AMS Surgical Charts

• Site conducted

  Select

• Ward and Facility Name

• Prepared by

Patient MRN

• MRN:

• Surgeon:

Surgery

• Type of surgery:

  Orthopaedic

  Caesarian

  CABG

  Other

  Eye Surgery

• Was the surgery a large joint replacement involving insertion of prosthetic, or an allograft material internal fixation of large bone fractures ?

  Yes

  No

• Was the surgery a Total Knee replacement

• Was the Surgery a Total Hip replacement

• Other joint replacement

• Was the surgery an allograft material internal fixation of large bone fractures ?

• Was an AB given within 60 mins before surgical incision?

  Yes

  No

  N/A

• Was IV Cefazolin 2g given? (30mg/kg for a child)

  Yes

  No

• Does the patient have an allergy to Cefazolin or severe allergy to Penicillin?

  Yes

  No

• Was Vancomycin 15mg/kg given as monotherapy as per TG?

  Yes

  No

• Was Vancomycin given in conjunction with another antibiotic?

  Yes

  No

• Please state other antibiotics administered:

• Does the patient have an active infection with cultures indicating administered antibiotic is the most appropriate treatment?

  Yes

  No

• If Vancomycin not given, please state which antibiotic administered:

• Is there documentation to indicate that the patient has an active infection? (eg Doctors progress notes or cultures indicating prescribed antibiotic is the most appropriate treatment?)

  Yes

  No

• Does the patient have an active infection with cultures indicating the antibiotic administered is the most appropriate for treatment?

  Yes

  No

• Please state antibiotic given:

• Please state antibiotic administered:

• Was any other type of AB used?

  Yes

  No

• Was IV Vancomycin 15mg/kg given?

  Yes

  No

• If not Vancomycin please state which AB was given:

• Does the patient have an active infection with cultures indicating administered antibiotic is the most appropriate treatment?

  Yes

  No

• Was the patient colonised or infected with MRSA? (Positive cultures)

  Yes

  No

• Is the patient at risk of being colonised or infected with MRSA? (Please check- high risk factors listed from the Therapeutic Guidelines, or other please state)

  Yes

  No

• Return to OT following joint arthroplasty procedure

• Early revision

• Previous history of colonisation or infection with MRSA

• Residence in an area with a high prevalence of MRSA (eg Northern Territory; remote communities in northern Queensland; regions north of metropolitan Perth in Western Australia, especially the Kimberly and Pilbara)

• Frequent stays, or a current prolonged stay, in a hospital with a high prevalence of MRSA, particularly if associated with antibiotic exposure or recent surgery

• Residence in an aged-care facility with a high prevalence of MRSA, particularly if the patient has had multiple courses of antibiotics

• Current residence, or residence in the past 12 months, in a correctional facility.

• Does the patient have an active infection with cultures indicating Vancomycin is the most appropriate treatment?

  Yes

  No

• Other orthopaedic surgery (Not large joint replacement or or an allograft material internal fixation of large bone fractures)

  Yes

  No

• Please state procedure performed:

• Were prophylactic antibiotics administered?

  Yes

  No

• Please state antibiotic given:

• Is there documentation to indicate that the patient has an active infection? (eg Doctors progress notes or cultures indicating prescribed antibiotic is the most appropriate treatment?)

  Yes

  No

• If other indication for antibiotics documented please state:

• Yes

  No

  N/A

• Was an AB given within 60 minutes before surgical incision?

  Yes

  No

  N/A

• Was IV Cefazolin 2g given?

  Yes

  No

• Was any other type of AB used?

  Yes

  No

• Was IV Vancomycin 15mg/kg given as per Therapeutic Guidelines? (For patients colonised with or AT RISK of MRSA)

  Yes

  No

• Vancomycin was administered against Therapeutic Guidelines

  Yes

  No

• If not Vancomycin please state which AB was given:

• Is there documentation to indicate that the patient has an active infection? (eg Doctors progress notes or cultures indicating prescribed antibiotic is the most appropriate treatment?)

  Yes

  No

• Does the patient have an allergy to Cefazolin or severe allergy to Penicillin?

  Yes

  No

• Is the patient colonised with or AT RISK of MRSA?

  Yes

  No

• Was the patient given Clindamycin 600mg IV PLUS Gentamycin 2mg/kg IV?

  Yes

  No

• If no please state which AB was given:

• Was the patient given Vancomycin 15mg/kg IV PLUS Gentamycin 2mg/kg IV?

  Yes

  No

  N/A

• If no please state which AB was given:

• Was an AB given within 60 minutes before surgical incision?

