A PATIENT WITH MUSCULOSKELETAL LIMITATIONS COMPLICATED BY A MEDICAL ILLNESS

1. Utilizing evidence, explain one of the SCIP core measures, and how it has impacted the prevention of surgical complications.

Surgical care improvement is an organizational partnership within the nation that seeks to reduce episodes of complications before during and after surgery by following a checklist of measures. To achieve this aim evidence based practice that utilizes available proven evidence is used with the goal of improving the patients’ outcome. Surgical care improvement seeks to utilize the best information to guide clinical practice with an overall aim of reducing surgical complications and thus healthcare costs. It utilizes several core measures that are prophylactic in nature.In this question I’ll be discussing prophylactic antibiotic received within one hour prior to surgical incision (SCIP Inf-1) and how it impacts patients’ outcome positively or otherwise. The chief goal of this measure is to reduce incidence of surgical site infections.

Antibiotic prophylaxis is recommended for invasive orthopedic procedures like arthroplasty. The reason for this is that such an invasive procedure has an infectious risk that ranges from 5% to 15% without antibiotics. This high rate of infection can greatly increase morbidity and mortality among these patients. Conversely if antibiotic prophylaxis is provided there is a marked reduction in the risk for infection to around 3%. Staphylococcus epidermidis and Staphylococcus aureus which are members of the normal flora are the leading causes of joint infections. The antibiotic of choice for prophylaxis against these organisms is cefazolin (ancef) since it’s the most effective choice against the aforementioned organisms. There is no evidence to support extension of prophylaxis post-surgery or addition of an aminoglycoside. Antibiotic prophylaxis was adopted as a core measure of ensuring better surgical outcomes since there is evidence to support its use. In the above case the patient receives cefazolin which is the antibiotic of choicefor prophylaxis against Staphylococcus aureus and Staphylococcus epidermidis. On the first post-operative day the administration of antibiotic ceases. This is also in agreement with the best practice that has demonstrated little benefit if any in extending the prophylaxis period.There is also no extra antibiotic given since additional antibiotics are of no proven value(Page, Bohnen, Fletcher, McManus, Solomkin and Wittmann, 1993).

The efficacy of antibiotic prophylaxis is not only influenced by the organisms to be targeted but also the timing of administration. The general recommendation is that the antibiotic should be administered within 30 minutes before the procedure. In the above case the patients receives the first dose 30 minutes before surgery which is in line with the best practice recommendations. To further confirm that this is the best practice the patients has uneventful post-operative period (Classen, Evans, Pestotnik, Horn, Menlove, and Burke, 1992).

Other authorities recommend the administration of prophylactic antibiotic to be within 60 minutes prior to surgery. The longer the time period between the antibiotic administration and the incision time the higher the risk of surgical site infectionthe right drug should be administered at the right dose the right route and right timing for optimal protective effects (Bratzler, Dellinger, Olsen, Perl, Auwaerter, Bolon, Fish, Napolitano, Sawyer, Slain, Steinberg and Weinstein, 2013).

In the above case the patient received the right drug at the right timing. The result of which was uneventful recovery period. Prophylactic antibiotics for surgical operations have greatly reduced incidences of infections during the perioperative period. As mentioned above the drop is from the ranges of 5%-15% to 3%. Failure by providers of healthcare to adhere to this best practice is what is resulting in increasing case of post-surgical wound sepsis, increased mortality and increased healthcare costs.

In conclusion the impact of this drop in infections is reduced morbidity and mortality, reduced hospital stay and reduced health care costs. It is therefore the right practice for healthcare providers to employ this measure since it has been proven to effective and beneficial for patients and the healthcare system as a whole. The administration of the right antibiotic within the stipulated time is the reason this measure will be effective or not.

2. Explain why, no hair removal was required for the surgical procedure. If it had been ordered, would a razor have been appropriate to use? Explain your rationale with evidence.

Previously the general recommendation prior to surgery was that hair at the site that is to be incised ought to be removed. The primary method of choice for hair removal was shaving using a razor blade. Following years of research this is no longer the case anymore. New information has been brought to light in relation to some of the down sides to hair removal as dictated by the method used. Hair removal is not therefore bad in itself. Whether it’s a bad thing or a good thing is depended on the hair removal method used and the timing.

