Prophylactic antibiotic and SSIs incidences

Part 1: Evidence based research on Prophylactic antibiotic timing and SSIs incidences
Background
According to the national statistics, there are about 5% reports of surgical site infection (SSI) in
all surgical processes every year. The study indicates that SSIs accounts about 2% of the
mortality; and increases healthcare cost by 10 to 20%. Additionally, it has also been found that it
increases hospital stays and increases the medical care costs (Shepard et al., 2013). Evidence
based research indicates that about 60% of the SSIs are preventable if there the government
implements quality based standards which should be implemented in the inpatient surgery.
Therefore, the federal government should explore SSIs epidemiology, clinical consequences and
the risk factors involved. This will help in establishing guidelines on the effective strategies such
as hand hygiene, sustaining normothermia. This article explores the evidenced based practice
that proper timing of prophylactic antibiotics could reduce the incidences of surgical site
infection (Rafique, 2012).
Research indicates that SSIs are the second most challenge facing the public health. According
to National Nosocomial Infection System, SSIs are infections that arise after operative
procedures, within one month after the procedures. The efforts to lower the incidences of SSIs
are not new concept. The efforts can be traced to the 19 th Century with Lister who pioneered the
use of antiseptic incidence in patients in the orthopedic ward. The issue of SSIs is not new in this
health care facility (Teija-Kaisa, Eija, Marja, & Outi, 2012). For instance, about of 2% of
patients undergoing surgical process in this health care facility reports SSIs. This causes about
5% readmission rates and 3% increase hospitalization days. In fact, it have been found that
patients who present SSIs are 5 folds likely to be readmitted, with 60%of them being more
likely stay in the ICU, and are two folds likely to pass away as compared to those who have

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no infection. The financial burden of the disease cannot be overlooked (Regimbeau et al., 2014;
Hopper et al., 2015).
Purpose of the study
This study proposes that administering of prophylaxis antibiotics one hour before surgical
procedures will lower the SSIs incidences. The study aims at establishing the most effective and
best timing for the administration of the prophylactic antibiotic during the surgical procedures.
This is because there is limited research on the adherence to the proposed Surgical Care
Improvement guidelines; this has failed to prove that timely administration of prophylactic
antibiotic reduces the incidence rates of SSIs (Alberta Health Services, 2014).
Evidence based practice
The issue of SSIs and its challenges is global. For instance, A retrospective study conducted
using the Veterans affairs data on antibiotic administration timing on patient who were
undergoing surgical procedures in the orthopedic, vascular, colorectal, and gynecologic
procedures from 2005 to 2009 indicates that timing rate influenced the rate SSIs. Another study
was conducted on 1922 patients who were primary care of hip arthroplasty in about 11 hospitals
(Center for Healthcare Related Infection Surveillance and Prevention and Tuberculosis Control,
2012). The hip arthroplasty have been associated high morbidity due to their difficultness to
study using the controlled trials. Additionally, the study indicated that the infection rate is
generally low and would therefore not indicate significant outcomes. However, several other
studies have indicates a proportional relationship indicating a U curve, with the lowest infection
rate being recorded when the prophylactic antibiotic was administered about half an hour
before incisions were made; and rates increased as time before the administration increased.

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Current US guidelines recommends that the prophylactic should be administered at least 60 to
120 min of incision (Fry, 2013).
Several other studies have demonstrated a good penetration of the tissue as well as excellent
concentration of the antibiotics in the tissue when the administration of the antibiotic is done
close incision time (Bowler, Welsby, Hogarth, & Towers, 2013).
The current clinical guideline on antimicrobial prophylaxis was developed by Burke. The
guideline resulted from an investigation on the rate of inflammatory response on the surgical
incision. The analysis found that the prophylactic antibiotic prophylactic process was most
effective if the antibiotic was administered within 1 hour before the incision process. The
analysis concluded that the bacteria were the most susceptible to the antibiotics, and their
susceptibility was determined by the antibiotic timing as well as selection. Another retrospective
study conducted by Classen and colleagues on 3000 patients who were undergoing surgical
procedure indicated that patients received antibiotic one hour before the surgical process
reported the lowest rates of SSIs (Anderson, 2014).
Study conducted by Merollini and colleagues using structured interviews on general
practitioners, the nurses and physicians in the orthopedic department recommended the use of
antibiotics within 30min to 1 hour before incision (Diamond, M. (2008). Other systematic review
study, which used key words such as SSIs, orthopedic as well as prevention; indicated most
studies reported that patients who received antibiotic prophylaxis would reduce the SSI rates to
1-3% in comparison to 4% without 8% with the control group. Based from this research study,
one can therefore suggest that the most effective period to administer prophylaxis antibiotic is
within one hour before the healthcare provider initiates the incision process because it reduces

