How many surgical patients receive antibiotics appropriately to prevent surgical infections?

During 2004–2005, hospitals reported that two-thirds of patients undergoing major surgery received antibiotics in a timely manner to prevent postoperative infections. Antibiotic timing was appropriate for less than one-half of Medicare patients undergoing the same kinds of surgeries in 2001.

Why is this important?

About three of every 100 operations performed in the United States are complicated by surgical site infections (Gaynes et al. 2001). Compared with uninfected patients, patients developing surgical site infections spend an additional 6.5 days in the hospital, are more likely to be readmitted to the hospital, and are more likely to die (Kirkland et al. 1999).

The Centers for Medicare and Medicaid Services and the Centers for Disease Control and Prevention partnered in 2002 to promote known evidence on appropriate antibiotics use to prevent surgical infections and minimize antibiotic complications and bacterial drug resistance (Bratzler and Houck 2004). Hospitals' baseline rate of compliance with this evidence was measured for Medicare beneficiaries in 2001.

Surgical infection prevention measures have since been adopted by the Hospital Quality Alliance, a public–private collaboration to voluntarily collect and publicly report hospital quality performance information.

Findings

In 2001, nearly all fee-for-service Medicare beneficiaries who underwent one of five types of major surgery in the hospital received preventive antibiotics, but the timing of antibiotic administration was poor: only a little more than one-half (56%) received antibiotics within one hour before surgical incision, and less than one-half (42%) had antibiotics discontinued within 24 hours after their surgery (Bratzler et al. 2005).

The appropriate timing of preventive antibiotics improved substantially by 2004–2005, when hospitals participating in the Hospital Quality Alliance reported that seven of 10 (71%) adult patients received antibiotics within one hour before surgical incision for one of the five types of surgery, and that about two-thirds (65%) of these patients had antibiotics stopped within 24 hours after surgery (CMS 2006).

Implications

Although performance is improving, preventive antibiotics are still not appropriately timed for about one-third of patients undergoing major surgery. Translating the evidence into actionable goals and measuring performance can help to improve the quality of care. Other practices that have been shown to reduce surgical infections include preventing hyperglycemia and hypothermia and avoiding shaving the surgical site (Dellinger et al. 2005).

Improvement Ideas and Resources

The Surgical Care Improvement Project, a national partnership of organizations seeking to improve surgical care by reducing postoperative complications, has launched a campaign to reduce the incidence of surgical complications by 25 percent by the year 2010.The National Surgical Infection Prevention Collaboration, involving 43 Medicare Quality Improvement Organizations and 56 medical centers across the country, reported a 27 percent reduction in surgical site infections associated with improvement in appropriate antibiotic timing, which was achieved for 85 percent to 92 percent of patients by the end of the project (Mangram et al. 1999). Some factors thought to be important to success included:

• establishing accountability for compliance and obtaining physician agreement on evidence;
• creating standard processes to reliably deliver the antibiotic before surgery; and
• revising postoperative order sets to discontinue antibiotics after surgery.

The American College of Surgeons offers a National Surgical QualityImprovement Program (NSQIP), modeled on asuccessful program developed by the Veterans Administration. NSQIP allows participating hospitals to compare standard surgical outcomes so that they can identify problems and make improvements, such as reducing postoperative wound infections (McCarthy 2005). The program was associated with a 27percent reduction in postoperative mortality in Veterans Administration hospitals (Khuri et al. 2002).

Measure:

The National Surgical Infection Prevention Project evaluated care for 34,133 Medicare inpatients undergoing cardiac, vascular, hip/knee, colon, or hysterectomy surgery at one of 2,965 acute care hospitals nationwide from Jan. 1 through Nov. 30, 2001. These surgical procedures were chosen based on their frequency in the Medicare population, the rates of surgical site infection, and consensus regarding antibiotic prophylaxis. Performance measures were developed by an expert panel based on a review of the literature (Bratzler and Houck 2004). The analysis excluded patients with indications for preoperative or postoperative antibiotic use and cases that were missing documentation of relevant dates and times. Among those lacking documentation of surgical incision time, results were similar when surgical start time was used as a proxy for incision time. All rates were weighted to be nationally representative after adjusting for the state-specific sampling scheme (Bratzler et al. 2005).

