Running Head: IMPACT ANALYSIS I
Impact Analysis I of Doctoral of Nursing Practice Project and
Methods of Sustainability
Arkansas State University
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Total knee arthroplasty (TKA) is the definitive treatment for degenerative joint
disease of the knee (Shahi & Parvizi, 2015). TKA is widely used to relieve the pain of
end stage primary osteoarthritis and improve activities of daily living (Weinstein et al.,
2013). The frequency of TKA has been increasing over the years along with the aging
population. Patel, Guild, and Kumar (2018) reported a projected increase in total knee
replacements of approximately 3.4 million by 2030 (p. 479). As the number of elderly
patients continues to grow in the United States, the younger population are potentially
experiencing longer lives while living with degenerative joint disease. The need for total
joint replacement will continue to show increased growth in the future (Nwachukwu et
al., 2015). In order to continue to provide patient care with high standards, preoperative
prophylactic antibiotics must be continually updated to ensure post-operative infections
remain relatively muted. A current review of the literature shows a gap in current
guidelines related to microbial involvement and antibiotic usage in total knee
arthroplasty. In order to bridge this gap, a proposed change in antibiotic prophylaxis will
be analyzed to determine if the current guidelines are adequate to combat the rate of total
knee arthroplasty joint infections.
Stakeholder Outcome
The proposed DNP project will directly impact three groups of stakeholders. White,
Dudley-Brown, and Terhaar (2016) define stakeholders are those individuals directly impacted
by the outcomes of proposed projects, (p. 201). This project directly affects patients as the first
stakeholder. The current guidelines for prophylactic antibiotic usage before a total knee
arthroplasty are based on information from studies more than a decade old. Over the last ten
years, MRSA has purportedly become a larger concern for infection and may be concentrated in
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certain geographical areas (Kourtis et al., 2019). Despite the decline over the last decade of
recorded MRSA bloodstream infections, S. aureus continues to cause significant morbidity and
mortality across the United States (Kourtis et al., 2019). According to Kourtis et al. (2019), “in
2017, an estimated 119,247 S. aureus bloodstream infections with 19,832 associated deaths
occurred, however, during 2005-2012 rates of hospital-onset MRSA bloodstream infection
decreased by 17.1% annually, but the decline slowed during 2013-2016”, (p. 214). Although a
decline in MRSA infections has been documented, the United States is still behind on the 2020
goal of the Healthcare-Associated Infection National Action Plan of a 50% reduction in hospital
onset MRSA infections (Kourtis et al., 2019, p. 214). As the incidence appears to be declining in
the rates of MRSA, the patient population continues to face higher health costs and treatment
failure (Labreche et al., 2013). Prevention of postoperative total knee infections should be a
priority to ensure a healthier patient population.
In addition to the patient population, healthcare providers are stakeholders as well and
will also be affected by a change in policy to decrease postoperative total joint infection rates.
The provider must be willing to use every available tool to combat the infections including
adjustments to preoperative antibiotic usage. Attempting to follow guidelines set forth by The
Infectious Diseases Society of America (IDSA) related to MRSA infections have resulted in
shorter times to resolution than MRSA infections treated without the recommendations
(Labreche et al., 2013). Incision and drainage along with antibiotic use resulted in a decreased
resolution time according to a study involving the South Texas Ambulatory Research Network
(STARNet), a practice-based research network (PBRN) (Labreche et al., 2013). Treating
patients before surgery with the right antibiotic before an infection occurs could be the credible
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first line defense in preventing readmissions for incisions and drainage and systemic antibiotic
infusions.
Many authors agree Cefazolin single preoperative dose before total joint arthroplasty is
the best choice. However, studies have shown in the presence of revision surgery, targeted use
of cefazolin and vancomycin significantly reduced the incidence of infections such as MRSA
(Ratto, Arrigoni, Rosso, Bruzzone, Dettoni, Bonasia, & Rossi, 2016). Although there are many
other proven preventative strategies to decreasing post-operative joint infections such as
decreasing operating room traffic, glove changes during procedure, pulsed lavage, and control of
glucose levels before and after surgery, preoperative antibiotic use one hour before incision
remains the most definitive measure utilized (Ratto et al., 2016).
Analysis of Systems: Micro, Meso, Macro
Clinical microsystems have been the building blocks of our healthcare systems. The
general patient population, healthcare payers, and the public have expectations concerning the
quality, safety, and costs associated with the delivery of services (Likosky, 2014). Stakeholders
expect optimization of the health care arena, and as such, change is evaluated through evidencebased research and implemented (Likosky, 2014). The small groups of professionals, the
microsystem, carry out the important first steps in providing primary care to the patient.
Surgeons, anesthesia providers, and the surgical team have a vested interest as a microsystem to
provide the lowest surgical infection rates related to total knee arthroplasty procedures.
Determining the correct antibiotic and dosage schedule, based on risk factors recommended by
the International Concensus Meeting (ICM) workgroup, may provide large scale improvements
in the incidence of post-operative joint infection (Likosky, 2014). Recognizing the gaps in
practice may initiate the first steps to improvement.
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The mesosystem is the glue that links the microsystems all together (Likosky, 2014).
Anesthesia providers recognize the importance of antibiotic timing and strive to achieve 100%
timely administration to prevent surgical site infections after total knee arthroplasty. Surgeons
rely on a network of individuals to assist them with managing the patient, sterility during the
procedures, and successful joint replacement without infection. Functioning as a healthcare
mesosystem allows the transfer of knowledge from one microsystem to another microsystem.
