Surgical Care Improvement Project
SCIPNational Initiatives to Improve Surgical Care
OBJECTIVES
1. Identify SCIP and SCIP measures.2. Discuss how these changes affect patient safety3. How these processes improve outcome measures for YOUR surgical patients.
WHAT IS SCIP?
National quality partnership of organizations focused on improving surgical care by significantly reducing surgical complications.
SCIP Steering Committee
• American College of Surgeons
• American Hospital Association
• American Society of Anesthesiologists
• Association of peri-Operative Registered Nurses
• Agency for Healthcare Research and Quality
• Centers for Medicare & Medicaid Services
• Centers for Disease Control and Prevention
• Department of Veteran’s Affairs
• Institute for Healthcare Improvement
• Joint Commission on Accreditation of Healthcare Organizations
Why focus on surgical quality?
~30 million major operations each year in the US
Despite advances in surgical and anesthesia technique and improvements in perioperative care, variations in outcomes for patients having surgery are well known
Why focus on surgical quality?
Among the most common complications• surgical site infections (SSIs) and postoperative sepsis• cardiovascular complications including myocardial
infarction• respiratory complications including postoperative
pneumonia and failure to wean• thromboembolic complications
Surgical Care Improvement ProjectNational Goal
To reduce preventable surgical morbidity and mortality by 25% by 2010
Final SCIP Modules
SCIP has four modules• Infection
• 7 Infection Prevention Process Measures• Venous Thromboembolus (VTE)
• 2 VTE Prevention Process Measures• Cardiac Prevention Module
• 1 Cardiovascular Prevention Measure• Respiratory
• Delayed implementation to use these measure in expanding the ICU Core Measure Set
Cost of Complications
Attributable costsInfectious complications - $1398
Cardiovascular complications - $7789
Respiratory complications - $52466
Thromboembolic complications - $18310
Dimick JB, et al. Hospital costs associated with surgical complications: a report from the private-sector National Surgical Quality Improvement Program. J Am Coll Surg. 2004;199:531-7.
Surgical Site Infections (SSI)
2-5% of operated patients will develop SSI 40 million operations annually in the U.S.
0.8 - 2 million SSI’s occur annually in the U.S.
SSI increases LOS in hospital average 7.5 days
Excess cost per SSI:*$2,734-26,019 (1985, US$)
US national costs: $130-845 million/year
*Jarvis, Infect Control HospEpidemiol. 1996;17.
Quality IndicatorsNational Surgical Infection Prevention Project
Proportion of patients who have their antibiotic dose initiated within 1 hour before surgical incision (2 hours for vancomycin or fluoroquinolones)
Proportion of patients who receive prophylactic antibiotics consistent with current recommendations (published guidelines)
Proportion of patients whose prophylactic antibiotics were discontinued within 24 hours of surgery end time (48 hours for cardiac surgery)
Performance Measure Review
SCIP Infection Module
Prophylactic Antibiotics
Antibiotics given for the purpose of preventing infection when infection is not present but the risk of postoperative infection is present
Relative Benefit from Antibiotic Surgical Prophylaxis
Operation Prophylaxis (%) Placebo (%) NNT*Colon 4-12 24-48 3-5Other (mixed) GI 4-6 15-29 4-9Vascular 1-4 7-17 10-17Cardiac 3-9 44-49 2-3Hysterectomy 1-16 18-38 3-6Craniotomy 0.5-3 4-12 9-29Total joint repl 0.5-1 2-9 12-100Brst & hernia ops 3.5 5.2 58
Prophylactic AntibioticsQuestions
• Which cases benefit?
• Which drug should you use?
• When should you start?
• How much should you give?
• How long should antibiotics be continued?
