Surgical Care Improvement SCIP Abstraction Overview Deborah D' Mattin, RN Quality Improvement Specia

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Surgical Care Improvement (SCIP) Abstraction
OverviewDeborah D. Mattin, RNQuality
Improvement SpecialistFor Discharges
4/1/07-9/30/07

• The enclosed material was prepared and assembled
  by Northeast Health Care Quality Foundation
  (NHCQF), the Medicare Quality Improvement
  Organization (QIO) for Maine, New Hampshire and
  Vermont, under contract with the Centers for
  Medicare Medicaid Services (CMS), an agency of
  the U.S. Department of Health and Human Services.
  The contents presented do not necessarily
  reflect CMS policy.
  0307-688

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SCIP Project Goal

• Reduce preventable surgical mortality and
  morbidity by 25 by 2010.

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SCIP Measures

• 1 Prophylactic antibiotic received within 60
  minutes prior to
• incision
• 2 Prophylactic antibiotic selection
• 3 Prophylactic antibiotic discontinued within
  24 hrs of surgery
• end time
• 4 Cardiac surgery patients with controlled
  postoperative
• glucose
• 6 Surgery patients with appropriate hair
  removal
• 7 Colorectal surgery patients with immediate
  postoperative
• normothermia
• Card 2 Surgery patients on beta blocker therapy
  prior to
• admission who received beta
  blocker during peri-
• operative period
• VTE 1 Surgery patients with recommended VTE
  prophylaxis
• ordered
• VTE 2- Surgery patients who received appropriate
  VTE
• prophylaxis within 24 hrs prior
  to surgery to 24 hrs after
• surgery

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Case Selection

• Cases are selected for SCIP review based on
  principal procedure code
• Table 5.10 in Specifications Manual
• Most vendor programs select cases based on
  billing data provided by hospital

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SCIP Strata

• Cases are abstracted for measures based on
  principal procedure not all measures are
  collected for all cases
• Table 5.01-5.08 Selected cardiac/CABG
  procedures, selected colorectal procedures,
  abdominal and vaginal hysterectomy, total knee
  and hip arthroplasty and selected vascular
  procedures are abstracted for
• All of the antibiotic prophylaxis measures, hair
  removal, beta blocker and VTE measures
• Glucose monitoring for cardiac procedure
• Normothermia for colon procedures

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8th Strata

• Cases from the major surgery table 5.10 are
  abstracted for
• SCIP 4 glucose monitoring
• Cardiac surgery only
• SCIP 6 hair removal
• SCIP 7- normothermia
• Colon surgery only
• VTE 1 and 2
• CARD 2 beta blocker
• Many hospitals have enough cases in this strata
  to be able to abstract only a sample
• of cases

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Case Abstraction Resources

• The Specifications Manual contains all the
  information needed to select, sample, abstract
  and submit cases
• http//www.qualitynet.org/dcs/ContentServer?cid11
  41662756099pagenameQnetPublic2FPage2FQnetTier2
  cPage
• Vendor abstraction programs often have links to
  the manual
• Tables listing meds, ICD-9 codes, inclusion terms
  are in the manual
• Case-specific abstraction questions may be
  submitted to NHCQF
• Abstraction_at_nhcqf.org
• Questions will be researched and answered within
  7 days
• Please specify a discharge period (or quarter)
  and the data element question

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General Abstraction Guidelines

• Always use the abstraction guidelines that
  correspond to the date of the record being
  abstracted.
• Always refer to the abstraction guidelines for
  specific instructions on how to answer each
  question.
• Send questions to the abstraction email box if
  unable to answer after researching in the
  specifications manual.

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SCIP Case Abstraction OR Information

• This information sets the stage by identifying
  type of procedure, pertinent patient history, and
  timing information needed to determine which
  measures are applicable to the case.

