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Electronic medical record interventions and recurrent perioperative antibiotic administration: a before-and-after
Alexander Hincker1, Arbi Ben Abdallah2, Michael Avidan2
1Department of Anesthesiology, Washington University School of Medicine, 660 S. Euclid Ave, Campus Box 8054, Saint Louis, MO, 63110, USA. hinckera@wustl.edu.
Purpose:
Perioperative antibiotics decrease rates of surgical-site infections. Numerous interventions have improved administration of the first antibiotic dose; however, failures in the administration of subsequent doses frequently occur. We hypothesized that modifications to the electronic medical record (EMR) would improve the administration of the second antibiotic dose and that such improvements would be sustained over time.
Methods:
This historical cohort before-and-after study of multipronged alerts in the EMR analyzed 1,348 operations on adult patients. The operations lasted ≥ 240 min, utilized cefazolin as the perioperative antibiotic-constituting 1,348 second and 182 third intraoperative antibiotic doses-and did not involve cardiopulmonary bypass. A decision support intervention provided dosing recommendations when clinicians documented antibiotics. The reminder intervention displayed a continuous bar in the EMR, starting at the time the antibiotics were dosed and ending 15 min before subsequent doses were indicated. The primary endpoints of the study were the change in the proportion of correctly administered second dose of cefazolin, given in accordance with hospital guidelines in the month after implementing the intervention, and whether any improvements declined by three to seven months after implementation.
Results:
Pre-intervention, 51.4% of second doses of cefazolin were correctly administered. In the immediate post-intervention period, 68.5% were correctly administered, representing a significant absolute improvement of 17.1% (95% confidence interval, 8.1 to 26.1; P < 0.001). Rates did not decline over time; clinicians correctly administered 73.3% of doses in the delayed post-intervention period (P < 0.001 vs pre-intervention).
Conclusions:
These inexpensive nonintrusive interventions to the EMR provided modest lasting improvements in proper administration of repeated doses of cefazolin. The fact that only approximately 70% compliance was reached highlights the difficulty in addressing this deficiency.
Insights
Modifications to the electronic medical record (EMR) improved the administration of subsequent perioperative antibiotic doses. These improvements in cefazolin administration were sustained over time, though full compliance was not achieved.
Area of Science:
- Infectious Disease
- Health Informatics
- Surgical Care
Background:
- Surgical-site infections are reduced by perioperative antibiotics.
- While initial antibiotic dosing is often successful, subsequent doses are frequently missed.
- Electronic Medical Record (EMR) interventions can potentially improve adherence to antibiotic protocols.
Purpose of the Study:
- To test the hypothesis that EMR modifications would improve the administration of the second dose of perioperative antibiotics.
- To determine if these improvements would be sustained over time.
Main Methods:
- A historical cohort, before-and-after study involving 1,348 adult operations.
- Interventions included EMR decision support for dosing recommendations and a visual reminder bar.
- The study analyzed the correct administration of cefazolin, focusing on the second intraoperative dose.
Main Results:
- Correct administration of the second cefazolin dose increased from 51.4% pre-intervention to 68.5% immediately post-intervention (17.1% absolute improvement).
- This improvement was sustained, with 73.3% correct administration in the delayed post-intervention period (3-7 months).
- The interventions were inexpensive and nonintrusive.
Conclusions:
- EMR modifications led to modest, lasting improvements in the administration of repeated cefazolin doses.
- Despite improvements, compliance rates around 70% highlight the persistent challenge in optimizing antibiotic administration.
- Further strategies may be needed to achieve higher adherence rates for perioperative antibiotics.