CMS Surgical Infection Prevention Target Procedures
• Coronary artery bypass grafting • Open chest cardiac operations • Colon operations • Hip or knee arthroplasty • Abdominal or vaginal hysterectomy • Vascular operations
– Aneurysm repair– Thromboendarterectomy– Vein Bypass
SCIP Infection 1
Prophylactic antibiotic received within one hour prior to surgical incision (two hours allowed for vancomycin or quinolone)
Efficacy Of Prophylaxis Is Independent Of The Specific Antibiotic
Age of Lesion at Antibiotic Injection (Hours)Age of Lesion at Antibiotic Injection (Hours)
Les
ion
Siz
e, m
m (
24 H
ou
rs)
Les
ion
Siz
e, m
m (
24 H
ou
rs)
00
55
1010
Penicillin, 40,000 UPenicillin, 40,000 U
Staph + PenicillinStaph + Penicillin
ControlControl
Chloramphenicol, 0.1 mg/KgChloramphenicol, 0.1 mg/Kg
Erythromycin, 0.1 mg/KgErythromycin, 0.1 mg/Kg
Tetracycline, 0.1 mg/KgTetracycline, 0.1 mg/Kg
00 22 44 66-2-2 00 22 44 66-2-2
00
55
1010
00
55
1010
00
55
1010
ControlControl ControlControl
ControlControl
Staph + ErythromycinStaph + Erythromycin
Staph + TetracyclineStaph + TetracyclineStaph + ChloramphenicolStaph + Chloramphenicol
Burke JF. Surgery. 1961;50:161.
0
1
2
3
4
≤-3 -2 -1 0 1 2 3 4 ≥5
Classen. Classen. NEJM.NEJM. 1992;328:281. 1992;328:281.
Perioperative Prophylactic Antibiotics
Timing of AdministrationIn
fect
ion
s (%
)In
fect
ions
(%)
Hours From IncisionHours From Incision
14/36914/369
5/6995/6995/10095/1009
2/1802/1801/811/81
1/411/411/471/47
15/44115/441
Prophylactic AntibioticsQuestions
When do we start?
2.7 1.24.3
20.3
56
2.8 1.4 0.9 0.9
9.6
0
10
20
30
40
50
60
> 24
0
240-
181
180-
121
120-
6160
-00-
60
61-1
20
121-
180
181-
240
> 24
0
Minutes Before or After Incision
Per
cen
t
Inc
isio
n
Antibiotic Timing Related to Incision
Bratzler DW, Houck PM, et al. Arch Surg. 2005;140:174-182.
SCIP Infection 2
Prophylactic antibiotic selection for surgical patients
Recently Updated Antibiotic Recommendations
Preferred: Cefazolin or cefuroxime
If patient high risk for MRSA: Vancomycin*
Beta-lactam allergy:
• Vancomycin or clindamycin
Cardiac or vascular
Preferred: Cefazolin or cefuroxime
If patient high risk for MRSA: Vancomycin*
Beta-lactam allergy:
• Vancomycin or clindamycin
Hip or knee arthroplasty
Antimicrobial recommendationsSurgery Type
* For the purposes of national performance measurement a case will pass the antibiotic selection performance measure if vancomycin is used for prophylaxis (in the absence of a documented beta-lactam allergy) if there is physician documentation of the rationale for vancomycin use (effective for July 2006 discharges).
Recently Updated Antibiotic Recommendations (continued)
• Neomycin + erythromycin base; neomycin + metronidazole
• Cefotetan, cefoxitin, cefazolin + metronidazole, or ampicillin-sulbactam
Beta-lactam allergy:
• Clindamycin + gentamicin or fluoroquinolone* or aztreonam
• Metronidazole + gentamicin or fluoroquinolone*
Colorectal †
• Cefotetan, cefazolin, cefoxitin, cefuroxime, or ampicillin-sulbactam
Beta-lactam allergy:
• Clindamycin + gentamicin or fluoroquinolone* or aztreonam
• Metronidazole + gentamicin or fluoroquinolone*
• Clindamycin monotherapy
Hysterectomy
Antimicrobial recommendationsSurgery Type
* Ciprofloxacin, levofloxacin, gatifloxacin, or moxifloxacin (effective for July 2006 discharges).
† For the purposes of national performance measurement, a case will pass the antibiotic selection indicator if the patient receives oral prophylaxis alone, parenteral prophylaxis alone, or oral prophylaxis combined with parenteral prophylaxis.
