Conaty Oisín, Gaughan Leah, Downey Colum, Carolan Noreen, Brophy Megan Joanne, Kavanagh Ruth, McNamara Deborah A A, Smyth Edmond, Burns Karen, Fitzpatrick Fidelma
Royal College of Surgeons in Ireland, Dublin, Ireland.
Beaumont Hospital, Dublin, Ireland.
Int J Health Care Qual Assur. 2018 Mar 12;31(2):162-172. doi: 10.1108/IJHCQA-05-2017-0078.
Purpose The purpose of this paper is to improve surgical antimicrobial prophylaxis (SAP) prescribing in orthopaedic surgery using the model for improvement framework. Design/methodology/approach Orthopaedic patients receiving joint replacements, hip fracture repairs or open-reduction internal-fixation procedures were included. Antimicrobial(s); dose, time of administration and duration of SAP were evaluated for appropriateness based on the local SAP guidelines. After baseline data collection, a driver diagram was constructed with interventions devised for plan-do-study-act cycles. Data were fed back weekly using a point prevalence design (PPD). Interventions included SAP guideline changes, reminders and tools to support key messages. Findings SAP in 168 orthopaedic surgeries from 15 June 2016 to 31 January 2017 was studied. Prescribing appropriateness improved from 20 to 78 per cent. Junior doctor changeover necessitated additional education and reminders. Practical implications Due to constant staff changeover; continuous data collection, communication, education and reminders are essential to ensure continuous compliance with clinical guidance. Patients with hip fractures are difficult to weigh, requiring weight estimation for weight-based antimicrobial dosing. Unintended consequences of interventions included the necessity to change pre-operative workflow to accommodate reconstitution time of additional antimicrobials and inadvertent continuation of new antimicrobials post-operatively. Originality/value Rather than perform the traditional retrospective focused audit, we established a prospective, continuous, interventional quality improvement (QI) project focusing on internal processes within the control of the project team with rapid cyclical changes and interventions. The weekly PPD was pragmatic and enabled the QI project to be sustained with no additional resources.
目的 本文旨在使用改进模型框架改善骨科手术中的外科抗菌药物预防(SAP)处方。
设计/方法/途径 纳入接受关节置换、髋部骨折修复或切开复位内固定手术的骨科患者。根据当地的SAP指南,评估抗菌药物的种类、剂量、给药时间和SAP持续时间是否合适。在收集基线数据后,构建了一个驱动图,并为计划-执行-研究-行动循环设计了干预措施。使用点患病率设计(PPD)每周反馈数据。干预措施包括SAP指南的更改、提醒以及支持关键信息的工具。
结果 对2016年6月15日至2017年1月31日期间168例骨科手术中的SAP进行了研究。处方适宜性从20%提高到了78%。初级医生的更换需要额外的教育和提醒。
实际意义 由于人员不断更换,持续的数据收集、沟通、教育和提醒对于确保持续遵守临床指南至关重要。髋部骨折患者难以称重,需要估计体重以进行基于体重的抗菌药物给药。干预措施的意外后果包括需要改变术前工作流程以适应额外抗菌药物的复溶时间,以及术后无意中继续使用新的抗菌药物。
原创性/价值 我们没有进行传统的回顾性重点审计,而是建立了一个前瞻性、持续性、干预性的质量改进(QI)项目,该项目聚焦于项目团队可控的内部流程,具有快速的周期性变化和干预措施。每周的PPD很实用,使QI项目能够在不增加额外资源的情况下持续进行。