The denominator for Hospital Compare data includes adult patients (ages 18 and older) who underwent cardiac, vascular, hip/knee, colon, or hysterectomy surgery at a participating acute care hospital between July 1, 2004, and June 30, 2005. Patients were excluded from the measures if they had indications for preoperative or postoperative antibiotic use. In addition, colon surgery patients who received only an oral prophylactic antibiotic were excluded from the antibiotic start time measure, and patients were excluded from the antibiotic stop time measure if they did not receive any prophylactic antibiotics or had other procedures of interest during separate surgical episodes during the hospital stay. The numerators included those in the denominator population who either received prophylactic antibiotics within one hour prior to surgical incision (two hours if receiving vancomycin or a fluoroquinolone), or who had prophylactic antibiotics discontinued within 24 hours after surgery end time (CMS 2005).

Limitations:

Hospital Compare data are electronically audited and edit-checked, but have not been externally validated for accuracy (CMS 2006). National rates are simple averages of hospital rates, calculated by summing the scores for all hospitals with at least one case for that measure and dividing by the total number of those hospitals.

Source:

The National Surgical Infection Prevention Project used systematic random samples of medical records from each state and was conducted by researchers at the Oklahoma Foundation for Medical Quality, the Centers for Disease Control and Prevention, the Centers for Medicare and Medicaid Services, and the Universities of New Mexico and Washington (Bratzler et al. 2005).

Hospital Compare data are compiled by the Centers for Medicare and Medicaid Services from information submitted by hospitals that voluntarily participate in the Hospital Quality Alliance (HQA). Hospitals collect this information from administrative data and medical records (CMS 2006).

References:

* Indicates source of data used in the chart(s).Bratzler, D. W., and P. M. Houck. 2004. Antimicrobial Prophylaxis for Surgery: An Advisory Statement from the National Surgical Infection Prevention Project. Clinical Infectious Diseases 38 (12): 1706–15.

* Bratzler, D. W., P. M. Houck, C. Richards et al. 2005. Use of Antimicrobial Prophylaxis for Major Surgery: Baseline Results from the National Surgical Infection Prevention Project. Archives of Surgery 140 (2): 174–82.

CMS (Centers for Medicare and Medicaid Services). 2005. Overview of Specifications of Measures Displayed on Hospital Compare as of December 15, 2005. Washington, D.C.: U.S. Department of Health and Human Services.

* CMS (Centers for Medicare and Medicaid Services). 2006. Hospital Compare. Washington, D.C.: Department of Health and Human Services.

Dellinger, E. P., S. M. Hausmann, D. W. Bratzler et al. 2005. Hospitals Collaborate to Decrease Surgical Site Infections. American Journal of Surgery 190 (1): 9–15.

Gaynes, R. P., D. H. Culver, T. C. Horan et al. 2001. Surgical Site Infection (SSI) Rates in the United States, 1992–1998: The National Nosocomial Infections Surveillance System Basic SSI Risk Index. Clinical Infectious Diseases 33 Suppl 2: S69–77.

Khuri, S. F., J. Daley, and W. G. Henderson. 2002. The Comparative Assessment and Improvement of Quality of Surgical Care in the Department of Veterans Affairs. Archives of Surgery 137 (1): 20–7.

Kirkland, K. B., J. P. Briggs, S. L. Trivette et al. 1999. The Impact of Surgical-Site Infections in the 1990s: Attributable Mortality, Excess Length of Hospitalization, and Extra Costs. Infection Control and Hospital Epidemiology 20 (11): 725–30.

Mangram, A. J., T. C. Horan, M. L. Pearson et al. 1999. Guideline forPrevention of Surgical Site Infection, 1999. Centers for Disease Control andPrevention (CDC) Hospital Infection Control Practices Advisory Committee. American Journal of Infection Control 27 (2): 97–132.

McCarthy, D. 2005. Case Study: The National Surgical Quality Improvement Program. Quality Matters (May). New York: The Commonwealth Fund.