Improvement in Antimicrobial Stewardship for Orthopaedics Procedures: A NSQIP Quality-Improvement Project

INTRODUCTION: Antimicrobial resistance is a notable threat to global health. In an institution-specific report generated through National Surgical Quality-Improvement Pediatric Program (NSQIP-P) for our institution, our orthopaedic surgery department was a high outlier for postoperative antibiotic prophylaxis duration of >24 hours. We describe an initiative to reduce the incidence of postoperative duration of antibiotics of >24 hours for pediatric patients undergoing orthopaedic surgery.

METHODS: An interdisciplinary team was formed to identify and monitor interventions for improvement. Patients undergoing orthopaedic surgeries and receiving postoperative intravenous antibiotics were included. First-stage interventions included verbal education for front-line staff to ensure that postoperative antibiotic prescribing did not exceed two doses. Second-stage interventions included a modification that changed the default postoperative antibiotic dose from three to two doses for the three most used orthopaedic admission order sets in the electronic medical record. Patient-level, electronic health record data elements were extracted and presented through a created electronic dashboard to track near-real-time metrics. Surgical site infections were tracked through NSQIP-P database as a balancing measure.

RESULTS: A total of 2,546 surgical cases met study criteria: 1,680 and 866 cases in the pre- and post-intervention cohorts, respectively. Cefazolin was the primary postoperative antibiotic prescribed in 95.4% of cases. In the preintervention cohort, <24 hours of postoperative antibiotics was 36.7% compared with 84.7% (48.0% improvement) in the post-second stage intervention cohort. A sampling of postintervention cases demonstrated no notable increase in surgical site infection events compared with matched period sampling of preintervention cases.

CONCLUSION: NSQIP-P can be leveraged to improve antibiotic stewardship in pediatric orthopaedic surgical cases. Multidisciplinary collaboration, front-line staff education coupled with electronic medical record order set modification, and near-real-time data tracking for provider feedback resulted in a 48.0% improvement of patients receiving <24 hours of perioperative antibiotics.

LEVEL OF EVIDENCE: III.