them remotely with the order going directly to the pharmacy, bypassing the nurses as an intermediary. Overall evaluation will also need to see consensus from the appropriate physicians and nurses, along with the pharmacy and techs for completeness and total medical oversight. Any changes or modifications to the protocol would need input by the appropriate staff members who agreed that the change was needed. Patient review via phone calls or web electronic forms would assist in finding patient comfort with the system as well. Appendix 1 National Research Council Wound Classification, Risk Assessment for Antibiotic Administration Wound Class Representative Procedures Expected Infection Rates Examples of Cases Clean (class I) Hernia repair, breast biopsy 1.0–5.4% Clean/contaminated (class II) Cholecystectomy, elective GI surgery (not colon) 2.1–9.5% Clean/contaminated (class II) Colorectal surgery 9.4–25% Contaminated (class III) Penetrating abdominal trauma, large tissue injury, enterotomy during bowel obstruction 3.4–13.2% Dirty (class IV) Perforated diverticulitis, necrotizing soft tissue infections 3.1–12.8% Appendix 2 Protocol Proposal and Procedures A. Protocol 1. Physician orders entered into EMR and sent directly to pharmacy, OR nursing, and intake. 2. Patient sent home with pre-operative instructions 3. Upon arrival to surgical unit, patient data retrieved and uploaded to tablet. Any drug administrations to be confirmed. 4. Any drug contraindications to be reviewed and confirmed. 5. IV processes started and any drug prophylaxis done no later than 1 hour prior to surgery. 6. Once patient wheeled to OR theater, doctor and anesthesiologist to check off and sign via electronic codes. Signature to include notification that patient has received all appropriate antibiotics and other medications prior to surgery. 7. Prior to administration of anesthesia, patient also to confirm what drugs they were given via HIPA A forms appropriate to the person. 8. Once surgery is complete, reminders will flash on screen to upload all data to central servers for storage and any new orders for pharmacy and nursing post-op care. B. Additional Helps for Staff 1. Colored charts on walls of nursing stations in appropriate places 2. In case of training needs, animation or short video segments can be placed on internal servers for refresher training during down times. 3. Reminder alerts for nurses and physicians can be done to remind to check wounds for infection and also be provided with pictorial reminders. References Camins, B. C. (2005). Reducing the Risk of Health Care-Associated Infections by Complying With CDC Hand Hygiene Guidelines. Joint Commission Journal on Quality and Patient Safety , 31 (3), 173-179. White, A. &. (2007). Improving Compliance With Prophylactic Antibiotic Administration Guidelines. AORN Journal , 85 (1), 173-180. Goldstein, J (2010), Jefferson Tackles Blood Clots Before They Occur, Jefferson Hospital Web Site, http://www.jeffersonhospital.org/The-Daily-Dose/jefferson-tackles-blood-clots-before-they-occur.aspx , retrieved May 18, 2011 Bucher BT, Warner BW, Dillon PA.; Antibiotic prophylaxis and the prevention of surgical site infection Current Opinion Pediatrics 2011 Jun;23(3):334-8. Benning A,et al; Multiple component patient safety intervention in English hospitals: controlled evaluation of second phase; BMJ. 2011 Feb 3;342:d199. doi: 10.1136/bmj.d199 Larson KA, Wiggins EF, Goldfarb MA; Reducing medication errors in a surgical residency training program; Am Surg.2004 May;70(5):467-71. Blair EA, Johnson JT, Wagner RL, Carrau RL, Bizakis JG; Cost analysis of antibiotic prophylaxis in clean head and neck surgery. Arch Otolaryngol Head Neck Surg. 1995 Mar;121(3):269-71. Carrau RL, Byzakis J, Wagner RL, Johnson JT.; Role of prophylactic antibiotics in uncontaminated neck dissections; Arch Otolaryngol Head Neck Surg. 1991 Feb;117(2):194-5. Sarah Petteys, MD*; Joshua Mitchell, MD; Jacob F. Collen, MD; Kathy Cazares, PharmD and Aaron B. Holley, MD; Implementation of an Electronic Reminder Improves Venous Thromboembolism Prophylaxis Rates According to ACCP Guidelines; Chest Journal, doi:10.1378/chest.10796Chest October 2010 vol. 138 no. 4 supp Walter Reed Army Medical Center, Washington, DC Read More