The framework of transfer of care from the preoperative nurses to the surgical nurses and
anesthesia team provides a good example of a business aim or mesosystem network (Likosky,
2014).
The macrosystem is the coordinating body of the mesosystems within an organization.
This tier includes the federal agencies and professional organizations that assist with guiding
health care. The CEO, board of directors, and administrators within this system assist with
managing the interconnections within the closely linked departments. Outside forces also
contribute to the macrosystems to maintain patient and payer expectations. The Perioperative
Surgical Home is a patient-centric, team-based model of care created by the American Society of
Anesthesiologists to assist with the demands set forth by the increasing changes in healthcare
(“Perioperative Surgical Home”, n.d.). The PSH overview explains the steps of the preoperative
services, intraoperative services, postoperative services, and lastly, the long-term recovery
(“Perioperative Surgical Home”, n.d.).
Project Sustainability
The efficacy of prophylactic antibiotic use for total joint arthroplasty has been in use
since the first procedures performed over 40 years ago. The history of postoperative joint
infections decreased from 5% to 1% after the introduction of preoperative antibiotics (Yates,
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2018). The current recommendations include the use of one dose of preoperative
antibiotics over a course of 24 hours with no additional antibiotics postoperatively
(Yates, 2018). The guidelines have been adjusted as additional evidence-based medicine
has been introduced over the years.
The current guidelines include a beta lactam agent as the preoperative
prophylactic choice for total joint arthroplasty. However, after several additional studies,
the addition of superbugs such as MRSA have led the medical community to question
whether or not the current guidelines are adequate. This project will include additional
information that may change the policy and procedure for the current preoperative
antibiotic at the project site. Upon the addition or change of vancomycin, data will be
measured to determine whether or not a decreased rate of infection has occurred. The
sustainability of additional or a change in antibiotics will need to be placed into a policy
via the pharmaceutical and quality departments which will include the guidance from all
orthopaedic surgeons involved in the study.
Sustainability of Scholarship
In order to maximize the delivery of the correct antibiotic for total knee arthroplasty, a
plan must be established to ensure the decrease in rate of infection mirrors the changes in
antibiotics. Action research concerns real-life situations over which providers have influence.
Action research focuses on creating meaningful and authentic change for those involved whether in
a hospital, classroom, or community (. Antibiotics prophylaxis can be a weakness if the
administration, timing, and selection are not based on evidence.
Sustaining a change in antibiotic selection and dosing will be based on the stakeholders
involved with the change. Patients will need to be monitored to determine whether or not a
decrease is occurring with total knee arthroplasty infections after the project has potentially been
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initiated as a policy or protocol change. The healthcare team will also need to remain involved to ensure
continued success with the implementation, administration, and timing of preoperative antibiotics.
Although bacteria continue to change as antibiotics are administered in the current fashion, preventing
infection in total joint replacements is a cost saving measure for all involved. Continuing research will be
paramount to ensure continued success of a change.
A short-term goal to increase sustainability could be a publication of findings related to the
changes in medication administration, timing, and selection. Collaboration between orthopaedic surgeons,
pharmacy, and anesthesia may promote patient satisfaction with retention of the initial hardware placed in
the total knee joint and decreased infection. Continued surveillance of potential microbes within the
hospital setting may also increase sustainability of the proposed protocol. Documenting and preventing
microbiology infectious material such as MRSA and MSSA is part of the 5 Million Lives Campaign (Institute
of Healthcare Improvement, 2014). This campaign focuses on basic changes in infection control processes
within the hospital setting (IHI, 2014). Nurses play a vital role in infection prevention and failure to
practice consistent prevention measures can result in occupational exposures or disease transmission
(Rebmann and Carrico, 2017). New or emerging infectious diseases can have devastating impacts on
morbidity, mortality, and costs to a rural area (Rebmann and Carrico, 2017).
Future of Scholarship
Basic knowledge of disease transmission through continued education of patients and hospital staff
remain as a foundation for future scholarship potential. Continuing strict aseptic technique is of supreme
importance in the operating room as well as patient care areas (CDC, 2019). According to the CDC (2011),
“if an infectious agent interacts with a susceptible host within an environment that enables transmission,
an infection can occur; this is known as the epidemiological triangle”, (para. 1). Additional research may be
needed to validate antibiotic recommendations that are current and beneficial for preoperative total knee
arthroplasty infection prevention. Staying abreast of continuing microbial activity may be the future of
prevention. The CDC outlines recommendations along with the College of Orthopaedic Surgeons, however,
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the guidelines are outdated when attempting to treat current microbial organisms that are usual
suspects (CDC, 2013).
Conclusion
The current guidelines for preoperative antibiotic recommendations for total knee
arthroplasty are a decade behind. The current microbes have manifested themselves to withstand
and flourish in the medium of tissue and total knee arthroplasty surgical sites. MRSA and MSSA are
the some of the most resilient of infectious organisms and are not susceptible to the current
guidelines of beta lactam antibiotics (Kourtis et al., 2019). In order to combat the infections related
to total knee arthroplasty, new guidelines will need to be researched and possibly applied to
determine the effectiveness of change for prevention. The addition of antibiotics or a change in
antibiotic protocol may be needed to combat the post-operative infection rates in regard to total
knee arthroplasty. The Doctoral of Nursing Practice prepared graduate student has taken on the
task as a leader in this endeavor to ensure the dissemination and implementation of project
findings at the academic and professional level.
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References
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