Standardization of Perioperative Antibiotic Prophylaxis through the Development of Procedure-specific Guidelines in the NICU Setting: Ann and Robert H. Lurie Children s Hospital of Chicago in Chicago, IL, is a pediatric facility with a 44-bed level IV neonatal intensive care unit (NICU) that admits approximately 500 infants per year and performs 250 surgeries annually. All of the neonates admitted to the NICU are born at outside facilities and are transfers for advance level of care or subspecialty evaluation and management. There are a few patients that present through the emergency department. The NICU is comprised of 32 neonatologists, 19 nurse practitioners, and 200 nurses who provide care to sick and premature infants. Additionally, we have a fellowship class of three fellows per year who participate in various research endeavors ranging from quality improvement to laboratory research. The team extends to pediatric hospitalists and pediatric residents. It also includes respiratory therapists, nutritional specialists, developmental specialists, social work, and child life specialists. Rationale: Hospitalized neonates have a high antibiotic burden largely because of low birth weight, long length of stays, and high number of central catheter days. The likelihood of these neonates receiving antibiotics during their hospital course increases even further if undergoing a surgical procedure. In fact, approximately 97% of neonates who undergo surgery receive antibiotics. The correct timing of perioperative antibiotic prophylaxis (within 1 hour of incision) and redosing for prolonged surgeries can potentially reduce the rate of surgical site infections (SSI). Choice of agent should be tailored to the site of surgery, avoiding unnecessarily broad therapy. In addition, almost all professional medical organizations recommend early discontinuation (<24 hours), though there is a paucity of neonatal and pediatric data. Wide variation is seen in the proportion of infants receiving perioperative antibiotics at children s hospitals. Review of our local data also indicates variation and reveals an opportunity for improvement. When looking at our most commonly performed procedures, such as gastrostomy tube placements, we see that only 85% of neonates received perioperative antibiotics within 60 min of incision, there were several regimens utilized by our surgeons for the procedure, and only 80% had antibiotics discontinued within 24 hrs. Thus, developing standardized protocols can minimize overall antibiotic utilization, decrease broad spectrum antibiotic use, and ensure appropriate match of prophylactic agent to surgery. Aim: The aim of this project is to standardize perioperative antibiotic prophylaxis for five key surgical procedures performed on NICU infants through the development of procedure-specific recommendations. We want to increase the use of these recommendations to 80% in the next 6 months. The procedure list is currently limited to inguinal hernia repairs, gastrostomy tube placement, gastroschisis repair, intestinal resection due to NEC, and small bowel atresia repair.
Currently, there are no written recommendations/guidelines in place. Drivers of change: Figure 1. Aim and driver diagram AIM: To standardize perioperative antibiotic prophylaxis for five key surgical procedures performed on NICU infants through the development of procedurespecific recommendations and increase their use to 80% in the next 6 months Primary Drivers: Procedure-specific prophylaxis recommendations and link for use Reviving the antibiotic time out as part of the preprocedure patient hand-off to discuss need/administration/ timing of antibiotics Score card for guideline utilization and compliance Secondary Drivers: Development of perioperative abtx ppx guidelines Scripting the Antibiotic time out content Staff education (Healthstream coursework on Antibiotic Stewardship and Quarterly staff mtgs) targeting surgeons, anesthesiologists, neonatologists, nurses (bedside/or) + Key procedures to include 1) inguinal hernia repair, 2) gastrostomy tube placement, 3) gastrochisis repair, 4) intestinal resection due to NEC, and 5) small bowel atresia repair Interventions/ Test of Change: We joined the VON QI collaborative during its second year, and identified areas for quality improvement based on our initial audit. We sought to promote antimicrobial stewardship across multiple subspecialties, and sought interdisciplinary cooperation. Additionally, we wanted to establish credibility as an antibiotic stewardship team among these groups to gain wide acceptance as partners in quality improvement. Even with our team still expanding, there was a strong need to evaluate perioperative