Hair removal was not required since unequivocal evidence is still lacking to support the use of pre surgical hair removal to reduce surgical site infections. Most studies have not yielded significant differences between patients who had hair removal prior to surgery and those who did not although some of the researches done were considered to be of low quality to be generalizable (Tanner, Woodings and Moncaster, 2007). The Centre for Disease Control (CDC) recommendation pertaining to pre-operative hair removal is that it should only be done if it will interfere with the surgical procedure to be done. This recommendation serves to discourage routine hair removal that had been the standard practice (CDC, 2008).

In addition to this other studies have indicated that hair removal of any kind can result in increased incidences of surgical site infections serve to discourage routine pre-surgical hair removal. Another authority that argues against hair removal is the Association of perioperative Registered Nurses’ (AORN). It recommends that hair should be left at the surgical site as much as it is possible. This too serves to dissuade healthcare providers from practicing routine hair removal on patients prior to surgery since in certain instances it can increase the risk of surgical site infections (AORN, 2008). With this information in mind a decision was made based on the existing evidence that hair removal wasn’t necessarily beneficial and if anything it can be detrimental to the patient as it can increase the risk of surgical site infections given the evidence above.

If hair removal had been ordered a razor blade would not have been the most appropriate instrument to use for the procedure. The key aim of pre surgical hair removal is to reduce infections at the surgical site and also ensure that hairs don’t interfere with the procedure in any way. The most readily available method for pre surgical hair removal is shaving with a razor. Shaving with a razor has been proven to result in micro cuts that can increase the incidence of surgical site infections defeating its very purpose.

Suvera and colleagues compared the use of depilatories against the use of a razor blade for pre surgical hair removal. From their findings they concluded that unlike depilatories use of razor increased the incidence of surgical site infections due to the skin injuries it produced. This research based information serves to discourage hair removal by the use of a razor as it proves it to be the worse option of the two (Suvera, Vyas, Patel, Varghese, Ahmed, Kashyap and Nair, 2013). From the above research conclusions the use of a razor won’t result in the best patient outcomes in fact it might result in increased of surgical site infection. Apart from that depilatories have in certain instances resulted in sensitivities that have even resulted in the cancellation of some surgical procedures. For this reason the CDC recommends the use of hair clippers if hair removal is really necessary and that this should be done just before the surgical procedure (CDC, 2008). The use of clippers will be the method of choice if pre-surgical hair removal had been ordered for and not the razor blade.

Other researchers recommend that depilatories and clippers are superior methods of pre surgical hair removal when compared to shaving using a razor. From their findings shaving should not be done under any circumstancesas they increase the chances of surgical site infections (Tanner et al 2007). In addition to that, a study conducted by Celik and Kara concluded that shaving with a razor just before a surgical procedure increases the rate of post-surgical operation infections. Although their research focused on patients undergoing spinal surgery this information can be generalized to the knee surgery. Rather than risk increasing the chances that the patient could get a surgical site infection not using a razor for hair removal will be the better option as this researchers found out (Celik and Kara, 2007).

And lastly a systematic literature review found increased surgical site infections from shaving using a razor in the pre-operative period (Orsi, Ferraro and Franchi, 2005).It is therefore self – evident from this finding that shaving using a razor does not confer the benefit it was once thought to confer. If anything, its use serves only to harm the patient.

In summary routine pre-surgical hair removal is not the practice of choice for reducing surgical site infections. And if hair removal has to be done the using clippers is preferable to shaving using a razor or even using depilatories. And if clipping is to be used it should be done immediately before surgery. The general recommendation is that razor blades should be removed from wards to help stop this practice of pre-surgical shaving that has been proven to result in increased surgical site infections.

3. What methods were used to ensure that the recommended VTE/DVT prophylaxis was implemented, and why is the timing important? Explain your rationale with evidence.

One of the core measures of surgical care improvement is surgery patients who received appropriate venous thromboembolism prophylaxis within 24 hrs prior to surgery to 24 hours after surgery (SCIP VTE- 2). The patient had a hose TED and sequential compression stockings. In addition to this measure the patient received levonox 30mg subcutaneously starting on the first post-operative day.