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OR Information

• Was procedure performed entirely by laparoscope?
• Used to identify population for
  inclusion/exclusion
• Options are yes/no/UTD
• Key here is entirely
• If done entirely by laparoscope yes
• If done partially/lap assisted no
• If some documentation about laparoscopy, but
  unable to determine if done entirely by lap UTD

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OR information

• Principal procedure start date
• Initial incision time
• Used to calculate SCIP 1 measure
• Very specific rules for this question based on a
  priority order of synonyms for incision time
• First priority is list of synonyms for incision
  time
• Second priority is synonyms for surgery start
  time
• Third priority is synonyms for anesthesia time
• Follow the priority order. If multiple times are
  found, use the earliest time in the highest
  priority synonym.

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OR Information

• Surgery end date
• Surgery end time
• Used to calculate SCIP 3 measure
• Very specific rules for this question based on a
  priority order of sources for surgery end time
• Anesthesia record
• Circulation record
• Nursing notes
• Operative report
• Progress notes

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Surgery end time, continued

• Using highest priority source, then go through
  list of inclusion times to identify surgery end
  time.
• If multiple procedures occur during the same
  surgical episode, and the principal procedure is
  not the first of those, the surgical incision
  time captured will be the incision that occurs
  first, and the surgery end time will be the end
  time that occurs last.

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OR information

• Other surgeries
• Other procedures requiring general or spinal
  anesthesia that occurred within three days (four
  days for CABG or Other Cardiac Surgery) prior to
  or after the principal procedure during this
  hospital stay
• Used to exclude cases from the SCIP 3 measure
• Multiple procedures are performed during the same
  surgical episode No
• Other procedures are performed during separate
  surgical episodes requiring general or spinal
  anesthesia and occur within 3 days (4 for
  CABG/Cardiac) of the principal procedure Yes

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OR Information

• Did the patient expire before leaving the OR?
• Used to exclude cases from the SCIP 7
  (normothermia) measure
• Did the patient expire during the timeframe from
  surgical incision through discharge from
  post-anesthesia care?
• Used to exclude cases from the SCIP CARD 2 (beta
  blocker) measure
• Refer to specifications manual for detailed
  information about how time is calculated for
  patients who do not go to PACU post-op -
  (patients who recover in ICU, etc.)
• The recovery period would end a maximum of 6
  hours after arrival to the recovery area unless
  the anesthesiologist signs off before the 6 hours
  has elapsed

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OR Information

• What method of surgical site hair removal was
  performed?
• No documented hair removal
• Record is silent about hair removal or actually
  says that none was done
• Razor
• shave
• Clippers
• Depilatory
• Other
• Patient performed own hair removal
• Regardless of method used, if pt did it, use this
  option
• UTD method
• Record indicates some hair removal done, but
  cant accurately identify which method was used

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OR information

• Neuraxial anesthesia
• This is used to calculate appropriate VTE
  prophylaxis
• Neuraxial anesthesia inclusions
• Epidural
• Spinal anesthesia
• Intrathecal anesthesia
• Exclusion
• MAC (monitored anesthesia care)

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Infection Pre/Post-op

• Did the pt have an infection during this
  hospitalization prior to the principal procedure?
• Used to exclude cases from antibiotic measures
  (SCIP 1,2,3)
• Use ONLY MD/NP/CRNA/PA documentation
• Documentation of symptoms (example fever,
  elevated white blood cells, etc.) is not enough
  to abstract as an infection
• Inclusion terms
• Abscess
• Bloodstream infection
• Bone infection
• Cellulitis
• Gross/extensive fecal contamination
• Penetrating abdominal trauma
• H. pylori
• Osteomyelitis
• Other documented infection
• Pneumonia or other lung infection
• Sepsis

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Infection Post-op

• Were any infections documented postoperatively?
• Used to exclude cases from SCIP 3 antibiotic
  discontinue measure
• Postoperative period is defined as within two
  days (three days for CABG or Other Cardiac
  Surgery) after surgery end date with day of
  surgery being day zero.
• Documentation of symptoms (example fever,
  elevated white
• blood cells, etc.) is not enough to abstract
  as an infection.
• If documentation of an infection occurs more than
  two days
• postoperatively (three days for CABG or
  Other Cardiac
• Surgery) with the day of surgery being day
  zero, select No.
• What was the date of first post-op infection?

