Name of the Procedure:

Common Names:

• Absence of Preoperative IV Antibiotic Order for Surgical Site Infection (SSI) Prophylaxis ##### Medical Term:
• Patient without Preoperative Order for IV Antibiotic SSI Prophylaxis (G8918)

Summary

This procedure refers to instances where patients undergoing surgery do not have a preoperative order for intravenous (IV) antibiotics, which are typically used to prevent surgical site infections (SSIs).

Purpose

The goal is to recognize and document cases where surgical patients did not receive preoperative IV antibiotics. Surgical site infections can significantly impact recovery and overall health, so this information helps evaluate surgical practices and outcomes.

Indications

• Situations where a patient is undergoing surgery and it has been determined that no preoperative IV antibiotic was ordered for SSI prophylaxis.
• Necessary for documentation and quality improvement in surgical settings.

Preparation

• No specific preparation is required from the patient as this is an observational and documentation procedure.
• Standard preoperative instructions apply as advised by the surgical team.

Procedure Description

1. Review the patient’s medical and surgical records for the upcoming surgery.
2. Identify whether a preoperative IV antibiotic was ordered for SSI prophylaxis.
3. Document the finding if no preoperative IV antibiotic was administered.
4. Continue with standard surgical protocols, ensuring other sterilization and infection control measures are in place.

Duration

• The documentation and review process typically take a few minutes.

Setting

• Hospital
• Outpatient Clinic
• Surgical Center

Personnel

• Surgeons
• Nurses
• Anesthesiologists
• Medical Record Technicians

Risks and Complications

• Documentation Risk: Ensuring accurate recording in the patient's medical records.
• Clinical Risk: Potential increased risk of SSI if not mitigated by other prophylactic measures.

Benefits

• Contributes to quality control and improvement in surgical practices.
• Helps in the assessment and prevention of SSIs in future surgical procedures.

Recovery

• No specific recovery is involved as this is a record-keeping procedure.
• Care according to standards for the type of surgery performed will apply.

Alternatives

• Other documentation methods or metrics for assessing preoperative readiness and SSI risks.
• Prophylactic measures other than IV antibiotics, depending on patient-specific strategies and surgical protocol.

Patient Experience

• The patient is generally unaware of this specific documentation unless directly informed by the medical team.
• They might not feel any difference as this involves no additional procedures or interventions.