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the risk of SSIs effectively (Center for Healthcare Related Infection Surveillance and Prevention
and Tuberculosis Control, 2012).
Solution description
The proposed is that the healthcare providers in the surgical department will be encouraged to
administer prophylactic antibiotic within one hour before the surgical process begins. This is
because it will lead to reduction of the microorganism burden by three folds. Additionally, due to
the increased residual effects associated with prophylactic antibiotic, the solution proposed will
be consistent improved quality of life for patients, and reduced cost of care (Pearse et al., 2014).
However, just like many organization, this strategy could face numerous barriers from the
healthcare providers. This is particularly so because the healthcare providers are not willing to
change their routine pattern because they feel that they have been applying the same strategy for
a long period of time, and would therefore hesitate to adopt the new developments/ change. To
start with, the healthcare professionals in the surgical department tend to have low priority of the
administration process (Fonseca, C. (2012).
This is attributable to the fact that they the anesthesiologists are more concerned in ensuring that
the environment is safe, the right equipment is sterilized and safe. The healthcare professionals
are more concerned about healthcare conditions that affect the patient immediately, and tend to
ignore the impacts of SSIs because they do not affect the patient immediately. Some of the
professionals claim that the administration process is tedious and time consuming thus limiting
the administration of medication on time. Additionally, the healthcare facility workflow could
limit the proper timing of the antibiotics .In most of the healthcare centers; the insertion of IV is
done by the nurses and is time consuming. The healthcare facility process of communication

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could affect the communication of the new an effective protocols (Jarral, McCormack, Ibrahim,
& Shipolini, 2010).
Majority of the health care facility communicate to their staff verbally, this indicates the
importance of effective process of exchanging information such as use of automated systems to
communicate new systems and to reduce confusions of adminsterring antibiotics in time by the
nurses. Lastly, the concept of role perception determines the rate of drug administration,
resulting to confusion as each healthcare provider denies that it is his or her responsibility. This
causes further delays in the administration of the prophylactic antibiotic (Erb et al., 2014).
Implementation strategies
The first implementation strategy will be to educate the healthcare professionals in the surgical
department on the important of using shorter duration for the administration of prophylactic
antibiotic. The advantages will be discussed first with by the head of the surgical department
with the aim of describing the feasibility of the matter. Secondly, poster concerning the best
antibiotic agent and the recommended prophylactic antibiotic administration time will be hung in
all vicinities surrounding surgical operation room including the physician room, the scrub sinks,
and the operation room. This education is aims at enlightening the healthcare providers at
individual level to transform the healthcare provider’s attitudes, behavior, as well as beliefs
(Samant & Ramugade, 2014)
The second step will be to establish a multidisciplinary protocol that will be used to influence the
healthcare providers on the effective management of SSIs through teamwork and effective
communication, which will specify the timing as well as the sequences necessary for the
achievement of the responsibility. Lastly, the institutions will implement the antibiotic timing
programs, which will involve the integration of systems that will reduce, curtail, and control the

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process of antibiotic administration program. This will include approaches to measure
parameters such as the written orders, computerized support programs among others (Feilmeier,
Dayton, Sedberry, & Reimer, 2014).
Expected outcomes
Research associates increased utility of quality care improvements where the management of
guidelines is followed reduces variability and miscommunication, which is often associated with
increased medication and diagnostic errors. In this context, a successful intervention is one,
which will involve identification of a nurse leader to serve and the motivator and change
champions. This will require a number of in service refresher course training, use of systems that
reminds the nurses on the timing of administration of prophylactic antibiotic and one with
specific bench marking of physician. The ultimate expectations of these actions is to improve
patients quality of life through reduced rates of SSIs, reduced hospital stays and overall
reduction of the healthcare costs (Johnson Et al., 2013).

