IV Vanco Question

When I work ICU, we start on call antibiotics when we get the call that the O.R. is sending for pick up as they go direct to surgery and bypass our holding area.

When I work day surgery (ambulatory surgery and holding area for floor patients), we call O.R. room to ask if the room is running on time or delayed, then will start pre-op Vanco about 30 minutes or so before and drip it in slowly. All other on call antibiotics are give by the anesthesiologists per agreement between our departments once we started our new computer system.

Im curious what others do in situations where patients require Vanco preop (either for pcn allergies or otherwise)

At my hospital a frequent problem is vanco not being started in ambulatory preoperatively out of fear of a room delay, and the patient not getting the vanco within a 1 hour window of incision.

So instead you can end up with patients vanco getting started after right after intubation, minutes before incision.

Does anyone's hospital's do anything that works ?

Not sure where the problem is here. Would it perhaps be better if the vanco was started earlier? Maybe, although I'll bet you'd be hard pressed to find data that says an hour or so prior to incision is any better than 10 minutes as far as outcomes. But as long as vanco is started anywhere within a 2 hr window prior to incision, the SCIP standard is satisfied.

As jwk said above, Vanc has a 2 hour window to be given prior to incision according to SCIP guidelines. From what I understood in our hospital's inservice about SCIP procedures, the antibiotics only need to be started prior to incision, and not completely infused. At our hospitals, the anesthesiologists start the antibiotics when we are in the operating room, instead of in the preop area, so we can be sure that we are still in the hour window for incision. This is a good breakdown of the SCIP guidelines for antibiotics, but I think some of the other things have changed since this was written in 2012. http://surgery.uc.edu/content/Education/residentresources/SCIP%20one%20page%20guidelines%20draft%204%204-24-2012.pdf

My facility policy requires that Vanco be administered over a full hour. There won't be much Vanco circulating at the time of incision if it is only started 10 minutes prior. That is why our policy is that it should be started 1 hour prior to incision (leaving a 1 hour leeway if a little later) and why our preop starts it. What's the point of giving prophylactic antibiotics if you aren't even going to give them time to infuse and circulate prior to incision? That's also why antibiotics are to be fully infused prior to inflating any tourniquets.

In a perfect and total fantasy world, surgeons would be on time, cases wouldn't get delayed for slow surgeons or emergencies, and we could start antibiotics at the exact appropriate time for every case. In the imperfect real world, that just doesn't happen. Anesthesia reimbursement can get dinged for improper antibiotic timing, even though as far as we're concerned, that should be a nursing responsibility since antibiotics have absolutely nothing to do with the anesthetic, but guess who gets stuck with that problem?

The best solution we've found for making sure antibiotics are given within the SCIP window is for anesthesia to be responsible for it, whether we like it or not. If the surgeon wants to wait for all of the antibiotic to be infused prior to incision or tourniquet inflation, he's welcome to wait it out - easy if it's cefazolin, and never gonna happen if it's vanco. Again - real world, AND, it's not required by the SCIP standard for the antibiotic to be infused prior to incision or tourniquet inflation. That's the problem with some of these stupid rules - they're really not based in reality, and certainly not written by people who actually provide hands-on patient care and deal with the logistical issues of a modern OR. They're written by people who sit behind desks and carry clipboards and only wear scrub clothes to give the appearance they work in the OR.