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Using the Lean Model Decreases the Overuse of Perioperative Antibiotics During Endourologic Surgery
Thomas Calvert, MD, MPH, Jennifer Yates, MD.
UMass Memorial Medical Center, Worcester, MA, USA.

BACKGROUND: Overuse of antibiotics poses numerous health risks to patients, including potential allergic reactions, suppression of normal flora, and development of antibiotic resistant organisms. The AUA has prepared a Best Practice Policy Statement for antibiotic prophylaxis for urologic procedures. Within our institution, we sought to determine whether our Urologists practice evidence based antibiotic administration at the time of urologic surgery. Prophylactic antibiotics should be utilized for the duration of the procedure, with use not to exceed 24 hours. We anecdotally noted that many patients at our institution were receiving antibiotics for longer than 24 hours.
METHODS: As part of an institutional quality initiative, we collected data on patients who underwent an endourological procedure in the operating room cystoscopy suite over a 2 week period of time. The physicians were blind to the data collection and were unaware of this project. Patients were excluded from the collection data if they had positive urine cultures on preoperative testing. All physicians using the cystoscopy suites were surveyed regarding their familiarity with the AUA Best Practice Policy Statement for prophylactic antibiotic administration. The survey results were analyzed to assess factors contributing to overuse of antibiotics. We used the lean management principles for healthcare to remove waste and improve overall outcomes. Lean methodology was used to identify reasons for overuse of perioperative antibiotics at our institution. Countermeasures were introduced to decrease the overuse of prophylactic antibiotics, including physician, patient, and nursing staff education. A copy of the AUA Best Practice Statements was placed in all charts for review. Post operative nursing staff were educated about overuse of antibiotics and collected data to assess the duration of antibiotic prescribed for patients discharged home. Data was collected for 1 week after implementation of the countermeasures.
RESULTS: Before interventions, 18/48 patients (37.5%) received prolonged durations of antibiotics. This was usually a 3 day course of antibiotics (most commonly fluoroquinolones) following a prophylactic dose of antibiotics at the time of surgery. Survey results showed that all physicians were aware of AUA recommendations for prophylaxis. However, only half of physicians followed the AUA recommendations for prophylactic antibiotic duration for less than 24 hours. After intervention and education, 1/20 (5%) of patients received a prolonged course of antibiotics.
CONCLUSIONS: Overuse of perioperative prophylactic antibiotics was common at our institution. Lean methodology was utilized to assess the reasons for overuse, and to design an intervention intended to decrease antibiotic overuse. The intervention consisting of education of physicians and nursing staff resulted in a decrease in antibiotic overuse. Future studies will include mid- and long-term follow-up to determine whether Urologists continue to adhere to the AUA Best Practice Policy Statement recommendation regarding perioperative antibiotic prescribing.


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