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Percent of Surgical Cases with On-time Prophylactic Antibiotic Administration


Definition
  • Antibiotic started means administration has begun but is not necessarily completed
  • Cases in which time of antibiotic administration or time of surgical incision is not documented should be excluded from the numerator and denominator

Exceptions:

(1) within two hours if patient receiving vancomycin due to beta-lactam allergy

(2) patients with tourniquets need to have all antibiotic administration completed before the tourniquet is inflated and within one hour prior to surgical incision

(3) patients undergoing C-section should receive the antibiotic as soon as the umbilical cord is clamped


Goal

Achieve on-time administation in 100 percent of cases beginning within one hour prior to surgical incision (see “Exceptions” above) within 13 months.


Data Collection Plan

Create system to capture data prospectively on 100 percent of patients.


Sample Graph
On-time Prophylactic Antibiotic
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