30% 5-6 0-0-31 received within one hour Nov-04-56% 5-9 0-0-37 prior to surgical incision- Dec-04 hysterectomy

SIP 1g Subtotal

SIP 1h Oct-04-100% 1-1 0-0-36 Prophylactic antibiotic Nov-04 0% 0-1 0-0-46 received within one hour Dec-04 0% 0-2 0-0-36 prior to surgical incision-

Vascular surgery

SIP 1h Subtotal

SIP 2a Oct-04-93% 27-29 0-0-8 Prophylactic

Antibiotic selection

Nov-04 for surgical patients Dec-04-100.00% 23-23 0-0-12 Overall Rate

SIP 2a Subtotal

Measure Title

Data Period

Rate/Value

Numerator

Denominator

Missing

Excluded

Cat-E) Invalid Cases

Population

Numerator

SIP 2b Data Prophylactic

Oct-04

Antibiotic selection for Nov-04 surgical patients

CABG Dec-04-100% 5-5 0-0-30 SIP 2b Subtotal

SIP 2c Prophylactic

Oct-04

Antibiotic selection for Nov-04

Cardiac Surgery

Dec-04 0-0 0-0-0-36 SIP 2c Subtotal

SIP 2d Prophylactic

Oct-04

Antibiotic selection for Nov-04 hip arthroplasty

Dec-04-100% 4-4 0-0-31 SIP 2d Subtotal

Measure Title

Data Period

Rate/Value

Numerator

Denominator

Missing

Excluded

Cat-E) Invalid Cases SIP 2e

Population

Numerator

Data Data Prophylactic

Oct-04

Antibiotic selection for Nov-04 surgical patients

Knee arthroplasty

Dec-04

SIP 2e Subtotals

SIP 2f Prophylactic

Oct-04

Antibiotic selection for Nov-04 surgical patients

Colon Surgery

Dec-04

SIP 2f Subtotals

SIP 2h Prophylactic

Oct-04

Antibiotic selection for Nov-04 surgical patients

Vascular surgery

Dec-04

SIP 2h Subtotals

Measure Title

Data Period

Rate/Value

Numerator

Denominator

Missing

Excluded

Cat-E) Invalid Cases Population Numerator Data SIP 3a Prophylactic

Oct-04 antibiotics d/c'd within 24 hours after Nov-04 surgery end time

Overall Rate

Dec-04

SIP 3a Subtotal

SIP 3b Prophylactic

Oct-04 antibiotics d/c'd within 24 hours after Nov-04 surgery end time

CABG Dec-04-80% 4-5 0-0-30 SIP 3b Subtotal

SIP 3c Prophylactic

Oct-04 antibiotics d/c'd within 24 hours after Nov-04 surgery end time

Cardiac Surgery

Dec-04

SIP 3c Subtotal

Measure Title

Data Period

Rate/Value

Numerator

Denominator

Missing

Excluded

Cat-E) Invalid Cases

Population

Numerator

SIP 3d Data Prophylactic

Oct-04 antibiotics d/c'd within 24 hours after Nov-04 surgery end time

Hip arthroplasty

Dec-04

SIP 3d Subtotal

SIP 3e Prophylactic

Oct-04 antibiotics d/c'd within 24 hours after Nov-04 surgery end time knee arthroplasty

Dec-04

SIP 3e Subtotal

SIP 3f Prophylactic

Oct-04 antibiotics d/c'd within 24 hours after Nov-04 surgery end time

Colon surgery

Dec-04

SIP 3f Subtotal

Measure Title

Data Period

Rate/Value

Numerator

Denominator

Missing

Excluded

Cat-E) Invalid Cases

Population

Numerator

Data Data SIP 3g Prophylactic

Oct-04 antibiotics d/c'd within 24 hours after Nov-04 surgery end time hysterectomy

Dec-04

SIP 3g Subtotal

SIP 3h Prophylactic

Oct-04 antibiotics d/c'd within 24 hours after Nov-04 surgery end time

Vascular surgery

Dec-04

SIP 3h Subtotal

Core Measures Gold Star Report - 2004 O4

3Q 2004

4Q 2004

Change from Provena St. Joseph Hospital - Elgin, IL previous quarter

SP1a Prophylactic Antibiotic received with one hour prior to surgical incision

Overall rate) 45.20% 40.80%

SP1b Prophylactic Antibiotic received with one hour prior to surgical incision

CABG 68.40% 48.70%

SP1c Prophylactic Antibiotic received with one hour prior to surgical incision

Cardiac Surgery 0% 50%

SP1d Prophylactic Antibiotic received with one hour prior to surgical incision

Hip Arthroplasty 40% 21.10%

SP1e Prophylactic Antibiotic received with one hour prior to surgical incision

Knee Arthroplasty 28.30% 28.90%

SP1f Prophylactic Antibiotic received with one hour prior to surgical...

General exclusion criteria included patients who were on antibiotics at the time of admission, except for those patients undergoing colon surgery who were on oral antibiotics. Also excluded were patients who were being treated for an infection prior to the first surgical procedure of interest, patients who had antibiotic start dates missing. The numerator data includes all patients who receive antibiotics within one hour before surgical incision (within two hours if vancomycin is required for prophylaxis). The denominator consisted of patients meeting the general inclusion criteria and measure specific exclusions (patients undergoing colon surgery who were given prophylactic oral antibiotics only, and those on whom it was unable to be determined if an antibiotic was started within one hour of the surgery start time due to missing time values.
Arguments for change

Studies clearly indicate that antimicrobial prophylaxis is the most effective when provided prior to the initial incision. Risk of infection is actually felt to increase when prophylaxis is given either too early (meaning more than 2 hours prior to initial incision) or too late (after initial incision) (Classen, Evans, et.al. 1992). The most optimal time for administration would appear to be in the 30 to 60 minutes prior to the initial incision. A brief course of antimicrobial prophylaxis shortly after procedures is no longer considered to be effective (Mauerhan et.al. 1994; Harbarth, Samore, Lichtenberg & Carmelly, 2000; Wymenga, Hekster, Theeuwes et.al., 1991). In the data obtained from Provena, there appeared to be a large amount of variance between the type of surgeries being performed which received prophylaxis within the specified time, or at all. In addition, the number of patients who were excluded from the data was also high, although no notation is made as to the reason for exclusion, whether it is due to pre-existing antibiotic prescription or lack of documentation surrounding the time of antibiotic administration. It is apparent that the mechanism is in place for the changes to be made. There appears to be a lack of process regarding the predictability and consistency of the administration and documentation of issues surrounding the rate of administration of prophylaxis, which would be a point of change well addressed by my project.

Proposed Strategic Plan to form a committee that will be responsible for overseeing the various programs for surveillance, prevention and control of infection and serves as the central review and policy making body for the Infection Prevention and Control program. The committee will continue to be multidisciplinary in form and include the members of the medical staff, nursing, administration, pharmacy and laboratory staff. I also plan to work with this team to recommend policies and procedures meant to protect not only the patient but healthcare workers as well to ensure optimal operation of our healthcare system within recommended infection control guidelines, proven in random controlled trials. I plan to identify with the team areas…