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Medications

• Antibiotics
• Is there documentation that the pt received an
  antibiotic via an approved route?
• Options are
• Antibiotic received only w/in 24 hrs prior to
  admission and not during stay
• Antibiotic received w/in 24 hrs prior to
  admission and during stay
• Antibiotic received only during stay (admission
  though 48 hrs post-op 72 hrs for cardiac/CABG)
• Antibiotic not received, or unable to determine

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Antibiotics

• Antibiotics listed as current or home meds,
  etc., should be inferred as taken within 24 hours
  prior to arrival unless there is documentation
  they were not taken within the last 24 hours.
• Only collect antibiotics that have been given PO
  or IV. Refer to exclusion list for a detailed
  list of exclusions.
• If at least ONE dose has an approved route, you
  can select whichever time-frame is appropriate
  (before admission, only during stay, etc.).
• Abstract the first and last dose of each specific
  antibiotic administered from hospital admission
  through the first 48 hours after surgery end time
  (72 hours postop for CABG or Other Cardiac
  Surgery).
• Then abstract the dose administered prior to and
  closest to
• surgical incision time.
• Refer to the specifications manual for additional
  details about this measure.

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Antibiotics

• May use antibiotic NOS if new antibiotic not
  yet on table 2.1 OR when there is documentation
  an antibiotic was administered but unable to
  determine name.
• Hang time or infusion time is only
  acceptable if found on ED record and only when
  other documentation cant be found.
• Abstract time infusion started if abstracting an
  antibiotic administered via an infusion.

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Antibiotics

• Were the only antibiotic combinations
  administered prior to hospital arrival or more
  than 24 hrs prior to incision either Neomycin
  Sulfate and Erythromycin Base or Neomycin Sulfate
  and Metronidazole?
• Used to calculate SCIP 2 appropriate antibiotic
  selection measure for colon surgery
• If only mention of antibiotics in this time frame
  is Nichol's Bowel Prep, select yes as this
  prep contains the recommended antibiotics for
  bowel prep
• If there is documentation of instructions for
  oral antibiotics
• to be taken at home OR documentation of
  instructions or
• prescriptions given to the patient in
  regards to oral
• antibiotics, AND there is documentation
  that the oral
• antibiotics are the antibiotics as listed
  above, assume they
• were taken select Yes.

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Antibiotics

• Did the patient have any allergies,
  sensitivities, or intolerance to
  beta-lactam/penicillin or cephalosporins?
• Used to calculate SCIP 2 appropriate antibiotic
  selection measure
• If the patient was noted to be allergic to
  cillins, penicillin, or all cillins, select
  Yes.
• If one source in the record documents Allergies
  penicillin and another source in the record
  documents penicillin causes upset stomach,
  select Yes.
• If a physician documents a specific reason not to
  give penicillin,
• beta lactams, or cephalosporins, select Yes.

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Antibiotics

• What reason was documented for using Vancomycin?
• Used to calculate SCIP 2 appropriate antibiotic
  selection measure
• If Vancomycin used, this question has to be
  answered
• Only use MD/NP/CRNA/PA documentation
• Select all that apply from these options
• Documentation of beta-lactam (penicillin or
  cephalosporin) allergy
• Documentation of known prior colonization with
  MRSA
• Documentation of patient being high-risk due to
  acute inpatient hospitalization within the last
  year
• Documentation of patient being high-risk due to
  LTC setting within
• the last year, prior to admission
• Documentation of increased MRSA rate, either
  facility wide or procedure-specific

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Vancomycin, continued

• In order to select any of the above allowable
  values, with the
• exception of 1 (Documentation of beta-lactam
  penicillin or
• cephalosporin allergy) and 9 (No documented
  reason),
• there must be physician/nurse practitioner/physic
  ian
• assistant/certified registered nurse anesthetist
  documentation
• of why Vancomycin was used for prophylaxis.

