Timing is everything when it comes to improving financial efficiency and boosting quality of care by maximizing the efficacy of antibiotics administered before and after surgery, according to new consensus guidelines.
The guidelines, published in the June 15 issue of Clinical Infectious Diseases, were the result of a year-long effort by a consortium of surgical and professional societies, the VHA, several universities and several government entities including CMS and the Centers for Disease Control and Prevention.
Their work indicates money can be saved by foregoing the cost of squandered antibiotics delivered too late to be effective, as well as by minimizing the added costs of treating patients with hospital-acquired infections when antibiotics are administered too late.
Study co-author Dale Bratzler, D.O., is principal clinical coordinator for the Oklahoma Foundation for Medical Quality, which contracted with CMS to coordinate the research. Bratzler said the first step was for work-group members to review the existing guidelines.
"We noticed when we looked at some of the guidelines there were some discrepancies and that some things weren't addressed," Bratzler said.
For example, when a patient was to undergo abdominal surgery but was allergic to the preferred antibiotic, there was no guideline suggesting alternatives, Bratzler said.
The next step was to get an agreement that uniform guidelines were needed, Bratzler said. Then the work began settling on what those guidelines would be.
Surgical-site infections are the second most common cause of hospital infections, with more than 500,000 occurring in the U.S. each year, according to the authors, citing CDC data.
On average, each infection adds seven extra days to a hospital stay and costs between $3,000 to $5,000 per incident, but in severe cases--say an infection following hip surgery that requires replacement of the entire implant--the cost can soar to upward of $50,000, according to John Hitt, M.D., a member of the study group.
The importance of timing in the administration of antibiotics is nothing new, Hitt said, with some research dating back to the 1960s.
"There is lots of data that shows you have to give it the right time before surgery and you have to have it on board during surgery," said Hitt, vice president of clinical affairs/clinical improvement for VHA. Hitt is an internist with a specialty in infectious diseases.
Hitt, Bratzler and other members of the work group examined best practices in five surgical areas: cardiothoracic, vascular, colon, hip or knee replacement and vaginal or abdominal hysterectomy. They recommended that antibiotics should be given one hour before surgery and should not be used more than 24 hours beyond the end of the operation.
Only about 55% of surgical patients receive antibiotics within an hour of surgery, and they are administered for an average of 40 hours postprocedure--in some instances as long as 96 hours after surgery.
Supplying the medications too soon can sometimes lead to weakened efficacy due to the half-life of certain antibiotics, said Hitt. Supplying them for too long after surgery simply wastes drugs and money.
"There is no compelling evidence that giving antibiotics after closing the surgical wound gives any benefit," Hitt said. "In only one of 30 studies did a longer duration show benefit over a shorter duration, and several people who have looked at that study suggest that one has questionable data."
"Anytime you use an unnecessary drug, that's flushing money down the toilet," Hitt says. And while antibiotics are fairly inexpensive, "you multiply that times a number of surgeries a year and it starts to amount to real money. We did some calculations for some of our hospitals; it's multiple thousands of dollars even for small hospitals."
The group reported that national data indicate one in four colon surgery patients do not receive the correct antibiotic, with similar rates running between 3% to 10% for other forms of surgery.
In addition to saving money, another goal of the project was to reduce the resistance to antibiotics by targeting the most effective use, thereby reducing overuse, Bratzler said.
Hitt said a couple of low-tech ways of improving performance is to add antibiotic timing to the timeout check list just before surgery and to work with the anesthesiologist to administer the drug through direct injection.
More than a dozen professional societies have endorsed the guidelines.
To obtain a copy of the paper, "Antimicrobial Prophylaxis for Surgery: An Advisory Statement from the National Surgical Infection Prevention Project," e-mail Diana Olson at the Infectious Diseases Society of America at [email protected] or call 703-299-0201. The abstract also is available online.
A crosswalk of the guidelines for the six surgical categories by five guidelines development groups that were reviewed by the panel is available at medqic.org.