Quality Initiative for the Administration of Vancomycin Prophylaxis in Penicillin-Allergic Neurosurgery Patients.

Introduction Vancomycin may be used as an alternative perioperative antibiotic for penicillin-allergic patients but follows a different infusion timing. At the institution presented herein, noncompliance with recommended vancomycin infusion timing has been hypothesized to contribute toward increased risk of surgical site infections and avoidable expenditures. The objective of this project was to utilize the Performance Improvement In Action methodology to identify, address, and solve the problem of vancomycin administration timing. Methodology This study took place at a multi-hospital, urban academic medical center. The protocol was developed by neurosurgery and anesthesia faculty, advanced practice providers, nursing, and pharmacy. Timing of the following points was recorded: initial order, order release, pharmacy verification, vancomycin infusion, and surgical incision. Fifty consecutive penicillin-allergic patients undergoing neurosurgical intervention were prospectively enrolled. Data comparison was made between the pilot and retrospective review cohorts. Results The pilot cohort achieved correct administration of vancomycin in 100% of cases. Average infusion start time prior to incision increased by 257% (p<0.0001). Conclusions This study demonstrates a departmental capacity for optimized timing of vancomycin infusions, in a budget- and workflow-neutral process, while reducing inappropriate administration. In the future, this protocol may be scaled to additional departments and institutions to appropriately and efficiently administer perioperative vancomycin and mitigate the risk for surgical site infections.

A Clinical Nurse Specialist-Directed Initiative to Reduce Postoperative Urinary Retention in Spinal Surgery Patients.

: Postoperative urinary retention (POUR) is the inability to void when the bladder is full after surgery. It is a common complication in postoperative patients, especially in patients undergoing spinal surgery. At our institution, patients who were discharged from the postanesthesia care unit (PACU) to the inpatient surgical unit typically had bladder distention and a bladder volume of more than 450 mL. In an effort to address this situation, an interprofessional group of advanced practice RNs and physicians formed a team, reviewed the existing literature, examined the PACU nursing practice guideline for evaluating and managing POUR, and devised a quality improvement (QI) project to raise the PACU nursing staff's awareness of the potential for POUR among postoperative patients and to develop an updated nursing practice algorithm for the evaluation and management of POUR in spinal surgery patients. A description of the QI process, including the revised algorithm and pre- and postintervention results, is reported here. In the preintervention group (n = 42), 19 indwelling urinary catheterizations were documented in patient records; no use of intermittent catheterization was documented. In the postintervention group (n = 43), seven indwelling urinary catheterizations were documented in patient records; the use of intermittent catheterization was documented in 11. As a result of our intervention, we decreased the number of indwelling urinary catheters inserted in the PACU, and supported the PACU nursing staff in more frequent and appropriate use of intermittent catheterization in patients undergoing spinal surgery.

Rationale, development, implementation, and initial results of a fast track protocol for transfemoral transcatheter aortic valve replacement (TAVR).

BACKGROUND: The care pathway for patients undergoing transcatheter aortic valve replacement (TAVR), particularly in the US, was initially based on open surgical techniques and often includes general anesthesia, transesophageal echocardiographic monitoring, and cardiothoracic intensive care unit (ICU) stays. Whether a subgroup of patients could benefit from early extubation, fewer days in the ICU, and early ambulation in terms of both cost and effectiveness is unknown. METHODS AND RESULTS: A fast track (FT) protocol was initiated at two institutions in our health system with specific inclusion criteria. Patients with complications or morbidity post procedure deemed ineligible to continue on the FT pathway were designated as deviations. Baseline characteristics, success and deviations, subsequent course, and direct costs were compared for FT eligible and ineligible patients over a 6-month study period. Among 99 patients undergoing Transfemoral TAVR, 39 (39%) met FT inclusion criteria. The mean age of eligible and ineligible patients was similar at 85 years, but by design, eligible patients had fewer co-morbid conditions. Successful completion of the FT protocol was achieved in 28 patients (72%). Patients on the FT had shorter ICU stays (28 ± 103 vs 45 ± 46 hours, P < 0.0001) and post-operative length of stay (4.3 ± 4.4 vs 7.2 ± 5.3 days, P < 0.0001), and incurred lower direct costs ($44,923 ± $14,187 vs $56, 339 ± 17,808, P < 0.0001). CONCLUSIONS: It is feasible to identify a large percentage of suitable patients preprocedure who are eligible for a FT postprocedure care pathway. There was no evidence for compromise of care and successful completion of the pathway was associated with shorter length of stay and fewer direct costs.

Interdisciplinary rounds in the postanesthesia care unit: a new perioperative paradigm.

Patients in the perioperative and postanesthesia care unit (PACU) experience several transitions in patient care at the same time that the majority of major morbidities will arise. The transitions for these patients are at the critical juncture between surgery and a steady sustained recovery. Historically these important medical problems have been addressed as a nonformalized process. The authors have introduced a formalized process, based on interdisciplinary rounding strategies used in intensive care units, to attend patients and address problems.