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Beta blockers

• Is there documentation that pt was on beta
  blocker therapy prior to admission?
• Used to identify population for SCIP CARD 2
  beta blocker measure
• If there is documentation that the beta blocker
  was a home or
• current medication, select Yes.
• Was there documentation of reasons for not
  prescribing a beta blocker during peri-operative
  period?
• Refer to specifications manual for determining
  end of peri-op period in pts who recover in ICU,
  etc.
• 24 hrs before incision -gt discharge from
  post-anesthesia care
• Contraindications include
• Bradycardia (heart rate less than 60 bpm)
• Bradycardia must be substantiated by
  documentation of a heart
• rate of less than 60 bpm.
• Other reasons documented by physician, nurse
  practitioner, physician assistant, or certified
  registered nurse anesthetist
• Is there documentation that a beta blocker was
  received during the peri-op period?

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VTE Prophylaxis

• Is there documentation that the patient was on
  Warfarin prior to admission?
• Used to exclude cases from VTE measures
• If there is documentation that Warfarin was a
  home or
• current medication, select Yes.
• If Warfarin was listed as a home or current
  medication,
• but placed on hold prior to surgery, select
  Yes.

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VTE Prophylaxis

• Is there documentation by MD/NP/CRNA/PA of
  contraindications to both pharmacological and
  mechanical prophylaxis?
• Used to exclude cases from VTE prophylaxis
  measures
• In order to select yes, there must be
  documentation of contraindications to both types
  of prophylaxis
• Only use MD/NP/CRNA/PA documentation
• Is there documentation by MD/NP/CRNA/PA of a risk
  for bleeding that contraindicates an order for
  pharmacological VTE prophylaxis?
• Used to calculate appropriate VTE prophylaxis
• Documentation must link bleeding risk to not
  ordering pharmacological prophylaxis, cannot
  assume link

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VTE prophylaxis

• 2 - part question
• What VTE prophylaxis was ordered during this
  admission?
• Select all that apply from the options listed
• Refer to Table 2.2 in Specifications Manual for
  inclusion terms
• Was the VTE prophylaxis timely (received within
  24 hrs prior to incision to 24 hrs after surgery
  end time)
• For each option selected in previous questions,
  answer yes or no to timely

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Normothermia

• This question applies only to colorectal
  surgeries.
• What was the first temperature recorded within
  the first hour after leaving the OR?
• Temp needs to be abstracted in 0F
• The one-hour time period begins when the pt
  leaves the OR
• Temp method inclusions
• Axillary, bladder, esophageal, oral, rectal,
  temporal artery,
• tympanic, skin surface, core temp

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Glucose Monitoring

• These questions apply only to cardiac surgery.
• What was the pts blood glucose level on POD 1
  and POD 2 closest to 6 a.m.?
• Abstract the value closest to 0600
• When two or more values qualify as the closest to
  0600, select the earliest time.
• Laboratory obtained values take precedence over
  bedside values when those results qualify as the
  closest to 0600.
• When two values are recorded with the same time,
  abstract the lowest value.
• When the value is recorded as being less than (lt)
  or greater than (gt) a limiting value, the
  abstractor should record the value at the
• corresponding lower limit (1) or upper limit
  (3000) of the allowable
• values.

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Questions?
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Contact Information

• Deborah Mattin, RN     Quality Improvement
  Specialist     Northeast Health Care Quality
  Foundation
• dmattin_at_nhqio.sdps.org603-842-8237800-772-0151
  Ext. 137603-749-1195 (fax)
• 15 Old Rollinsford Road, Suite 302
• Dover, NH 03820  www.nhcqf.org