Development and Utility of a Hospital-level Comparative Performance Report Card for Surgical Prophylaxis Utilization in Non-emergent Pediatric Surgery

Background: Antimicrobial stewardship and surgical site infection (SSI) prevention are important goals in the appropriate use of surgical antimicrobial prophylaxis. The purpose of this study is to explore the utility of a standardized report card to assist hospitals with identifying quality improvement opportunities around these goals, and to identify high-performing centers for the elucidation of best practices.

Methods: Perioperative prophylaxis and SSI data for non-emergent surgical procedures were collected by 90 hospitals participating in an American College of Surgeons National Surgical Quality Improvement Program-Pediatric (ACS NSQIP-Pediatric) antibiotic stewardship collaborative from June 2019 to June 2020. Prophylaxis data included antibiotic agents, administration timeline, and duration. Prophylaxis measures included timing compliance (administration before incision), compliance with appropriate spectrum of coverage based on consensus guidelines, and proportion of cases with prolonged utilization following incision closure (any postoperative utilization and utilization > 24 hours). Incisional and organ space infection rates were included in the report card as balancing measures. Hierarchical regression was used to estimate hospital-level odds ratios (ORs) for each measure, adjusting for differences in comorbidities and procedure-mix across hospitals. Hospitals were considered performance outliers if their adjusted 95% confidence interval (CI) did not include 1.0. The distribution of performance outliers was explored to assess the report card’s utility for identifying quality improvement opportunities (low performing outliers) and exemplar hospitals for best practice elucidation (high performing outliers).

Results: 10,398 children who underwent a non-emergent general pediatric surgical procedure were included in the analysis. Substantial differences were found in adjusted ORs across hospitals for each prophylaxis measure, with variation ranging from 2.9-fold for organ space SSI to 82-fold for non-compliance with appropriate spectrum antibiotics (Table). The proportion of hospitals with high and low performing outliers ranged from 7.8% for appropriate prophylaxis timing to 35.6% for use of any postoperative prophylaxis (Table). 31.1% of hospitals were a low performer for at least one measure and 45.6% a high performer for at least one measure. Substantial differences in adjusted ORs across hospitals were found for incisional SSI but not for organ space infection. Only 2 hospitals (2.2%) were identified as an outlier for the SSI measures (Table).

Conclusion: Variation in prophylaxis utilization among hospitals was considerable with performance outliers identified across all measures. These results would suggest substantial utility for a report card in identifying hospitals with opportunities for improvement and those where best practices could be identified. Although SSI rates and variability among hospitals was low, inclusion of SSI balancing measures in the report card provide a mechanism for monitoring SSI rates over time as targeted stewardship efforts are implemented.