Improving Compliance With Prophylactic Antibiotic Administration Guidelines

JANUARY 2007, VOL 85, NO 1 • AORN JOURNAL • 173

Anne White, RN; Todd Schneider

Surgical site infections (SSIs) are aserious complication of surgery,significantly increasing the mor-

bidity, mortality, length of hospital stay,and costs associated with surgical pro-cedures.1-9 The risk for SSIs varies de-pending on the surgical procedure andpatient characteristics including age;steroid use; nicotine use; malnutrition;and comorbid conditions, including di-abetes and obesity.10,11

In an effort to prevent SSIs, healthcare practitioners employ a variety ofinterventions, such as using sterile sur-gical instruments, maintaining a sterilesurgical field, ensuring rigorous anti-septic preparation of the incision site,clipping hair at the incision site insteadof shaving, and maintaining normo-thermia.12-14 In addition, several studieshave shown that administering pro-phylactic parenteral antibiotics imme-diately before the beginning of theprocedure significantly decreases theincidence of postoperative SSIs inselected surgical procedures.15-18 Appro-priate administration of antibiotics alsois one of several quality measures iden-tified by the Surgical Care Improve-ment Project as important processes forhealth care facilities to implement toprevent SSIs (Table 1).

National guidelines emphasize theimportance of timing in prophylacticparenteral antibiotic administration,with recommendations stating that ad-ministration should occur within 60minutes before the initial incision ismade.2,19-23 Despite the widespread dis-semination of information about theneed to administer prophylactic par-enteral antibiotics, a recent study andanecdotal observations indicate that

compliance rates with the nationalguidelines are low.24 The purpose of thisquality improvement (QI) project wasto determine whether selected changesin perioperative processes for prophy-lactic antibiotic administration wouldimprove compliance rates with theguidelines for medication administra-tion to occur within 60 minutes of theinitial incision.

CHANGES IN PREOPERATIVE PROCESSESAt Tallahassee Memorial HealthCare

(TMH) in Tallahassee, Fla, the SSI im-provement team—composed of staffmembers from the main OR, pharmacy,and infection control and performanceimprovement departments—decided toaddress inconsistencies in preoperativeantibiotic administration by makingchanges to preoperative processes. Infec-tion reduction was part of the surgicalservices strategic plan, which was linked

© AORN, Inc, 2007

Improving Compliance WithProphylactic Antibiotic

Administration Guidelines

• TO REDUCE THE INCIDENCE of surgical siteinfections, preoperative prophylactic antibioticsshould be administered within 60 minutes beforethe initial incision is made. A recent study and an-ecdotal observations, however, indicate that ratesfor compliance with these guidelines are low.

• A QUALITY IMPROVEMENT PROJECT wasundertaken at a Florida health care facility to de-termine if implementing changes in preoperativeprocesses would increase compliance with pro-phylactic antibiotic administration guidelines.

• AFTER THE STRATEGIES were implemented,compliance rates with the national guidelines foradministration of antibiotics within 60 minutes ofsurgical incision increased from 75% at baseline to95% postimplementation. AORN J 85 (January2007) 173-180. © AORN, Inc, 2007.

ABSTRACT

174 • AORN JOURNAL

JANUARY 2007, VOL 85, NO 1 White — Schneider

to the hospital’s vision to be recognizedas a world-class community health caresystem. In addition, SSI process measuresare publicly reported measures by theCenters for Medicare and Medicaid Ser-vices. To achieve rapid change, TMHjoined the Institute for Healthcare Im-provement’s Breakthrough Series Collab-orative. Staff members implementedstrategies designed to improve compli-ance with prophylactic antibiotic admin-istration within 60 minutes of initial inci-sion, including• making changes in the electronic

documentation of perioperative care; • changing the preoperative processes

for antibiotic administration; • revising preoperative standing orders

for select surgical diagnoses; and• introducing a preoperative holding

area process for screening preopera-tive antibiotic orders according to na-

tional guidelines and immediatelynotifying noncompliant physicians. EXPANSION OF COMPUTERIZED CHARTING. Intra-

operative electronic documentation wasinstalled one year before this QI projectbegan. These processes were expandedto include prompts regarding prophy-lactic antibiotics that included antibioticselection and time of administration.The electronic chart included a questionasking if antibiotics had been ordered.The perioperative nurse then chartedthe timing and antibiotic selection forantibiotic administration.