antibiotic prophylaxis regimens and their lack of standardization among NICU infants undergoing identical procedures. Additionally, we leveraged request of these data by the US World and News Report (USNWR) Survey to begin conversations with leadership and engage key stake holders. Baseline Adherence to Recommendations for Perioperative Prophylaxis Metric % Adherence Preoperative dose within 1 hour prior to incision 85 Recommended antibiotic(s) given 75 Duration of antibiotic(s)< 24 hours 73 *60 surgeries reviewed DO: After we established perioperative antibiotic prophylaxis as our focus for improvement, we reviewed local data and determined which surgical procedures were performed most commonly on newborns at Ann and Robert H. Lurie Children s Hospital in Chicago, IL. Based on this information and requests from our surgical colleagues, we joined with the pediatric surgery residents to carry out a survey soliciting each attending surgeon s antibiotic prophylaxis
preference. Based on those responses, we devised our list of procedures and began reviewing national prophylaxis guidelines to inform our own recommendations on antibiotic choice during a neonatal surgery. We also reviewed our own epidemiologic data to tailor our antibiotic selection and develop our final table. This was subsequently presented to our infectious disease colleagues for review and then returned to the surgeons for final approval. Figure 2. List of Interventions to date: Activity Date Joined VON QI Collaborative Summer 2016 Identified surgical prophylaxis as improvement goal February 2017 Identified most common surgeries performed March- May 2017 Created antibiotic prophylaxis guidelines May 2017 Redesign of antibiotic time out and insertion into patient hand-off August 2017- present process from NICU to Anesthesia Implementation of recommendations- anticipated go live date October 2017 Though the plan at the outset of this project was to develop order sets based on the final list of procedures and antibiotic recommendations, we quickly realized that order sets did not ensure the discussions that were needed regarding antibiotic choice and administration prior to incision, even with education in place. As a result, we were forced to consider alternative strategies for having access to our recommendations and ensuring timely discussion about them with the appropriate stake holders. The following PDSA cycle and list of interventions to date (figure 2) reflect these changes. 1 st PDSA- A table with recommendations for the top five neonatal procedures was created (figure 3). This will be accessible to all providers via a weblink from our Epic interface. This type of information sharing is not trackable, so it will not inform any of our proposed measures. By incorporating into a hand-off/time out process, we will be able to measure compliance and resulting outcomes to inform future PDSA cycles. Figure 2. Perioperative Antibiotic Prophylaxis Guidelines AS QI Project Recommendations (to be administered within 1 hour of incision) Surgery Antibiotic MRSA: History of colonization or infection Duration Inguinal hernia repair None required Gastrostomy tube cefazolin clindamycin + gentamicin 1 dose Gastroschisis repair cefazolin clindamicin + gentamicin 1 dose Intestinal resection due to NEC If already on ampicillin + gentamicin + flagyl, If already on ampicillin + gentamicin + flagyl, give 1 dose
give cefazolin x1 clindamycin x1 Small bowel atresia repair cefazolin + flagyl clindamycin + gentamicin 1 dose Preferred practice for neonates on pre-operative antibiotics If not on antibiotic for at least 24 hrs, dose surgery-specific antibiotics as indicated STUDY: We anticipate spending a total of 3 days observing the neonatal hand-off process and neonatal surgeries, specifically focusing on communication strategies and documentation surrounding antibiotics and antibiotic prophylaxis. Data from this experience will be reviewed to inform an antibiotic time out template to fully integrate into the current hand-off experience. This will be scripted with input from the anesthesiology providers and ultimately documented in their record of care. ACT: We anticipate that adherence to our perioperative antibiotic prophylaxis recommendations for the top five consensus procedures studied will occur through the collaboration between neonatal, infectious disease, surgery, anesthesia, and nursing teams. The hope is that the antibiotic time out during the hand-off process will offer a moment of reflection about antibiotic choice, timing, and duration, which can then flow into the perioperative experience. Once this is operationalized, education to the OR and NICU staff will be provided and refined