- Antibiotic started means administration has begun but is not necessarily completed
- Cases in which time of antibiotic administration or time of surgical incision is not documented should be excluded from the numerator and denominator
(1) within two hours if patient receiving vancomycin due to beta-lactam allergy
(2) patients with tourniquets need to have all antibiotic administration completed before the tourniquet is inflated and within one hour prior to surgical incision
(3) patients undergoing C-section should receive the antibiotic as soon as the umbilical cord is clamped
Achieve on-time administration in 100 percent of cases beginning within one hour prior to surgical incision (see “Exceptions” above) within 13 months.
Data Collection Plan
Create system to capture data prospectively on 100 percent of patients.