TIMING OF ANTIBIOTIC ADMINISTRATION. To en-sure that prophylactic antibiotics wereconsistently administered within 60minutes before the initial incision wasmade, it was necessary to determine theappropriate time for the health care prac-titioners to administer them. The appro-priate time for administration was deter-mined by observing the average timefrom when the patient entered the OR towhen the initial incision was made,which for all procedures ranged from 20to 30 minutes. Based on this information,the SSI improvement team determinedthat the anesthesia care provider shouldadminister the antibiotics immediatelybefore the patient leaves the preopera-tive holding area. This process changeenabled health care practitioners to con-sistently administer antibiotics within 60minutes of the initial incision.

It was necessary to make adaptationsto this process for cardiac surgical patientsbecause of longer surgical prep times forthese patients in the OR. The ideal timefor administering antibiotics to the cardiacsurgical patient was determined to bewhen the anesthesia care provider insert-ed the pulmonary artery catheter becausethe initial incision was made approxi-mately 30 minutes after this point.

It also was necessary to make processadaptations for patients receiving fluo-roquinolone or vancomycin. The na-tional guidelines for administering

TABLE 1Quality Measures to Prevent

Surgical Site Infections1

Prophylactic antibiotics were administered on time.

Appropriate prophylactic antibiotics were selected.

Prophylactic antibiotics were discontinued within 24 hours after surgery.

Perioperative serum glucose was controlled (ie, wasless than 200 mg/dL) among major cardiac surgery patients.

Postoperative wound infection was diagnosed duringindex hospitalization (ie, the admission during whichthe surgical procedure occurred).

Appropriate hair removal was performed.

Perioperative normothermia was maintained among colorectal surgical patients.

Perioperative serum glucose was controlled (ie, wasless than 200 mg/dL) among noncardiac major surgerypatients.

Major surgery patients who did not undergo plannedhypothermia maintained normothermia during the perioperative period.

1. FMQAI—Florida's Medicare Quality Improvement Orga-nization. Surgical Care Improvement Project (SCIP) page 2.Available at: http://www.fmqai.com/Professionals-Providers/hospital/Identified-Participant-Groups/Surgical-Care-Improvement-Project/Surgical-Care-Improvement-Project-Page-2/. Accessed November 7, 2006.

AORN JOURNAL • 175

White — Schneider JANUARY 2007, VOL 85, NO 1

fluoroquinolone or vancomycin statethat the infusion must be started within120 minutes before the anticipated timeof the initial incision so that the medica-tion is completely infused within 60 min-utes before the initial incision is made.25

Preoperative holding area staff mem-bers, therefore, were instructed to ad-minister fluoroquinolone or vancomycinwhen the patient arrived in the preoper-ative holding area to meet the nationalguidelines for administering these med-ications. For cardiac patients who re-ceived fluoroquinolone or vancomycin,the infusion was started when the pa-tient departed the preoperative holdingarea, which allowed approximately onehour for the medication to infuse beforethe initial incision was made.

To meet these strict timelines for an-tibiotic administration, the antibioticneeded to be easily accessible to preop-erative holding area staff members. Tomitigate delays related to pharmacy de-livery, antibiotics were stored in an au-tomated medication dispensing systemin the preoperative holding area, en-abling immediate retrieval of antibioticswhen needed.

APPROPRIATE STANDING ORDERS FOR ANTIBI-OTICS. The standing orders were revisedto include preoperative antibiotic ad-ministration. The revised orders speci-fied antibiotic selection and timing forsurgical procedures for which preoper-ative antibiotics were recommended.23

PREOPERATIVE HOLDING AREA STAFF MEMBER ROLE.Previously, there was no systematicprocess for ensuring timely antibiotic ad-ministration. One procedure change in-cluded assigning responsibility to thepreoperative holding area staff for ensur-ing that patients appropriate for preoper-ative antibiotics (ie, based on nationalguidelines) had an order for antibiotics(Table 2). If orders were not present whena patient was transferred to the preopera-tive holding area, a holding area staffmember called the physician for an an-

tibiotic order. After obtaining the order,the preoperative holding area staff mem-ber retrieved the antibiotic from the auto-mated dispensing system and preparedand hung the antibiotic for administra-tion at the appropriate time.

IMPLEMENTATIONImplementation of these interventions

began in October 2004 and was complet-ed in March 2005. Implementation of theinterventions was staggered over a five-month period to ensure adequate timefor staff members to become familiarwith the new processes.

As individual components of the in-terventions were implemented, it wasnecessary to make some adjustments toperioperative processes to improve im-plementation. For example, a prompt inthe intraoperative electronic documenta-tion system reminded the circulatingnurse to discuss antibiotics with thephysician to make sure antibiotics wereordered so that they could be adminis-tered within 60 minutes before the initialincision was made. Initially, there wasconfusion regarding which patient pop-ulations required antibiotic orders. Thisresulted in some physicians being askedfor antibiotic orders when it was not in-dicated and other physicians not beingasked about antibiotics when antibioticswere indicated. To overcome this prob-lem, the names of patients for whom an-tibiotics were recommended accordingto national guidelines were highlightedon the OR schedule.

