IN THE BAG Windy Hill Hospital's circulating nurse Kathy Bigilin, RN, CNOR, is in charge of starting antibiotic infusions

Pre-op prophylactic antibiotics must be administered within 60 minutes of initial surgical incisions or procedure start times. Starting infusions even 1 minute too soon will require you to report that antibiotics weren't delivered on time. We've been using the program I'm about to describe for 5 years, and have seen our monthly on-time start rates improve from less than 90% to 100%. Follow our lead, and you'll never have to worry about improperly timed IV starts again.

FIRST CHECK Pre-op nurse Kathie Haines, RN, obtains needed antibiotics from an automated medication dispensing unit at Windy Hill Hospital.

1. Rely on the circulator
Does this sound familiar? In the hustle and bustle of getting patients properly identified and ready for transfer to the OR, and making sure needed paperwork is completed, every member of our clinical team used to help confirm, hang and chart the appropriate antibiotic. But because so many hands were involved in the process, the job didn't get done properly. Pre-op nurses said they'd start the antibiotics. Anesthesia providers promised they'd take care of it. Circulating nurses swept by the patient and swore they'd start the drip. In addition, if pre-op nurses started the antibiotics when they started IVs, the too-soon delivery often didn't fall within the 1-hour recommended timeframe. If anesthesia hung the antibiotics, they often didn't document that they had. The delivery process was inconsistent at best, which meant our patients weren't receiving their antibiotics within the acceptable timeframe. We'd miss by a minute or two, but that wasn't good enough.

The inconsistencies pushed us to get a better plan in place, and we've found that the circulating nurse is the surgical team member best suited to take ownership of the process. She interviews patients, checks allergies and physician orders, and has immediate access to surgeons for needed clarification. She also has her finger on the pulse of the surgery department, knows when patients are prepped and ready in pre-op, and when ORs have been turned over for the next case.

2. Confirm drug orders
Our outpatient surgery department is part of a large hospital, so we fax pre-op medication orders to the hospital's pharmacy the day before surgery. The pharmacists prepare the medications, including pre-op antibiotics, and send them to our unit later that day. No matter how medications are pulled or prepared in your facility, be sure your pre-op nurses capitalize on lulls in the schedule to check the accuracy of medication orders for the next day's cases.

3. Start and document infusions
When patients arrive for surgery, the pre-op nurses should go through the standard identification confirmations — name, date of birth and procedure to be performed. They must then verify allergies the patients have, if any, double-check medication orders to see what drugs are needed and hang antibiotic IV bags on patients' stretchers. When the circulating nurse arrives to interview the patients and take them to the OR, have her confirm the physicians' orders, begin the antibiotic infusions and document the start times as she signs the pre-op checklists. (The nursing mantra "You didn't do it if you didn't chart it" is never truer than it is today.) We've found that starting the drip in the pre-op holding area, about 30 minutes before taking the patient to the OR, the antibiotic hits the patient's bloodstream at the perfect time, just as he's being positioned, sedated and prepped — and comfortably within 1 hour of the incision time.

Never take for granted that medications, correct surgery sites and patient allergies have been confirmed at the previous stop along the surgical pathway. Be sure to warn patients that they'll be asked the same questions several times, and not to be concerned that your staff doesn't know what it's doing. Tell them that you're in fact double-checking the information for their safety.

4. Read and react
There are recommended antibiotics for certain procedures. Patients undergoing orthopedic surgery, for example, typically receive cephalosporin. If patients are allergic to penicillin, they usually receive vancomycin. Keep in mind that vancomycin and fluoroquinolones must be delivered within 2 hours of incision time — not the typical 60 minutes. In these instances, you might not be able to wait for your circulator to start the antibiotic IV. Have your pre-op nurses alert the circulator that a 2-hour start-time antibiotic has been ordered; they should then stay in constant communication with the OR. From there, the circulator can keep them updated on when the case will end, so the antibiotic can be started by the pre-op staff at the appropriate (earlier) time.

On the other hand, be aware that difficult intubations before the start of surgery can delay the beginning of procedures and negatively impact on-time antibiotic delivery. If anesthesia providers anticipate difficult airways, have them alert the circulating nurse so she can delay the medication start time appropriately. Cases that demand challenging patient positioning — for example, one of our surgeons prefers his rotator cuff patients in the lateral position — or waiting for additional surgical team members to help position obese patients can also delay surgery starts. In these cases, waiting to start the antibiotic in the OR might be necessary in order to fall within the required delivery window.