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2019 HSR&D/QUERI National Conference Abstract

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1083 — Surgical Specialty and Facility Type Are Associated with Suboptimal Surgical Antimicrobial Prophylaxis in Ambulatory Surgery

Lead/Presenter: Westyn Branch-Elliman,  COIN - Bedford/Boston
All Authors: Branch-Elliman W (COIN-Boston), Pizer SD (Partnered Evidence-based Policy Resource Center (PEPReC), , Department of Veterans Affairs) Dasinger EA (Birmingham VA Medical Center) Gold HS (Harvard Medical School) Abdulkerim H (COIN-Boston) Rosen AK (COIN-Boston) Charns MP (COIN-Boston) Hawn MT (COIN-Palo Alto) Itani KMF (COIN-Boston) Mull HJ (COIN-Boston)

Objectives:
Unless an infection is present, guidelines recommend early discontinuation of antimicrobial prophylaxis after surgery. The Surgical Care Improvement Project (SCIP) included discontinuation as a core measure for general and orthopedic inpatient procedures. VA SCIP compliance exceeds 95%; however, little is known about guideline adherence for prompt discontinuation of antimicrobial prophylaxis in subspecialties not targeted by the program (ear/nose/throat and urology) or in ambulatory surgical centers (ASCs) where infection prevention resources are limited. We evaluated the relationship between antimicrobial guideline adherence, surgical specialty, and facility type for VA ambulatory surgeries.

Methods:
We used a national VA retrospective cohort of FY16-17 ambulatory surgeries in VA hospitals and ASCs for five surgical specialties (general surgery, orthopedics, ophthalmology, ear/nose/throat, and urology) to assess the rate of antimicrobials prescribed for a duration > 24 hours and filled < 2 days postoperatively. Patients with a preoperative infection were excluded. We evaluated subspecialty and facility type and controlled for patient and procedural factors in a logistic regression model predicting guideline non-adherent prolonged antimicrobial prophylaxis.

Results:
Among 153,097 ambulatory surgeries, 7,712 (5.0%) filled a prescription for antimicrobial prophylaxis immediately after surgery; rates varied with < 1.0% for ophthalmology and general surgery, 4% for orthopedics, 9% for ear/nose/throat, and 14% for urology surgeries. Cystoscopies and cystoureteroscopy with lithotripsy procedures had the highest rates of prolonged antimicrobial prophylaxis (16% and 20%), while hernia repair, cataract surgeries, and laparoscopic cholecystectomies had the lowest (0.2 - 0.3%). In an adjusted logistic regression model, ASCs had higher odds of prolonged antimicrobial prophylaxis compared to tertiary care hospitals (OR, 1.32, 95% CI: 1.2 - 1.5).

Implications:
Despite long-standing evidence that prolonged antimicrobial prophylaxis is ineffective and increases preventable harm, guideline non-adherence was observed in ear/nose/throat and urology specialties not targeted by SCIP. Furthermore, facility complexity appears to play a role in guideline adherence.

Impacts:
SCIP improved guideline adherence in targeted surgical specialties and inpatient care and may confer similar improvements if measurement is expanded to include ear/nose/throat and urology as well as ambulatory surgery. Expanding infection prevention and antimicrobial stewardship resources to lower complexity hospitals and ASCs may increase guideline adherence and improve patient safety.