With the addition of each new strate-gy during the implementation phase, pe-rioperative nursing and medical staffmembers were educated and supported.A critical step in ensuring staff membercompliance with the new interventionswas allowing adequate time for staffmember education. This was particularlyevident when educating physiciansabout the project. Numerous presenta-tions were made to physicians at regular

A critical step in ensuring staff member compliance with the new interventions was allowing adequate time for staff member

education, particularly for educating physicians.



surgical section meetings to present infor-mation and data regarding the imple-mentation strategies for increasing therates of antibiotic administration within60 minutes of initial incision and appro-priate antibiotic selection. In addition tophysicians, administrative, risk manage-ment, and nursing staff members attend-

ed these meetings. A clinical pharmacistalso spoke at physician meetings andwith individual physicians to discuss ap-propriate selection and timing of antibi-otics. It was essential to bring data aboutcompliance rates with the nationalguidelines, as well as literature sourcesfor the guidelines, to meetings with the

TABLE 2Antibiotic Recommendations for Select Surgical Procedures1-3

Surgical procedure Recommended Recommendation for patientscategory antibiotic prophylaxis with beta-lactam allergy*Cardiothoracic

Gastrointestinal

Genitourinary

Gynecologic and Obstetric

• Cefazolin 1 g to 2 g IV • Cefuroxime 1.5 g IV• Vancomycin** 1 g IV (if high

risk for methicillin-resistantStaphylococcus aureus [MRSA])

• Vancomycin** 1 g IV • Clindamycin 600 mg to 900 mg IV

Esophageal,gastroduodenal, biliary tract (high-riskpatients only)

Colorectal

Appendectomy, nonperforated

Ruptured viscus

• Cefazolin 1 g to 2 g IV

• Ampicillin/sulbactam 1.5 g IV• Cefazolin 1 g to 2 g IV plus

metronidazole** 0.5 g to 1 g IV

• Cefazolin 1 g to 2 g IV plusmetronidazole** 0.5 g to 1 g IV

• Cefoxitin 1 g to 2 g IV plusgentamicin** 1.5 mg/kg IV

• Clindamycin 600 mg to 900 mgIV plus gentamicin** 1.5 mg/kgIV or aztreonam** 1 g to 2 g IVor levofloxacin** 750 mg IV

• Metronidazole** 0.5 g to 1 g IVplus gentamicin** 1.5 mg/kg IVor levofloxacin** 750 mg IV

High-risk patients only • Levofloxacin** 750 mg IV

Abdominal or vaginal hysterectomy

Cesarean section

Abortion—first trimester,high risk patients

Abortion—secondtrimester

• Ampicillin/sulbactam 1.5 g IV• Cefazolin 1 g to 2 g IV• Metronidazole 0.5 g to 1 g IV

• Cefazolin 1 g to 2 g IV (administered after umbilical cord is clamped)

• Aqueous penicillin G** 2 millionunits IV

• Doxycycline** 300 mg orally


• Clindamycin 600 mg to 900 mgIV plus gentamicin** 1.5 mg/kgIV or aztreonam** 1 g to 2 g IVor levofloxacin** 750 mg IV

• Clindamycin 600 mg to 900 mg IV• Metronidazole** 0.5 g to 1 g IV

plus gentamicin** 1.5 mg/kg IVor levofloxacin** 750 mg IV

All procedures



physicians and anesthesia care providersto ensure their acceptance of and adher-ence to the changes needed on their part.

MEASURING PROGRESSTo determine whether the interven-

tions had improved compliance rateswith preoperative antibiotic adminis-

tration guidelines, staff members atTMH used a pre-experimental static-group comparison design26 to comparecompliance rates before and after thechanges were made in preoperativemedication administration processes.The QI project leaders employed a ret-rospective review of existing databases

TABLE 2Antibiotic Recommendations for Select Surgical Procedures (continued)

Surgical procedure Recommended Recommendation for patientscategory antibiotic prophylaxis with beta-lactam allergy*Head and neck

Neurosurgery

Ophthalmic

Orthopedic

Vascular Surgery

General recommendations• One dose of antibiotic should be administered within 60 minutes before the initial incision is made.• Vancomycin and fluoroquinolones (ie, levofloxacin) should be administered within 120 minutes before the

initial incision is made so the medications are completely infused within 60 minutes of the initial incision.• Readminister antibiotic every 3 hours for prolonged procedures (ie, longer than 4 hours); in cases of

major blood loss; or unless contraindicated.• Consider higher antimicrobial dose for patients who weigh 80 kg or more. • All antibiotics should be discontinued within 24 hours after the procedure.

