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The Surgical Infection Prevention and Surgical Care Improvement Projects National Initiatives to Improve Surgical Care

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Title: The Surgical Infection Prevention and Surgical Care Improvement Projects National Initiatives to Improve Surgical Care


1
The Surgical Infection Preventionand Surgical
Care Improvement ProjectsNational Initiatives
to Improve Surgical Care
1
Dale W. Bratzler, DO, MPH QIOSC Medical Director
2
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

3
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

4
Cost of Complications
  • Attributable costs
  • Infectious 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.
2004199531-7.
5
Surgical Care Improvement ProjectNational Goal
36
  • To reduce preventable surgical morbidity and
    mortality by 25 by 2010

6
SCIP Steering Committee
37
  • Centers for Medicare Medicaid Services
  • Centers for Disease Control and Prevention
  • Department of Veterans Affairs
  • Institute for Healthcare Improvement
  • Joint Commission on Accreditation of Healthcare
    Organizations
  • American College of Surgeons
  • American Hospital Association
  • American Society of Anesthesiologists
  • Association of peri-Operative Registered Nurses
  • Agency for Healthcare Research and Quality

7
Performance Measure Review
8
Surgical Site Infections (SSI)
2
  • 2-5 of operated patients will develop SSI
  • 40 million operations annually in the U.S.
  • 0.8 - 2 million SSIs 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. 199617.
9
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)

10
Revision to SCIP Inf 2
22
  • We will allow for the use of vancomycin for
    prophylaxis for cardiac, vascular, and orthopedic
    surgery, if
  • There is a physician-documented reason in the
    medical record
  • Beta-lactam allergy
  • We may do some hospital-specific audits of
    vancomycin use in outlier institutions

11
Recently Updated Antibiotic Recommendations
25
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).
Bratzler DW, Hunt DR. Clin Infect Dis. 2006 (in
press).
12
Recently Updated Antibiotic Recommendations
(continued)
26
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.
Bratzler DW, Hunt DR. Clin Infect Dis. 2006 (in
press).
13
Other Points about the Antibiotic Measures
  • SCIP Inf 2 May see public reporting on Hospital
    Compare of July 2006 discharges
  • SCIP Inf 3 Any antibiotics given in the first
    48 hours after surgery (72 hours for cardiac
    surgery) are considered prophylactic in the
    absence of a documented infection

14
Surgical Care Improvement ProjectNew Performance
measures - Process
39
  • Surgical infection prevention
  • Glucose control in cardiac surgery patients (lt
    200 mg/dL)
  • Blood glucose closest to 0600 on PO day 1 and 2
    (surgery end date is PO day 0)
  • Proper hair removal
  • No hair removal, clippers, or depilatory
  • Normothermia in colorectal surgery patients
  • Temperature between 96.8-100.4 F within the
    first hour after leaving the OR

15
Cardiovascular Complication Prevention
43
16
Prevention of Cardiac EventsIntroduction
44
  • 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.
200216263-69. Mangano DT, et al. N Engl J Med.
19963351713-1720. Selzman CH, et al. Arch Surg.
2001136286-290.
17
Surgical Care Improvement ProjectPerformance
measure - Process
45
  • Perioperative cardiac events
  • Perioperative beta blockers in patients who are
    on beta blockers prior to admission
  • perioperative is defined as 24 hours prior to
    incision through discharge from the
    post-anesthesia care/recovery area

18
Venous Thromboembolism Prevention
50
19
Prevention of Venous ThromboembolismIntroduction
51
  • VTE Remains a major health problem
  • 200,000 new cases annually in US
  • In addition to the risk of sudden death
  • 30 of survivors develop recurrent VTE within 10
    years
  • 28 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. 199833993-104. Silve
rstein MD, et al. Arch Intern Med.
1998158585-593. Heit JA, et al. Thromb Haemost.
200186452-463. Heit JA. Clin Geriatr Med.
20011771-92. Heit JA, et al. Mayo Clin Proc.
2001761102-1110.
20
Surgical Care Improvement ProjectPerformance
measures - Process
55
  • Prevention of venous thromboembolism
  • Surgery patients with recommended VTE prophylaxis
    ordered
  • Surgery Patients Who Received Appropriate Venous
    Thromboembolism Prophylaxis Within 24 Hours Prior
    to Surgery to 24 Hours After Surgery

Based on the 2004 ACCP Consensus Recommendations
21
www.medqic.org/scip
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