Developing a Reliable System to Improve Peri-Operative Antibiotic Administration

Baystate Medical Center
Springfield, Massachusetts, USA

Evan Benjamin, MD, FACP, Vice President, Healthcare Quality Baystate Health
Jan Fitzgerald, MS, RN, Director Quality and Medical Management, Division of Healthcare Quality
Gary Kanter, MD, Associate Medical Director, Division of Healthcare Quality and Medical Director Pre-Admission Evaluation Unit
Peter K. Lindenauer, MD, Medical Director, Informatics
Prasad Kilaru, MD, Chairman, Anesthesiology, Baystate Medical Center
Deb Provost, MS, RN, BHS, Director, Surgery and Anesthesia
Kay Tetherly, RN, Manager, Centennial OR
Barb Niemiec, RN, Manager, Perianesthesia Services
Deb Fuller, RN, Assistant Director, BMC Surgical Services

  • To increase and sustain the rate of administration of prophylactic antibiotics < 60 minutes prior to incision to top decile performance (October 2002 to October 2006)
  • To increase and sustain the rate of discontinuing prophylactic antibiotics within 24 hours of surgery end time to top decile performance (October 2004 to October 2006)

  • Development of standardized guidelines for use of prophylactic antibiotics by procedure (timing, duration)
  • Global education to all clinicians providing care to surgical populations re: Surgical Infection Prevention (SIP) project
  • Use of PDSA to change process after small tests of change
  • Developed CPOE care sets to expedite ordering and availability
  • Included prophylactic antibiotics in pre-admission booking process
  • Oversupply of prophylactic antibiotics available in pre-op and OR areas
  • Prophylactic antibiotics primed and hung by Pre-op Holding areas staff
  • Changes in supply and locations completed
  • Anesthesiologists took on responsibility for administering prophylactic antibiotics < 60 minutes prior to incision for all procedures
  • Anesthesia forms and operative record revised to prompt administration and support ease of documentation
  • Population specific group review and academic detailing re: evidence and recommendations
  • Hospital national “SIP” position reviewed using external benchmarks
  • Changed CPOE order sets to DC AB within 24 hours of surgery end time  
  • Real time monitor in place and daily compliance reported to clinical champion for 1:1 follow up 
  • Communication for “misses” in place
  • Ongoing rates adopted as a program monitor and reported monthly to Surgical Services, SCIP/Surgery Anesthesia/Surgery PI teams
    • Overall Baystate Medical Center rate compared to national rates
    • Individual physician rates compared to national rates
    • Physician-to-physician rates compared internally and then benchmarked (score cards)
    • Internal competition
  • Drill down of misses preformed — physician score cards developed and used to drive improvement (anesthesiologists and surgeons) 
  • Performance incorporated into annual evaluation 







Summary of Results / Lessons Learned / Next Steps
Implementing specific evidence-based care recommendations can be a slow process. Our continued efforts and focus on prophylactic antibiotics have resulted in sustained high rates of administration (from 11 percent to >99 percent) and discontinuation (from 42 percent to >92 percent) as a result of our multi-pronged team interventions. Reliable application of these two processes has helped to keep our surgical infection rate at the lowest rate since we started tracking. Physician support has been key in adopting these processes.

Lessons Learned
  • Involve the right people. It is important for the “players” or those directly involved in the process to have a voice. This helps in identifying problem areas and to more quickly obtain buy-in.
  • Use rapid cycles of change. This eliminates wasted time in researching, planning, developing, education, implementing, etc., without knowing if the process truly works. 
  • Make the process as simple as possible. Make “the right thing the easy thing.” This helps to make it a win-win situation for both the patient and staff.
  • Share the success. Print graphs, make posters, buy pizza, take pictures, etc., to celebrate your accomplishments.
  • Don’t be afraid of failure. You can learn as much from a failed test as you can from a successful one.
  • Don’t reinvent the wheel. If another organization has used a strategy, idea or form that works, adopt it.
  • Communicate, communicate, communicate! Get the word out to everyone. It helps to use different vehicles to communicate: meetings, hospital publications, flyers, etc.
  • Gain a strong commitment from senior leadership. Their support is crucial. When they round to different units, have them ask the staff about their role in reducing events, what they have identified that could cause harm, or what they have to do in their jobs to prevent harm.



Contact Information
Evan M. Benjamin, MD, Vice President, Healthcare Quality
Baystate Medical Center



[Storyboard presentation at IHI's 2006 National Forum]




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