August 1, 2013 Volume 77, Number 8
SEE Question

A recent study examined the impact on compliance and surgical site infections (SSI) of introducing interactive prompts for antibiotic administration into an electronic anesthesia information management system. Based on this study, which of the following is MOST likely true?

(A)Compliance did not change.

(B)The overall rate of SSI decreased.

(C) The rate of SSI decreased only for some procedures.

(D) Alert fatigue as manifest by decreased compliance was noted after six months.

Anesthesia information management systems (AIMS) are rapidly being incorporated into routine practice, encouraged in part by financial incentives. Tangible, substantial benefits from these programs, however, have not yet been demonstrated in terms of patient care. Administration of antibiotics within one hour before surgical skin incision is a core indicator of the Surgical Care Improvement Project (SCIP 1) and is linked to reimbursement by the Centers for Medicare and Medicaid Services.

Recently, a multicenter health care network sought to determine the effects of electronically embedded point-of-care electronic prompts (POCEP) within an AIMS to administer antibiotics. The anesthesia group within this hospital system had been assigned responsibility for compliance with antibiotic administration guidelines, and previous efforts to achieve goals with education alone had failed. The authors examined provider compliance with antibiotic administration and SSI for six months before (period A) and six months after (period B) inserting POCEP. They continued to audit compliance rates and SSI for the subsequent two years to see if results could be sustained or if “alert fatigue” set in.

A total of 19,744 procedures were analyzed: 9,127 in period A and 10,617 in period B, involving 120 anesthesia providers. Obstetrical, endoscopic, and interventional radiology procedures were excluded. Antibiotics were required within one hour before surgical incision (or two hours for vancomycin). An electronic prompt appeared on the AIMS screen five minutes after the patient was admitted to the operating room and every 20 minutes thereafter until antibiotic documentation was completed. The provider could either document antibiotic administration or indicate that the antibiotic was being withheld for one of three reasons:

  • An antibiotic was not indicated.

  • There was documented prior administration.

  • A delay was needed to obtain surgical cultures.

Patients from the two study periods were comparable in terms of age, sex, American Society of Anesthesiologists physical status score, duration of surgery, and nosocomial surveillance score (an estimate of risk for infection based on type of surgery and patient risk factors). To see whether compliance changes altered patient outcome, SSI was routinely tracked for 30 days; if devices were implanted, they were tracked for one year.

Following implementation of POCEP (period B), documentation increased from 62 percent to 92 percent (P < .001), compared to period A. The rate of SSI also decreased from 1.1 percent to 0.7 percent (P = .003). This decrease in SSI occurred with all surgeons, surgical services, and locations. Follow-up analysis for the two years after implementation demonstrated that these benefits were sustained which indicates that the level of intrusion into anesthetic management by the POCEP did not lead to ignoring these alerts (ie, alert fatigue).

Answer: B

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  • Schwann NM, Bretz KA, Eid S, et al. Point-of-care electronic prompts: an effective means of increasing compliance, demonstrating quality and improving outcome. Anesth Analg. 2011;113(4):869-876.