Q: Preop Antibiotics

I’m looking for input as to how you (particularly ASCs) handle the preop antibiotics. Do you start them as you go into the OR? Do you give them in preop? Also, with the new guidelines for documentation/reimbursement upcoming, how do you document start/stop times? Thanks for any info you can provide. Thoughts?

 

A: In my current consulting experiences with performing antibiotic timing QI studies with data analysis and statistical reporting for my ASC clients, a variety of approaches are taken. The decision as to where to administer antibiotics comes down to individual center preference. The majority administer in pre-op with careful time coordination to assure there will be no delays for procedure start time within the 60-minute administration time frame (or 120 min for fluoroquinolones, etc.). Other centers have the anesthesiologist administer in the OR or in preop immediately prior to transfer to the OR. Regarding documentation, administration start times and incision/tourniquet times are legally/regulatory required to be documented in the medical record. For data collection, some centers use a QI tool for each individual patient indicating the antibiotic given, administration start time, and incision/ tourniquet time while other clients utilize a log sheet that the OR nurse is required to complete for every patient who receives an antibiotic. The log sheet contains the same information as the QI tool. At the end of the monthly or quarterly study period, data is then provided to me for statistical analysis, reporting, compliance outcomes, and antibiotic utilization for cost analysis purposes. From a patient safety perspective in reducing SSIs, having the factual statistical outcomes is often the best way to educate staff and improve compliance as well as meet the national standards. Hope that helps.

A: With the SCIP data r/t timing we went round and round with who gives it and what times. We have never had a problem in the past, but since the SCIP data it seems people are getting confused. We ended the confusion and now it is solely the anesthesia provider who gives it and documents the time given and that seems to have taken the confusion away from everyone. The antibiotic is hung on the patient’s gurney in pre-op and the anesthesia takes care of it from there.

A: We do the same and we also go one step further. We have our unit secretary make sure and check the anesthesia record each day to make sure the time is documented. A copy of the anesthesia record is deposited at the OR desk for billing.

A: Our orthopod is the one who pushes us for faster turnover times, but I tell my staff the cleanliness of the room and infection control is more important than turnover time. We strive for 20-30 minutes; sometimes we make it, sometimes we don’t.

A: The OR staff starts the IV antibiotic when the patient rolls into the OR holding area. This covers us with the SCIP project, making sure the antibiotics are given within an hour of the incision time. We have not had any problems with reimbursement as yet; we only document the start time.

 

Q: ASC Charting

Reviewing our medical records process here in an ASC setting, and wondering if you would share your process for how the charts get completed when signatures, op reports, etc. are missing. Who is responsible for all of this, specifically clinical or business office? Also, do you have a person who does this full time?
A: Medical Records is responsible for obtaining signatures; they determine what is missing and bring them to the OR or surgeon’s boxes for signatures. They are full-time employees.

A: As an ASC Quality Improve- ment consultant, I assist many of my clients with this issue and their medical record audits. Various methods are employed regarding the initial chart completion process. In some centers, the PACU nurse is responsible for assuring all components are completed at the end of each surgery day and, if incomplete, flagging them for missing components. However, this still leaves someone else, usually clerical, responsible for assuring reports and missing signatures are acquired within required time frames. Other centers assign clerical personnel to review each chart within 24-48 hours, using checklists, to identify missing components and assure completion before the charts are permanently filed. The QI/QA audit process that I provide is then performed at the end of each quarter period (non-clerical). This process utilizes a specifically designed checklist to assure all critical documentation and reports have been completed. Following the review, the data is then statistically analyzed to identify outliers, trends, and responsible parties (surgeon, anesthesia, nurse, clerical). When presented with a measurable objective outcomes report, a corrective action plan for education/remediation can then be developed as part of the QI process to improve the outcomes. It’s always interesting to see the factual statistics that either prove or disprove assumptions about performance and compliance. Also, additional QI studies are often implemented as a result of the outcomes, always a plus with regulatory and accreditation evaluators. Hope this was helpful.

A: Can you share your checklist template?

A: Each of the clerical and audit checklists that are used are collaboratively developed with each ASC and individually designed to fit each center’s unique processes, forms, needs, etc., as well as assuring the capture of licensing and accredita- tion components and high problem prone areas such as time-out documentation, etc.