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Part B: Picot analysis

Research Question: How effective is prophylactic antibiotic administration timing effective in
the reduction of Surgical Sites Infections Incidences (SSIs)?
Type of
patient/Problem

Intervention Comparison
intervention

Outcome

Patient in surgical
Wards

Close administration
of antibiotics (within
one hour) before
incision

Compared to delayed
administration of
antibiotics

Reduced incidences
of SSIs
Reduced readmission
rates
Reduced mortality
and reduced length of
hospital stays

Key word:
Colorectal patients,
orthopedic, hip
arthroplasty patients
Surgical site infection

Key Word
Prophylactic
antibiotics,
Administration rate
within one hour
Antibiotic
Surgical site infection

Key Word:
Prophylactic
antibiotics,
Administration rate
within one hour
Health care quality

Key Word:
Hospital stays
Readmission rates
SSIs mortality
Practice guidelines

Search History
Literature search was done in three main databases using the University online database. The
database included CINAHL, Proquest, and EBSCOhost. The key word used to run the search

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included ; Colorectal patients, orthopedic, hip arthroplasty patients, Surgical site infection,
Prophylactic antibiotics, Administration rate within one hour, Antibiotic, Surgical site infection,
Prophylactic antibiotics, Administration rate within one hour, Health care quality, Hospital
stays, Readmission rates, SSIs mortality, Practice guidelines
From these key words, approximately 534 articles were generated. The articles were narrowed
down using filter methods such as publication year. The articles chose were supposed to from
2010, to avoid generating outdated information. From these, the articles were narrowed down to
235, and when Key words “SSIs” and “prophylactic antibiotics” were applied, the articles were
narrowed down to 45 articles. Out of these articles, 17 articles were chosen to compile the work
based on the relevance of the abstract and the year of the publication.
Example
Hooper, T.D., Hibbert P.D., Hannaford, N.A, Jackson, N., Hindmarsh, D.M., Gordon, D.L.,
Coiera, E.C., Runciman, W.B.(2015). Surgical site infection—a population-based study
in Australian adults measuring the compliance with and correct timing of appropriate
antibiotic prophylaxis. Anesthesia and intensive care 43 (4); 461- 469
P- The population being studied by this article is the Australian Adults who are undergoing
operative procedures. The problem being investigated is the rate of SSIs to evaluate the
infection rates with and without correct timing of prophylactic antibiotic administration
I- The intervention suggested by this article is that proper timing of the administration
of the prophylactic antibiotic reduces the incidences of SSIs considerably.
C- The study compares health outcomes of patients who experienced proper timing of the
administration of the drugs with those who had delayed administration of the drug.

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O- The outcome evaluated is the rate of adherence to proper timing, reduced health care costs
and overall improve quality of life for patient.
T- Not applicable

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Reference list.
Alberta Health Services. (2014). Best Practice Guideline for the Selection, Handling, Application, Use
and Storage of Patient Skin Antiseptic Products for Invasive Procedures Outside of the Operating
Room. Retrieved May 31, 2015 from http://www.albertahealthservices.ca/hp/if-hp-ipc-bpg-skin-
antiseptic-products.pdf
Anderson, D. (2014). Prevention of Surgical Site Infection: Beyond SCIP. AORN Journal, 99(2),
315-319. doi:10.1016/j.aorn.2013.11.007
Bowler, P., Welsby, S., Hogarth, A., & Towers, V. (2013). Topical antimicrobial protection of
postoperative surgical sites at risk of infection with Propionibacterium acnes: an in-vitro
study. Journal Of Hospital Infection, 83(3), 232-237. doi:10.1016/j.jhin.2012.11.018
Center for Healthcare Related Infection Surveillance and Prevention and Tuberculosis Control. (2012).
Guideline: Surgical Skin Disinfection. Queensland Government. Retrieved May 31, 2015 from
http://www.health.qld.gov.au/chrisp/ic_guidelines/documents/Guideline_CHRISP_01.pdf
Diamond, M. (2008). Postsurgical Adhesions. Seminars In Reproductive Medicine, 26(04), 287-

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    Erb, S., Sidler, J., Elzi, L., Gurke, L., Battegay, M., Widmer, A., & Weisser, M. (2014). Surgical
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    Feilmeier, M., Dayton, P., Sedberry, S., & Reimer, R. (2014). Incidence of Surgical Site
    Infection in the Foot and Ankle with Early Exposure and Showering of Surgical Sites: A
    Prospective Observation. The Journal Of Foot And Ankle Surgery, 53(2), 173-175.
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    Fonseca, C. (2012). Nursing Care Indicators to Nursing Homes. Journal Of Nursing & Care,
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