Shayna L. Henry, Neil G. Harness
Reducing Overuse of Prophylactic Antibiotics in Carpal Tunnel Release
To assess the effect of a program directed at reducing the use of unnecessary antibiotic prophylaxis in clean hand surgeries, and elicit reasons for continued use of prophylactic antibiotics despite evidence indicating its ineffectiveness.
A surgeon leader implemented a program in 2018 to reduce the use of antibiotics for carpal tunnel release (CTR) at 10 hospitals within Kaiser Permanente Southern California (KPSC). It consisted of 1) an evidence based educational session for all participating Orthopedic and Plastics hand surgeons during which the elimination of use of antibiotics in CTR was requested, and 2) a year-long, monthly antibiotic use audit and feedback cycle for individual surgeons. Rate of antibiotic use in CTR the year of the intervention was compared to the rate prior to the intervention. A survey was distributed among surgeons to elucidate reasons for continued use.
Overall rate of antibiotic use decreased from 51% in 2017-2018, to 13.5% the final month of the feedback cycle. One-sided Wilcoxon Signed rank test found the decrease in median rate of antibiotic use to be statistically significant (T=0, α level < 0.05). The follow up surgeon survey received an 89.74% response and revealed strong positive correlation between surgeon willingness to administer antibiotics and patient HgA1c and BMI. 97.1% of respondents agreed with literature on the lack of benefit when using prophylactic antibiotics in clean hand surgery. Noteworthy systemic barriers to cessation of unnecessary antibiotic use were lack of physician assistant (PA) awareness and erroneous ordering of prophylactic antibiotics by PAs.
The rate of antibiotic usage in CTR decreased from 51.4% the year prior, to 13.5% the final month of implementing a surgeon led program to reduce unnecessary antibiotic prophylaxis in CTR. Multiple barriers were identified in the follow up cross sectional survey which may limit implementation of this best practice.
Level of Evidence: 4