with subsequent PDSA cycles. Measurement: Proposed Process Measures - Choice of prophylaxis adherent to developed guidelines (obtained through review of pharmacy records) - Participation in antibiotic time out during hand-off (obtained through audits of current hand-off process between NICU staff and anesthesia) - First dose of antibiotic within 60 min prior to incision (obtained through review of pharmacy records) - Intraoperative dose given for prolonged surgeries (if needed) (obtained through review of anesthesia and pharmacy records) - Discontinuation of antibiotics after one dose (obtained through review of pharmacy records) Proposed Outcome Measures - Systemic infection within 3 days of procedure (for each of the 5 procedures) o number of patients with positive blood cultures within 3 days of procedure when ppx recommendations were used
total number of patients who underwent a specific procedure when ppx recommendations were used Proposed Balancing Measures - Antibiotic restarts following procedure (obtained through review of pharmacy records) - Surgical site infection rates (obtained through review of infection control audits) Results: Through a multidisciplinary process involving neonatology, infectious diseases, and surgery, we compiled a list of frequently performed procedures, plus procedures of high interest to the group, to inform our own perioperative antibiotic prophylaxis guidelines. This step was solicited through an in-person survey yielding approximately 80% compliance in participation. The five procedures chosen included inguinal hernia repairs, gastrostomy tube placement, gastroschisis repair, intestinal resection due to NEC, and small bowel atresia repair. We then reviewed published adult and pediatric antibiotic prophylaxis guidelines, had personal communication with other institutions with prophylaxis regimens in place, and devised a suggested prophylaxis strategy based on surgeons most commonly used antibiotic regimens that also matched current standards of care per procedure. This resultant regimen was then taken to colleagues in infectious diseases for vetting and approval. These vetted recommendations for appropriate perioperative antibiotic prophylaxis were then redistributed to the surgical team for final approval for recommendation table. We identified the best way to ensure the use of our guidelines was through the incorporation of an antibiotic time-out into an already established patient hand-off/time-out process between NICU and anesthesia. We will target our intervention efforts toward operationalizing this process. Discussion: We chose to focus on perioperative prophylaxis as antibiotic use is common for this indication and substantial variation in care exists. The optimization of antibiotic prophylaxis can potentially reduce post-operative infections and the selection of antimicrobial resistance. Establishing ownership of perioperative prophylaxis decisions is challenging, as decisions are shared by neonatologists, surgeons, and anesthesiologists. The perioperative hand-off process which happens between NICU and anesthesia is a logical place to insert an antibiotic time-out that includes discussion of recommendations when appropriate. This can ensure that appropriate prescribing actions are subsequently done in the operating room suite. Additionally, it empowers the appropriate stake holders. It is important to achieve multidisciplinary consensus to ensure acceptability of guidelines. It is equally relevant to develop guidelines with hospital epidemiological data in mind to incorporate local resistance patterns. This is both highly desirable and must be revisited frequently. Another aspect of equal importance is how this project impacts care beyond the procedures specified. We believe that once the intervention occurs and undergoes various PDSA cycles for refinement, we will have reduction in prescribing variability that will lead to recommendations for more procedures. We believe this standardization will lead to improved outcomes as per our measures.
We also believe that this will result in increased family/patient satisfaction as it will reflect our commitment to judicious antibiotic use and transparency. Keywords: Antibiotic stewardship, multidisciplinary, perioperative, antibiotic prophylaxis, neonatal intensive care unit, neonates, quality improvement Team Acknowledgment: Aaron Hamvas, MD (Chief of Neonatology) Marleta Reynolds, MD (Head of Pediatric Surgery and Surgeon in Chief) Sameer Patel, MD (Infectious Diseases) Kenny D. Kronforst, MD, MPH, MS (Neonatology) Lauren Baumann, MD (Pediatric Surgery) Kibileri Williams, MD (Pediatric Surgery) Lisa Sohn, MD (Anesthesiology) Emily Merrick (Student)