Publication: Evaluación y mejora del procedimiento de profilaxis antibiótica quirúrgica en el Hospital Clínico Universitario Virgen de la Arrixaca
Authors
Sánchez Rodríguez, Inés
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Escuela Internacional de Doctorado
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López-Picazo Ferrer, Julio José
Publisher
Universidad de Murcia
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DOI
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info:eu-repo/semantics/doctoralThesis
Description
Abstract
Introducción: Las infecciones del lugar quirúrgico (ILQ) representan más del 20% de las infecciones nosocomiales. La profilaxis antibiótica quirúrgica (PAQ) es una de las medidas más efectivas para prevenir estas infecciones, pero los estudios demuestran que frecuentemente no se administra de forma adecuada. A la vez, la PAQ supone una cantidad considerable de los antibióticos usados en hospitales y puede contribuir al aumento de la resistencia antimicrobiana.
Objetivo: El objetivo de este trabajo es evaluar, mejorar y monitorizar la adecuación de la PAQ, en cuanto a indicación, tipo de antibiótico, momento de administración, duración de la profilaxis y registro, en el Hospital Clínico Universitario Virgen de la Arrixaca (HCUVA, Murcia).
Material y métodos: Se realizó un ciclo de mejora que evaluó la PAQ en 120 pacientes adultos, 60 de ellos en febrero de 2018 y 60 en abril de 2019, antes y después del diseño e implementación de un nuevo procedimiento y una nueva guía de práctica clínica (GPC) de PAQ. Para la valoración de la situación inicial se utilizaron técnicas tanto cuantitativas como cualitativas. Las etapas del proyecto incluyeron la creación de un grupo multidisciplinar, la elaboración de una GPC actualizada de PAQ, la integración de las nuevas recomendaciones en el programa de prescripción electrónica asistida (PEA), y la formación presencial a los equipos quirúrgicos. La GPC se elaboró siguiendo los pasos que propone el método de adaptación-elaboración-actualización de Osteba, adaptados al entorno. Para la reevaluación se calcularon los porcentajes de cumplimiento con un intervalo de confianza del 95% antes y después, y las mejoras absolutas y relativas y, en caso de mejora, se usó la prueba z para comparar dos proporciones, y la tabla de distribución normal de una cola para conocer el nivel de significación estadística de la comparación. Finalmente se estableció un plan de monitorización semestral para la vigilancia del correcto cumplimiento y detectar nuevas oportunidades de mejora, en su caso. Se crearon tres indicadores de monitorización, de los cuales uno se mide mediante cruce directo de los datos de las fuentes de información y los otros dos mediante la técnica LQAS.
Resultados: La reevaluación, en mayo de 2019, mostró una mejora amplia y significativa respecto a la primera evaluación, tanto en la duración de la PAQ como en el registro de esta, pasando de un cumplimiento del 56,7% al 90% (p<0,001) y del 65% al 85% (p=0,006), respectivamente. La mejora relativa fue del 76,9% en cuanto a la duración, y del 57,1% en cuanto al registro, que fueron los criterios que acumulaban el 77% de los incumplimientos en la primera evaluación. El principal producto y eje director de esta mejora fue el desarrollo de una GPC de PAQ propia del HCUVA, basada en la literatura más reciente, con recomendaciones específicas por tipo de intervención en cada servicio quirúrgico. La monitorización semestral muestra una mejora progresiva en la adecuación de la PAQ en cuanto a indicación, tipo de antibiótico y duración, pero el registro en el PEA sigue precisando acciones de mejora.
Conclusiones: El empleo de las tres principales actividades para la mejora continua de la calidad: realización de un ciclo de evaluación y mejora, diseño e implementación de intervenciones para mejorar, y construcción de indicadores y monitorización, puede mejorar la adecuación de la profilaxis antibiótica quirúrgica en un hospital. La intervención más destacada y que, probablemente, ha contribuido de forma más significativa a la mejora en este estudio ha sido la elaboración de una GPC de PAQ actualizada y propia del HCVUA. También es importante implicar a los equipos quirúrgicos en el proceso para conocer de cerca las dificultades y mejorar el cumplimiento.
