Sustained Improvement of Appropriateness in Surgical Antimicrobial Prophylaxis with the Application of Quality Control Circle

Figures & data

Figure 1 A flow diagram illustrating the ten QCC steps beside the PDCA workflow.

Figure 2 The key problems of the inappropriate implementation of SAP in clean surgery that need to be improved.

Figure 3 Analysis of the root causes of inappropriate implementation of SAP in clean surgery by Fishbone diagram.

Figure 4 Pareto chart demonstrates the essential causes of the inappropriate administration of SAP in clean surgery that need to be improved.

Table 1 Type of Surgical Procedures

Clean Surgeries	Before QCC n (%)	After QCC n (%)
Hernia repair	241 (22.07%)	227 (19.88%)
Thyroidectomy	174 (15.93%)	189 (16.55)
Breast surgery	139 (12.73%)	117 (10.25%)
Internal fixation of bone	124 (11.36%)	133 (11.65%)
Ophthalmic surgery	103 (9.43)	121 (10.60%)
Brain surgery	92 (8.42%)	108 (9.46%)
Joint replacement plasty	87 (7.97%)	125 (10.95%)
Spinal cord operation	35 (3.21%)	33 (2.89%)
Carotid endarterectomy	26 (2.38%)	19 (1.66%)
Varicose vein surgical treatment	19 (1.74%)	24 (2.10%)
Others	52 (4.76%)	46 (4.03%)
Total	1092	1142

Table 2 SAP Appropriateness Before and After QCC Intervention

Variables	Before QCC n (%)	After QCC n (%)	χ^2	P
Receiving SAP
Overall appropriateness^a	279 (68.72%)	476 (93.7%)	11.542	0.003
Appropriateness in selection^b	320 (78.82%)	488 (96.06%)	9.324	0.005
Cefazolin	213 (52.46%)	293 (57.68%)
Cefuroxime	107 (26.35%)	195 (38.39%)
Piperacillin tazobactam	34 (8.37%)	2 (0.39%)
Third generation cephalosporins	21 (5.17%)	11 (2.16%)
Others	31 (7.64%)	7 (1.38%)
Appropriateness in duration^c	366 (90.15%)	490 (96.46%)	6.417	0.011
Single dose	81 (19.95%)	97 (19.09%)
<24 h	285 (70.20%)	393 (77.35%)
>24 h	40 (9.85%)	18 (3.54%)
Appropriateness in indication^d	382 (94.09%)	496 (97.64%)	5.161	0.019
Appropriateness in time of first dose^e	392 (96.55%)	504 (99.21%)	7.354	0.023
At the beginning of anesthesia	54 (13.30%)	63 (12.40%)
30–60 min before incision	338 (83.25%)	441 (86.81%)
During or post operative	14 (3.45%)	4 (0.79%)
Appropriateness in usage^f	393 (96.8%)	505 (99.41%)	6.983	0.028
Appropriateness in re-dosing^g	401 (98.77%)	507 (99.8%)	7.025	0.039
Received re-dosing	15 (3.69%)	26 (5.12%)
Re-dosing is necessary	20	27
Not receiving SAP
Appropriateness in indication^d	671 (97.81%)	625 (98.58%)	6.753	0.047

Notes: ^aSAP prescriptions fully adherent to guidelines, ^bCefazolin or cefuroxime (Vancomycin is recommended for high-risk patients in healthcare facilities with a high incidence of MRSA), ^cNot exceed 24 h after surgery completion, ^dSAP administered only if indicated in guidelines or not administered if not recommended for the specific surgical procedure, ^eAntimicrobial should be administered within 30–60 min before incision or at the beginning of anesthesia, ^fCefazolin: Adults: 2 g (3 g for patients weighing ≥ 120 kg); Pediatrics: 30 mg/kg, Cefuroxime: Adults: 1.5 g; Pediatrics: 30 mg/kg, Vancomycin: 15 mg/kg, ^gRepeated doses in cases of procedures lasting > 3 h or prolonged beyond two times the half-life of the administered antibiotic or when blood loss exceeds 1500 mL during the procedure.

Table 3 Surgical and Antibiotic-Related Complications After Clean Surgery in Two Groups

Variables	Before QCC	After QCC	P value
SSI	4	3	0.442
Other surgical complications
Partial skin necrosis	2	1	0.353
Hematoma or seroma	8	7	0.581
Wound dehiscence	3	2	0.435
Antibiotic-related ADR
Allergic reaction (skin rash, itching, flushing, macules, urticaria)	7 ()	6	0.586
Digestive system (nausea, vomiting, acid reflux, abdominal discomfort)	6	4	0.542
Cardiovascular system (phlebitis, palpitations, induration of infusion site)	1	0	0.356
Nervous system (headache, convulsions, dizziness, quadriplegia)	1	0	0.356

Figure 5 Analysis of the circle capability by radar diagram.