October 2003 Bulletin

Patient safety tip from Dr. Herndon -- Best practice vs. actual practice: When we don't practice what we preach
An editorial in the September 11, 2003 issue of the Wall Street Journal began with a case report. A patient who had undergone a routine primary total hip replacement developed an infection in her new hip. “It was the start of a three-year nightmare” for the patient, including revision surgeries, further hospitalizations, more pain and additional rehabilitation.

Each of us has had a postoperative infection in a patient under our care. It is a complication that happens. However, in this case the patient never received prophylactic antibiotics with her primary operation! Why, we ask? It’s a commonly accepted standard of care to administer antibiotics in such cases before the skin incision is made and before a tourniquet is inflated and to continue them for 24 hours postoperatively.

Yet the author goes on to state that “recent studies show that in anywhere from 25 percent to 50 percent of surgeries, doctors aren’t following the most basic prevention steps, like administering the recommended antibiotics before the operation.” I have heard unofficially that in a current Centers for Disease Control study, up to 40 percent of surgical cases requiring preoperative antibiotics did not receive them preoperatively. Rarely do patients not receive antibiotics at all as in the above case, but I know that often antibiotics are not given until after the operation has started, sometimes even in the recovery room. I know also that sometimes the antibiotic is given after the tourniquet has been inflated, obviously preventing the antibiotic from reaching the operative tissues where its presence is needed.

A recent article in the New England Journal of Medicine titled “The Quality of Health Care Delivered to Adults in the United States” provides even more evidence that underuse of accepted practice standards (quality indicators) like preoperative antibiotics or “deficits . . . in adherence to recommended processes for basic care pose serious threats to the health of the American public.” The authors identified accepted quality indicators for treatment for a wide variety of medical and surgical problems. Four conditions involved orthopaedics: low back pain, orthopaedic conditions, osteoarthritis and hip fractures. The percentage of recommended care practices received by patients in these four categories ranged from only 23 percent to a high of 69 percent. Interestingly the lowest was in the treatment of hip fractures where two indicators were underused—prophylactic anti-thrombotic drugs and, yes, prophylactic antibiotics before surgery.

Given all the discussion of medical errors as a result of systems’ problems, we might ask if technology could be used to correct this “underuse” or lack of preoperative antibiotics in high-risk patients. That is not the solution in my opinion—I believe this is our problem. We are the treating physicians, the surgeons, and it is our responsibility to ensure that antibiotics are used appropriately and given at the proper time for our patients. No matter how busy we are, no matter how many distractions occur in the course of an operative day for each of us, we must follow appropriate and accepted standards of care. The use of preoperative antibiotics in high-risk patients is one such standard. No patient should suffer an infected total hip or an infection after any other major orthopaedic procedure because they never received preoperative antibiotics at the appropriate time.

This is one more example where each one of us can turn the wrench one more time for the improved safety of our patients.

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