Introduction: Surgical site infections (SSIs) account for more than 20% of hospital-acquired infections. Surgical antibiotic prophylaxis (SAP) is one of the most effective measures to prevent these infections, but studies show that it is often not administered appropriately. Moreover, SAP represents a substantial proportion of antibiotics used in hospitals and may contribute to the increase in antimicrobial resistance. Objective: The objective of this study is to evaluate, improve, and monitor the adequacy of surgical antibiotic prophylaxis (SAP) regarding indication, type of antibiotic, timing of administration, duration of prophylaxis, and documentation at the Hospital Clínico Universitario Virgen de la Arrixaca (HCUVA, Murcia). Materials and Methods: An improvement cycle was carried out to evaluate SAP in 120 adult patients—60 of them in February 2018 and 60 in April 2019—before and after the design and implementation of a new procedure and a new SAP clinical practice guideline (CPG). Both quantitative and qualitative techniques were used to assess the baseline situation. The project stages included the creation of a multidisciplinary group, the development of an updated SAP CPG, the integration of the new recommendations into the computer-assisted electronic prescribing (CAEP) program, and in-person training for the surgical teams. The CPG was developed following the steps proposed by Osteba’s adaptation–development–updating method, adapted to the setting. For the re-evaluation, compliance percentages with a 95% confidence interval were calculated before and after, as well as the absolute and relative improvements; and, in the event of improvement, the Z-test was used to compare two proportions, and the one-tailed standard normal distribution table to determine the level of statistical significance of the comparison. Finally, a semi-annual monitoring plan was established to oversee correct compliance and to detect, where applicable, new opportunities for improvement. Three monitoring indicators were created, one of which is measured by direct cross-checking of data from the information sources, and the other two by the LQAS technique. Results: The second evaluation, conducted in May 2019, revealed a significant improvement in both the duration of SAP and its documentation, with increases from 56.7% to 90% compliance (p<0.001) and from 65% to 85% (p=0.006), respectively. The relative improvement was 76.9% regarding duration, and 57.1% regarding documentation, which were the criteria that accounted for 77% of the noncompliance in the first evaluation. The main product and guiding axis of this improvement was the development of an HCUVA-specific SAP CPG, based on the most recent literature, with specific recommendations by type of surgery in each surgical service. Semi-annual monitoring indicates progressive improvement in the adequacy of SAP in terms of indication, type of antibiotic, and duration; however, documentation in the CAEP still requires improvement measures. Conclusions: The use of the three main activities for continuous quality improvement—carrying out an evaluation and improvement cycle, designing and implementing interventions to improve, and developing indicators and monitoring—can improve the adequacy of surgical antibiotic prophylaxis in a hospital. The most noteworthy intervention, and probably the one that contributed most significantly to improvement in this study, was the development of an updated, HCUVA-specific SAP CPG. It is also important to involve surgical teams in the process in order to understand the difficulties firsthand and improve compliance.
Introduction: Surgical site infections (SSIs) account for more than 20% of hospital-acquired infections. Surgical antibiotic prophylaxis (SAP) is one of the most effective measures to prevent these infections, but studies show that it is often not administered appropriately. Moreover, SAP represents a substantial proportion of antibiotics used in hospitals and may contribute to the increase in antimicrobial resistance. Objective: The objective of this study is to evaluate, improve, and monitor the adequacy of surgical antibiotic prophylaxis (SAP) regarding indication, type of antibiotic, timing of administration, duration of prophylaxis, and documentation at the Hospital Clínico Universitario Virgen de la Arrixaca (HCUVA, Murcia). Materials and Methods: An improvement cycle was carried out to evaluate SAP in 120 adult patients—60 of them in February 2018 and 60 in April 2019—before and after the design and implementation of a new procedure and a new SAP clinical practice guideline (CPG). Both quantitative and qualitative techniques were used to assess the baseline situation. The project stages included the creation of a multidisciplinary group, the development of an updated SAP CPG, the integration of the new recommendations into the computer-assisted electronic prescribing (CAEP) program, and in-person training for the surgical teams. The CPG was developed following the steps proposed by Osteba’s adaptation–development–updating method, adapted to the setting. For the re-evaluation, compliance percentages with a 95% confidence interval were calculated before and after, as well as the absolute and relative improvements; and, in the event of improvement, the Z-test was used to compare two proportions, and the one-tailed standard normal distribution table to determine the level of statistical significance of the comparison. Finally, a semi-annual monitoring plan was established to oversee correct compliance and to detect, where applicable, new opportunities for improvement. Three monitoring indicators were created, one of which is measured by direct cross-checking of data from the information sources, and the other two by the LQAS technique. Results: The second evaluation, conducted in May 2019, revealed a significant improvement in both the duration of SAP and its documentation, with increases from 56.7% to 90% compliance (p<0.001) and from 65% to 85% (p=0.006), respectively. The relative improvement was 76.9% regarding duration, and 57.1% regarding documentation, which were the criteria that accounted for 77% of the noncompliance in the first evaluation. The main product and guiding axis of this improvement was the development of an HCUVA-specific SAP CPG, based on the most recent literature, with specific recommendations by type of surgery in each surgical service. Semi-annual monitoring indicates progressive improvement in the adequacy of SAP in terms of indication, type of antibiotic, and duration; however, documentation in the CAEP still requires improvement measures. Conclusions: The use of the three main activities for continuous quality improvement—carrying out an evaluation and improvement cycle, designing and implementing interventions to improve, and developing indicators and monitoring—can improve the adequacy of surgical antibiotic prophylaxis in a hospital. The most noteworthy intervention, and probably the one that contributed most significantly to improvement in this study, was the development of an updated, HCUVA-specific SAP CPG. It is also important to involve surgical teams in the process in order to understand the difficulties firsthand and improve compliance.
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