Improvement in Antimicrobial Stewardship for Orthopaedics Procedures: A NSQIP Quality-Improvement Project

Antimicrobial resistance is a notable threat to global health. In an institution-specific report generated through National Surgical Quality-Improvement Pediatric Program (NSQIP-P) for our institution, our orthopaedic surgery department was a high outlier for postoperative antibiotic prophylaxis duration of >24 hours. We describe an initiative to reduce the incidence of postoperative duration of antibiotics of >24 hours for pediatric patients undergoing orthopaedic surgery.

An interdisciplinary team was formed to identify and monitor interventions for improvement. Patients undergoing orthopaedic surgeries and receiving postoperative intravenous antibiotics were included. First-stage interventions included verbal education for front-line staff to ensure that postoperative antibiotic prescribing did not exceed two doses. Second-stage interventions included a modification that changed the default postoperative antibiotic dose from three to two doses for the three most used orthopaedic admission order sets in the electronic medical record. Patient-level, electronic health record data elements were extracted and presented through a created electronic dashboard to track near-real-time metrics. Surgical site infections were tracked through NSQIP-P database as a balancing measure.

A total of 2,546 surgical cases met study criteria: 1,680 and 866 cases in the pre- and post-intervention cohorts, respectively. Cefazolin was the primary postoperative antibiotic prescribed in 95.4% of cases. In the preintervention cohort, <24 hours of postoperative antibiotics was 36.7% compared with 84.7% (48.0% improvement) in the post-second stage intervention cohort. A sampling of postintervention cases demonstrated no notable increase in surgical site infection events compared with matched period sampling of preintervention cases.

NSQIP-P can be leveraged to improve antibiotic stewardship in pediatric orthopaedic surgical cases. Multidisciplinary collaboration, front-line staff education coupled with electronic medical record order set modification, and near-real-time data tracking for provider feedback resulted in a 48.0% improvement of patients receiving <24 hours of perioperative antibiotics.

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