  Yes

  No

  N/A

• Was IV Cefazolin 2g given? (30mg/kg for a child)

  Yes

  No

• Was any other type of AB used?

  Yes

  No

• Was IV Vancomycin 15mg/kg given?

  Yes

  No

• If not Vancomycin please state which AB was given:

• Is there documentation to indicate that the patient has an active infection? (eg Doctors progress notes or cultures indicating prescribed antibiotic is the most appropriate treatment?)

  Yes

  No

• Was the patient colonised or infected with MRSA? (Positive cultures)

  Yes

  No

• Is the patient at risk of being colonised or infected with MRSA? (Please check- high risk factors listed from the Therapeutic Guidelines, or other please state)

  Yes

  No

• Does the patient have an active infection with cultures indicating Vancomycin is the most appropriate treatment?

  Yes

  No

• Return to OT or early revision

• Previous history of colonisation or infection with MRSA

• Residence in an area with a high prevalence of MRSA (eg Northern Territory; remote communities in northern Queensland; regions north of metropolitan Perth in Western Australia, especially the Kimberly and Pilbara)

• Frequent stays, or a current prolonged stay, in a hospital with a high prevalence of MRSA, particularly if associated with antibiotic exposure or recent surgery

• Residence in an aged-care facility with a high prevalence of MRSA, particularly if the patient has had multiple courses of antibiotics

• Current residence, or residence in the past 12 months, in a correctional facility.

• Does the patient have an allergy to Cefazolin or severe allergy to Penicillin?

  Yes

  No

  N/A

• Was the patient given Vancomycin 15mg/kg IV PLUS Gentamycin 5mg/kg IV?

  Yes

  No

  N/A

• If no please state which AB was given:

• Does the patient have an active infection with cultures indicating administered antibiotic is the most appropriate treatment?

  Yes

  No

• Please state surgical procedure:

• Was an AB given before surgical incision?

  Yes

  No

• Was IV Cefazolin 2g given?

  Yes

  No

• Does the patient have an allergy Cefazolin or severe allergy to Penicillin?

  Yes

  No

• Does the patient have MRSA or AT RISK of MRSA?

  Yes

  No

• Please state AB given:

• Is the AB given in compliance with Therapeutic Guidelines (

  Yes

  No

  N/A

• Is there documentation to indicate that the patient has an active infection? (eg Doctors progress notes or cultures indicating prescribed antibiotic is the most appropriate treatment?)

  Yes

  No

• Does the patient have MRSA or AT RISK of MRSA?

  Yes

  No

• Please state AB given:

• Were any other AB given?

  Yes

  No

• Please state which AB:

• Does the patient have MRSA or AT RISK of MRSA?

  Yes

  No

• Is the surgery Cataract surgery?

  Yes

  No

• Was Surgical prophylaxis antibiotics used?

  Yes

  No

• Was Cephazolin 1mg/0.1ml administered intracamerally (injected into anterior eye chamber) at the end of surgery?

  Yes

  No

• State type of Antibiotic used:

• Does the patient have allergy to Cephazolin

  Yes

  No

  N/A

• Was the surgery greater than 4 hours? <br>

  Yes

  No

• Was second dose antibiotics given for surgery > 4 hours? (Cephazolin only)

  Yes

  No

  N/A

• Was second dose antibiotics given for surgery > 6 hours? (Clindamycin only)

  Yes

  No

  N/A

• Was second dose antibiotics given for surgery > 12 hours? (Metronidazole and Vancomycin only)

  Yes

  No

  N/A

• No redosing required for Gentamicin

• All other antibiotics please check TG redosing interval requirement

Documentation

• Are allergies listed in patients theatre paperwork?

  Yes

  No

• Is the antibiotic given appropriate for the weight of the patient?

  Yes

  No

  N/A

• AB consideration not given for obese patients (Patients >120 kg should have 3g Cefazolin).

• Other reason, please state:

• Is the route of AB administration correct as per TG (IV or injection into eye)?

  Yes

  No

  N/A

• Was the AB used as a graft soak?

• Was the AB used for a washout

• Other (Topical/oral etc) please state:

• Is the indication for use documented for every Antibiotic in the medication chart, (other than prophylactic AB use).

  Yes

  No

  N/A

• Has the appropriateness of ALL continued prophylactic antibiotic been reviewed by the surgeon 24 hrs. after initial orders

  Yes

  No

  N/A

Consider Engagement

• Did the patient receive information on antibiotic use and resistance eg. QR codes available

  Yes

  No

  N/A