1. Antimicrobial prophylaxis for surgery. Treat Guidel Med Lett. 2004;2:27-32.2. Bratzler DW, Houck PM, Surgical Infection Prevention Guidelines Writers Workgroup, et al. Antimicrobial pro-phylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project. Clin InfectDis. 2004;38:1706-1715.3. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection,1999: Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol. 1999;20:250-278.

* For patients with beta-lactam allergies, any medication in this column is appropriate for this surgical procedurecategory. ** These medications should not be readministered in the event of a long procedure or major blood loss.

• Clindamycin 600 mg to 900 mg IVplus gentamicin 1.5 mg/kg IV


• Cefazolin 1 g to 2 g IV • Vancomycin** 1 g IV

• Cefazolin 100 mg subconjunctivally

Hip or knee arthroplasty • Cefazolin 1 g to 2 g IV • Cefuroxime 1.5 g IV• Vancomycin** 1 g IV (if high risk

for MRSA)

• Vancomycin** 1 g IV • Clindamycin 600 mg to 900 mg IV

Incisions through oral orpharyngeal mucosa

• Cefazolin 1 g to 2 g IV • Cefuroxime 1.5 g IV• Vancomycin** 1 g IV (if high risk

for MRSA)

• Vancomycin** 1 g IV• Clindamycin 600 mg to 900 mg IV

All procedures

All procedures

All procedures



and medical records of patients whounderwent surgical procedures beforeand after the preoperative antibioticadministration process changes wereimplemented for this project.

Following approval by the institution-al review board of the health care facility,specially trained staff members reviewedperioperative databases to identify eligi-ble participants among patients who un-derwent elective surgical procedures be-tween Sept 1, 2004, and Oct 31, 2004, (ie,the pre-implementation group) and be-tween June 1, 2005, and July 31, 2005 (ie,the postimplementation group). The staffmembers then retrospectively reviewedmedical records for the presence of in-clusion and exclusion criteria for the QIproject. Participants were restricted topatients who underwent one of the fol-lowing surgical procedures: • total joint replacement (ie, hip, knee,

shoulder);• cardiac surgery (ie, coronary artery

bypass, cardiac valve repair or re-placement);

• major vascular surgery; • gastric bypass; or • colon resection. Participants were excluded if they hada contaminated wound classification.A total of 398 participants met the cri-teria, with 205 participants in the pre-implementation group and 193 partici-pants in the postimplementation group.

Data on the following variables were

extracted from participants’ medicalrecords or the hospital databases: • type of surgical procedure, • the physician who performed the

procedure, • wound classification, • time of preoperative antibiotic ad-

ministration,• time of initial incision, • type of antibiotic administered, and • any patient allergies. Data were summarized using descrip-tive statistics. The project leaders calcu-lated the rates of compliance with theguidelines for administering prophy-lactic antibiotics within 60 minutes ofthe initial incision for the two groups(ie, the pre-implementation and post-implementation groups). Time lengthsthat were within the zero- to 60-minuteperiod before the initial incision wereconsidered compliant, and those occur-ring outside that recommended periodwere considered noncompliant.

RESULTSData from the pre-implementation

period of this project validated the re-sults of a previous study24 and anecdot-al observations that administration ofpreoperative antibiotics within thetime period identified in nationalguidelines does not occur for all pa-tients (Table 3). During the baseline pe-riod of the project, preoperative antibi-otic administration for 25% of patients

TABLE 3Rates of Compliance With National Guidelines for Administering

Prophylactic Antibiotics Before and After Implementation of Strategies to Improve Compliance

Surgicalprocedure Compliance before Compliance after Change ingroups implementation implementation complianceTotal joints 86% (n = 56) 97% (n = 79) 11%

Cardiac surgery 80% (n = 50) 95% (n = 41) 15%

Gastric bypass 88% (n = 16) 92% (n = 12) 4%

Colon resection 74% (n = 38) 96% (n = 26) 22%

Vascular surgery 53% (n = 45) 87% (n = 35) 34%

All groups 75% (N = 205) 95% (N = 193) 20%



was found not to be in compliancewith the national guidelines. Of partic-ular concern was the disparity in com-pliance rates between different surgicalprocedure groups, with one subgroupof surgical procedures (ie, vascularprocedures) having a compliance rateof only 53%.