The risk for pulmonary embolism that ends in death for patients undergoing orthopedic surgery under general anesthesia is estimated at 0.8% to 1.0%. The chances of a patient developing deep venous thrombosis reduce if prophylaxis with heparin (low molecular weight) is instituted early.The generally accepted time frame that ensures best results for drug prophylaxis is within 8 hours of surgery. Mechanical methods also serve together with pharmacological methods to produce better results for thromboembolism prophylaxis. Mechanical options available function by preventing the pooling of blood mainly in the lower extremities. They achieve this role by promoting blood flow and the amount of fibrinolysins in circulation.

According to a graduated compression stockings in the preventions of postoperative venous thromboembolism a meta-analysis this stockings result in significant reduction in the risk of thromboembolism. The stocking works by preventing the pooling of blood in the lower extremities thus preventing formation of blood clots. These stockings promote linear flow of blood hence no pooling of blood occurs. Furthermore these stockings stimulate fibrinolysis on the endothelium preventing formation of clots. Graduated stockings alone reduced the incidence of deep venous thrombosis by approximately14%.Case in point is that elastic stockings are effective as a method of prophylaxis against deep venous thromboembolism(Ross-Adjie, McAllister, & Bradshaw, 2012).

Together with pharmacological intervention they achieve synergistic effect that is more beneficial unlike if each method was employed singly. A combination if intermittent compression device and heparin for thromboembolism prophylaxis was found to be more effective than aspirin or warfarin alone.

In respect to this evidence the patient received two prong approach for prophylaxis against development of deep venous thrombosis and the resultant embolism. Both the pharmacological and mechanical methods for DVT prophylaxis were employed. The use of mechanical devices served as adjuncts to drug therapy helped to guarantee better results for the intervention(Ross-Adjie et al., 2012).

The timing for the prophylactic intervention is also important. Time is allowed to let the hemostasis at the surgical wound settle before the pharmacological prophylaxis is instituted. Without this window period allowance the pharmacological intervention can result in the hemorrhage of the surgical site negating its benefits altogether. In addition to this one of the risk factor for formation of thrombi is prolonged immobility. Intervention is instituted earlier before the effects of immobility set in. In case of prolonged immobility there is resultant pooling of blood that serves to encourage clot formation.

The recovery period of this patient was uneventful. No deep venous thrombosis resulted lending credence that the prophylactic measures against it were effective. The combination of thromboembolic stockings and anticoagulants is now part of routine post-operative management for patients at risk of deep venous thrombosis. The impact of instituting this measure is reduction in the incidence of thromboembolism with their associated complications.

In conclusion choosing the right prophylactic method against deep venous thrombosis and instituting it in a timely manner can greatly reduce the incidence of thromboembolism and its related complications. Rather than sticking to old ways healthcare providers should be able to stay abreast with the latest findings that have a direct bearing to the patients’ health. This evidenced based approach will go a long way in improving the quality of care patients receive.

REFERENCE

AORN,(2008).Recommended practices for preoperative patient skin antisepsis. Perioperative Standards and Recommended Practices.Denver. p. 537-555.

Bratzler D., Dellinger E., Olsen K., Pearl T., et al. (2013). Clinical practice guidelines for Antimicrobial prophylaxis in surgery.Am J Health Syst Pharm. 70(3):195-283.

CDC (2015). Surgical site infections (SSI): Data and statistics. Retrieved on 21st September 2015 from https://www.cdc.gov/ncidod/dhqp/dpac_ssi_data.html

Celik S., Kara A.(2007). Does shaving the incision site increase the infection rate after spinal surgery? Spine;32(15): 1575-1577.

Mukesh S., Patrick V., Mansukh P., et al. (2013). Two methods of pre-operative hair removal and their effect on post-operative period. Int J Med Sci Public Health; 2(4): 885-888

Orsi G., Ferraro F. &Franchi C. (2005).Preoperative hair removal review.Ann Ig. 17(5):401-12.

Phillip S., Anthonie W. & Hirsh J. (1994).Graduated Compression Stockings in the Prevention of Postoperative Venous ThromboembolismA Meta-analysis.Arch Intern Med. 154(1):67-72.

Ross-Adjie, G., McAllister, H., & Bradshaw, S. (2012). Graduated compression stockings for the prevention of postoperative venous thromboembolism in obstetric patients: A best practice implementation project.International Journal of Evidence-Based Healthcare, 10(1), 77–81.

Tanner J., Moncaster K., Woodings D.,(2007). Preoperative hair removal: a systematic review. J Perioper Pract.17:118-21, 124-32.


 

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