SCIP Infection 3
Prophylactic antibiotics discontinued within 24 hours after surgery end time (48 hours for cardiac patients)
26.2
10
22.6
6.2 6.32.2 2.7
9.3
14.5
40.7
50.7
73.3
79.5
85.888
90.7
0
20
40
60
80
100
12 o
r les
s
>12-
24
>24-
36
>36-
48
>48-
60
>60-
72
>72-
84
>84-
96>
96
Hours After Surgery End Time
Pe
rce
nt
0
20
40
60
80
100
Cu
mu
lati
ve
Pe
rce
nt
Discontinuation of Antibiotics
Patients were excluded from the denominator of this performance measure if there was any documentation of an infection during surgery or in the first 48 hours after surgery.
Bratzler DW, Houck PM, et al. Arch Surg. 2005;140:174-182.
Antibiotic ProphylaxisDuration
Most studies have confirmed efficacy of 12 hrs.
Many studies have shown efficacy of a single dose.
Whenever compared, the shorter course has been as effective as the longer course.
Duration of Antibiotic Prophylaxis:What is Best for Our Patients?
• Antibiotic prophylaxis is one of many methods for reducing the incidence of SSI
• There is a lack of evidence that antibiotics given after the end of the operation prevent SSI’s
• There is evidence that increased use of antibiotics promotes antibiotic resistance
• Duration of prophylactic antibiotic administration should not exceed the 24-hour post-operative period.
• Prophylactic antibiotics should be discontinued within 24 hours of the end of surgery.
• Medical literature does not support the continuation of antibiotics until all drains or catheters are removed and provides no evidence of benefit when they are continued past 24 hours.
http://www.aaos.org/wordhtml/papers/advistmt/1027.htm
SCIP Infection 4
Cardiac surgery patients with controlled 6 a.m. postoperative serum glucose
Diabetes, Glucose Control, and SSIsAfter Median Sternotomy
0
5
10
15
20
<200 200-249 250-299 >300
% I
nfe
ctio
ns
Latham. ICHE 2001; 22: 607-12
Hyperglycemia and Risk of SSI after Cardiac Operations
• Hyperglycemia - doubled risk of SSI• Hyperglycemic:
48% of diabetics12% of nondiabetics30% of all patients
• 47% of hyperglycemic episodes were in nondiabetics
Latham. Inf Contr Hosp Epidemiol. 2001;22:607Dellinger. Inf Contr Hosp Epidemiol. 2001;22:604
Deep Sternal SSI and Glucose
0
1
2
3
4
5
6
7
8
100-150 150-200 200-250 250-300
Day 1 Glucose (mg%)
% D
eep
Ste
rnal
In
fect
ion
Zerr. Ann Thorac Surg 1997;63:356
Glucose Control and Mortality after CABG in 3554 Diabetics
Furnary. J Thorac Cardiovasc Surg 2003;125:1007
SCIP Infection 5
Postoperative wound infection diagnosed during index hospitalization
(OUTCOME)
This One is Difficult!
• The purpose of the process measures is to lower SSI rates, & if we don’t survey we won’t know if they’re working
• There is not agreement regarding the most effective and efficient methods for SSI surveillance
• More than half of all SSI are detected after hospital discharge
SCIP Infection 6
Surgery patients with appropriate hair removal
Shaving, Clipping and SSI
Cruse. Arch Surg 1973; 107: 206
% Infected
0
0.5
1
1.5
2
2.5
Shave Clip Neither
Shaving vs ClippingCardiac Surgery
NumberInfected
(%)
Shaved 99013 (1.3%)
Clipped 9904 (0.4%)
p < 0.03Ko. Ann Thorac surg 1992;53:301
SCIP Infection 7
Colorectal surgery patients with immediate postoperative normothermia
Temperature and Tissue O2 tension
• Subcut temp increase 4° C
• Subcut O2 tension increase 40 torr
• Linear correlation between temperature and O2 tension
• Threefold increase in local perfusion
Rabkin. Arch Surg 1987;122:221
Local Warming and SSI after Clean Operations
• Elective hernia repair
• Varicose vein operation• Breast operation, incision > 3cm
• Pre-op warming > 30 minWhole body forced air - systemicIncision site radiant heat - local
Melling. Lancet 2001;358:876
Temperature and Surgical Site Infections
Hypothermia reduces tissue oxygen tension by vasoconstriction
Hypothermia reduces leukocyte superoxide production
Hypothermia increases bleeding and transfusion requirement
Hypothermia increases duration of hospital stay even in uninfected patients
Can We Prevent SSI’s in the Operating Room?