Compliance rates after implementa-tion increased from an overall pre-implementation rate of 75% to an over-all postimplementation rate of 95%. Thelargest improvements in compliancewere in the two surgical subgroups withthe lowest pre-implementation scores,with compliance rates for vascular pro-cedures increasing from 53% to 87% andcompliance rates for colon resection pro-cedures increasing from 74% to 96%. Thesubgroups that had the least increase incompliance over the project period werethe two groups with the highest pre-implementation scores; compliance ratesfor joint replacement procedures in-creased from 86% to 97% and compli-ance rates for gastric bypass surgeriesincreased from 88% to 92%.

The project leaders used chi squareanalysis to determine whether a signifi-cant change in compliance scores oc-curred after the intervention was imple-mented. They found that all of theincreases in compliance rates were sta-tistically significant (P < .05).

PROJECT OUTCOMESThis project demonstrated that signifi-

cant improvements in compliance withnational guidelines can occur with imple-mentation of a variety of strategies tochange perioperative processes for pro-phylactic antibiotic administration. Notsurprisingly, the largest improvements incompliance rates occurred in those surgi-cal categories with the lowest baselinecompliance rates before implementationof the strategies. Other health care facili-ties also may be able to increase theirrates of compliance with prophylactic an-

tibiotic administration guidelines by im-plementing similar changes to their pre-operative processes. ❖

Anne White, RN, BSN, CNOR, is thedirector, main OR at TallahasseeMemorial HealthCare, Tallahassee, Fla.

Todd Schneider, BSIE, EIT, is a man-agement engineer and improvementadvisor at Tallahassee MemorialHealthCare, Tallahassee, Fla.

The authors acknowledge Patricia Folsom,RN, BSN, CNOR, assistant nurse manager,main OR; Natalie Robertson, PharmD,MHA, pharmacy clinical coordinator; andLinda Russell, RN, CNOR, improvementadvisor, Tallahassee Memorial Hospital, Tallahassee, Fla, for their contributions toand assistance with this project.

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Emerg Infect Dis. 2001;7:828-831.16. Zmora O, Pikarsky AJ, Wexner SD.Bowel preparation for colorectal surgery.Dis Colon Rectum. 2001;44:1537-1549.17. Boxma H, Broekhuizen T, Patka P,Oosting H. Randomised controlled trial ofsingle-dose antibiotic prophylaxis in surgi-cal treatment of closed fractures: the DutchTrauma Trial. Lancet. 1996;347:1133-1137.18. Barker FG II. Efficacy of prophylacticantibiotic therapy in spinal surgery: a meta-analysis. Neurosurgery. 2002;51:391-400.19. Classen DC, Evans RS, Pestotnik SL,Horn SD, Menlove RL, Burke JP. The tim-ing of prophylactic administration of antibi-otics and the risk of surgical-wound infec-tion. N Engl J Med. 1992;326:281-286.20. Dellinger EP, Gross PA, Barrett TL, et al.Quality standard for antimicrobial prophy-laxis in surgical procedures. Infect ControlHosp Epidemiol. 1994;15:182-188.21. Antimicrobial prophylaxis for surgery.Treat Guidel Med Lett. 2004;2:27-32.22. Butts JD, Wolford ET. Timing of periop-erative antibiotic administration. AORN J.1997;65:109-115. 23. Bratzler DW, Houck PM, Surgical Infec-tion Prevention Guidelines Writers Work-group, et al. Antimicrobial prophylaxis forsurgery: an advisory statement from theNational Surgical Infection Prevention Pro-ject. Clin Infect Dis. 2004;38:1706-1715.24. Bratzler DW, Houck PM, Richards C, etal. Use of antimicrobial prophylaxis formajor surgery: baseline results from theNational Surgical Infection Prevention Pro-ject. Arch Surg. 2005;140:174-182.25. Burlingame B. OR fire extinguishers;classifying wounds and minor procedures;antibiotic infusion time; mopping afterminor procedures [Clinical Issues]. AORNJ. 2006;83:1384-1393.26. Campbell DT, Stanley JC. Experimentaland Quasi-Experimental Designs for Research.Chicago: R McNally; 1963:12-13.

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AORN’s 54th Congress in Orlando, March 11-15, 2007.Funding for these grants is made possible by a gener-ous donation from the Integra Foundation.

The deadline to apply for a grant is Feb 9, 2007,

and all applications must be mailed to the AORNFoundation office. Winners of 2006 Congress grantsare not eligible to apply for 2007 Congress grants.For more information and to obtain an application,please visit the AORN Foundation web site at http://www.aorn.org/foundation/grants.asp.

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Improving Compliance With Prophylactic Antibiotic Administration Guidelines