Improvement Report: Promoting Quality Through Prevention of Infection

Baystate Medical Center
Springfield, Massachusetts, USA

Core Project Team
Senior Leader:  Vice President of Quality
Operational Leader: Nurse Manager of OR
Day-to-Day Leader: Quality Improvement Nurse Physician
Champion: Chief of Cardiac Surgery

Key Stakeholders
Cardiothoracic Surgery, Vascular Surgery, Anesthesiology
ID, Endocrine
Operating Room, Post Anesthesia Care Unit, Critical Intensive Care Unit
Nursing Pharmacy Infection Control


Decrease morbidity and mortality associated with postoperative infection in the surgical patient population.





Antibiotic Timing
  • Presented baseline data and evidence-based resources to perioperative team (Anesthesiology, Surgery, and Surgical Staff)
  • Standardized antibiotic administration and documentation process
    • Anesthesiologist to try administering antibiotic in Operating Room rather than nurse administration in pre-op holding
    • Highlighted importance of administering within 60 minutes
    • Anesthesia begins documenting administration of antibiotic of incision
  • Circulated nurse verified that Anesthesiologist gave initial antibiotic and reminded to re-dose based on half-life of antibiotic-use of count board to track timing
  • Revised order sets to change "on call" to "anesthesia to give in Operating Room within 60 minutes of incision"
  • Monitored and gave feedback to clinicians daily
  • Shared and posted information (staff areas, performance improvement teams, newsletter)



Summary of Results / Lessons Learned / Next Steps
The team identified the need to continue to educate the staff and physicians on the process changes. The team has seen sustained improvements in antibiotic administration in all surgical patients since the program began on April 28, 2002.

  • Increase in percent of both cardiac patients and increase in vascular patients receiving antibiotics on time but overall holding the gains
  • Increases in appropriate antibiotic selection for both cardiac and vascular patients
  • Slow sustained overall increase noted in perioperative glycemic control for cardiac surgery patients but ongoing work needed to achieve target
  • Overall improvement in normothermia for both patients populations some variation present
  • Great improvement in duration of antibiotics discontinued at 24 hours
  • Continuing to work on all interventions

Contact Information

Janice Fitzgerald





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