OxygenationTemperature
Fluid ManagementAntibiotics
GlucoseShaving?Other
The period of maximum influence on SSI risk begins and ends in the operating room.
Surgical Care Improvement ProjectNew Performance measures - Process
Surgical infection preventionGlucose control in cardiac surgery patients (< 200
mg/dL)Blood glucose closest to 0600 on PO day 1 and 2
(surgery end date is PO day 0)
Proper hair removalNo hair removal, clippers, or depilatory
Normothermia in colorectal surgery patientsTemperature between 96.8-100.4° F within the first
hour after leaving the OR
39
SCIP Cardiac Module
Prevention of Cardiac EventsIntroduction
As many as 7 to 8 million Americans that undergo major noncardiac surgery have multiple cardiac risk factors or established coronary artery disease
More than 1 million cardiac events annually
Myocardial ischemia either clinically occult or overt confers a 9 - fold increase in risk of unstable angina, nonfatal myocardial infarction, and cardiac death
Schmidt M, et al. Arch Intern Med. 2002;162:63-69.
Mangano DT, et al. N Engl J Med. 1996;335:1713-1720.
Selzman CH, et al. Arch Surg. 2001;136:286-290.
44
SCIP Cardiac Module
SCIP Card 2:Surgery patients on a beta-blocker prior to arrival
that received a betablocker during the perioperative period
45
Medication List for Beta Blockers
Acebutolol AerosolAtenolol/chlorthalidone BetapaceBetapace AF Betaxolol Bisoprolol Bisoprolol/fumarateBisopropol/hydro-chlorothiazideBlocadrenBreviblocCarteolol CartrolCarvedilolCoregCorgardCorzide 40/5Corzide 80/5Esmolol
InderalInderal LAInderideInderide LA KerloneLabetalol LevatolLopressorLopressor HCTLopressor/hydrochlorothiazideMetoprololMetoprolol/hydrochlorothiazideMetoprolol Tartrate/hydrochlorothiazideNadololNadolol/bendroflumethiazideNormodynePenbutololPindololPropranolol Propranolol HC1Propranolol HydrochloridePropranolol/hydrochlorothiazide
SectralSorineSotalolSotalol HC1Tenoretic TenorminTenormin I.V.Timolide TimololTimolol Maleate/hydrochlorothiazideTimolol/hydrochlorothiazideToprol Toprol-XLTrandateTrandate HCl ViskenZebetaZiac
Venous Thromboembolism Prevention
50
SCIP VTE Module
Prevention of Venous ThromboembolismIntroduction
VTE Remains a major health problem200,000 new cases annually in USIn addition to the risk of sudden death
30% of survivors develop recurrent VTE within 10 years28% of survivors develop venous stasis syndrome within 20 years
The incidence of VTE is more than 100 times greater for patients who have been hospitalized than among community dwelling
Incidence increases with age
Goldhaber SZ. N Engl J Med. 1998;339:93-104.
Silverstein MD, et al. Arch Intern Med. 1998;158:585-593.
Heit JA, et al. Thromb Haemost. 2001;86:452-463.
Heit JA. Clin Geriatr Med. 2001;17:71-92.
Heit JA, et al. Mayo Clin Proc. 2001;76:1102-1110.
51
SCIP VTE Module
SCIP VTE 1:Surgery patients with recommended venous
thromboembolism prophylaxis ordered
SCIP VTE 2:Surgery patients who received appropriate
venous thromboembolism prophylaxis within 24 hours prior to surgery to 24 hours after surgery
55
Orthopedic Intra-operative Thermal Management
Anesthesia record revised for documentation of interventions:
FluidsBlanketH recorded in ORME ( Heat
Moisture Exchange)Core Temperature
Engineering:
Confirmation & maintenance of all thermostats in OR Suites
OR rooms being maintained at
68° - 72°F
PACU
Tympanic thermometers were re-calibrated
upgraded thermometers purchased
SCIP Respiratory
Module
Why is this Important?
PAY FOR PERFORMANCEQUALITY CARE
EVIDENCE-BASED PRACTICE PUBLIC INFORMATION
HEALTHCARE CONSUMER RIGHTS