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.


OBJECTIVE
The primary aim was to deliver cefazolin 30 mg·kg-1to 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-1from 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-1was significantly higher when given after an electronic order than when given verbally, 94% vs 76%.


CONCLUSIONS
This comprehensive quality improvement project improved practitioner compliance with evidence-based preoperative antimicrobial dosing recommendations to reduce the risk of surgical site infections.
Division of Pediatric Anesthesiology, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Lucile Packard Children's Hospital Stanford, Stanford, CA, USA.
Thomas J
http://orcid.org/0000-0002-0723-5262
TJ
Caruso
Division of Pediatric Anesthesiology, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Lucile Packard Children's Hospital Stanford, Stanford, CA, USA.
Ellen
E
Wang
Division of Pediatric Infectious Diseases, Department of Pediatrics, Stanford University School of Medicine, Lucile Packard Children's Hospital, Stanford, CA, USA.
Hayden T
HT
Schwenk
Department of Management Science and Engineering, Stanford University, Stanford, CA, USA.
David
D
Scheinker
Department of Pharmacy Services, Lucile Packard Children's Hospital Stanford, Stanford, CA, USA.
Calida
C
Yeverino
Department of Perioperative Services, Lucile Packard Children's Hospital Stanford, Stanford, CA, USA.
Mary
M
Tweedy
Department of Pharmacy Services, Lucile Packard Children's Hospital Stanford, Stanford, CA, USA.
Manjit
M
Maheru
Department of Pediatrics, Stanford University School of Medicine, Lucile Packard Children's Hospital, Stanford, CA, USA.
Paul J
PJ
Sharek
D000900:Anti-Bacterial Agents / Q000008:administration & dosage / Q000627:therapeutic use; D019072:Antibiotic Prophylaxis / Q000379:methods / Q000592:standards*; D002437:Cefazolin / Q000008:administration & dosage / Q000627:therapeutic use; D002648:Child; D011307:Drug Prescriptions / Q000592:standards; D055695:Electronic Prescribing / Q000592:standards; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D008297:Male; D009726:Nurses; D010595:Pharmacists; D010820:Physicians; D058996:Quality Improvement; D013530:Surgical Wound Infection / Q000517:prevention & control
D000900:Anti-Bacterial Agents; D002437:Cefazolin
anti-infective agents; antibacterial agents; antibiotic prophylaxis; cefazolin; risk factors; surgical wound infection