Surgical Care Improvement Project SCIP National Initiatives to Improve Surgical Care

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Surgical Care Improvement ProjectSCIPNational
Initiatives to Improve Surgical Care
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(No Transcript)
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OBJECTIVES
1. Identify SCIP and SCIP measures. 2.
Discuss how these changes affect patient
safety 3. How these processes improve outcome
measures for YOUR surgical patients.
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WHAT IS SCIP?
National quality partnership of organizations
focused on improving surgical care by
significantly reducing surgical complications.
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SCIP Steering Committee

• 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

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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

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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

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Surgical Care Improvement ProjectNational Goal
To reduce preventable surgical morbidity and
mortality by 25 by 2010
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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

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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.
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Surgical Site Infections (SSI)

• 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.
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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)

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Performance Measure Review
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SCIP Infection Module
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Prophylactic Antibiotics

• Antibiotics given for the purpose of preventing
  infection when infection is not present but the
  risk of postoperative infection is present

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Relative Benefit from Antibiotic Surgical
Prophylaxis

• Operation Prophylaxis () Placebo () NNT
• Colon 4-12 24-48 3-5
• Other (mixed) GI 4-6 15-29 4-9
• Vascular 1-4 7-17 10-17
• Cardiac 3-9 44-49 2-3
• Hysterectomy 1-16 18-38 3-6
• Craniotomy 0.5-3 4-12 9-29
• Total joint repl 0.5-1 2-9 12-100
• Brst hernia ops 3.5 5.2 58

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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?

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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

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SCIP Infection 1

• Prophylactic antibiotic received within one hour
  prior to surgical incision (two hours allowed for
  vancomycin or quinolone)

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Efficacy Of Prophylaxis Is Independent Of The
Specific Antibiotic
Penicillin, 40,000 U
Erythromycin, 0.1 mg/Kg
Control
Control
Staph Penicillin
Staph Erythromycin
Chloramphenicol, 0.1 mg/Kg
Tetracycline, 0.1 mg/Kg
Lesion Size, mm (24 Hours)
Control
Control
Staph Chloramphenicol
Staph Tetracycline
Age of Lesion at Antibiotic Injection (Hours)
Burke JF. Surgery. 196150161.
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Perioperative Prophylactic AntibioticsTiming of
Administration
14/369
15/441
1/41
1/47
Infections ()
1/81
2/180
5/699
5/1009
Hours From Incision
Classen. NEJM. 1992328281.
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Prophylactic AntibioticsQuestions

• When do we start?

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Antibiotic Timing Related to Incision
Bratzler DW, Houck PM, et al. Arch Surg.
2005140174-182.
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SCIP Infection 2

• Prophylactic antibiotic selection for surgical
  patients

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Recently Updated Antibiotic Recommendations
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).
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Recently Updated Antibiotic Recommendations
(continued)
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.
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SCIP Infection 3

• Prophylactic antibiotics discontinued within 24
  hours after surgery end time (48 hours for
  cardiac patients)

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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.
2005140174-182.
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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.

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Duration of Antibiotic ProphylaxisWhat 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
  SSIs
• There is evidence that increased use of
  antibiotics promotes antibiotic resistance

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• 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
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SCIP Infection 4

• Cardiac surgery patients with controlled 6 a.m.
  postoperative serum glucose

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Diabetes, Glucose Control, and SSIsAfter Median
Sternotomy
Latham. ICHE 2001 22 607-12
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Hyperglycemia and Risk of SSI after Cardiac
Operations

• Hyperglycemia - doubled risk of SSI
• Hyperglycemic 48 of diabetics 12 of
  nondiabetics 30 of all patients
• 47 of hyperglycemic episodes were in nondiabetics

Latham. Inf Contr Hosp Epidemiol.
200122607 Dellinger. Inf Contr Hosp Epidemiol.
200122604
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Deep Sternal SSI and Glucose
Zerr. Ann Thorac Surg 199763356
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Glucose Control and Mortality after CABG in 3554
Diabetics
Furnary. J Thorac Cardiovasc Surg 20031251007
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SCIP Infection 5

• Postoperative wound infection
• diagnosed during index hospitalization (OUTCOME)

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This One is Difficult!

• The purpose of the process measures is to lower
  SSI rates, if we dont survey we wont know if
  theyre 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

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SCIP Infection 6

• Surgery patients with appropriate hair removal

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Shaving, Clipping and SSI
Cruse. Arch Surg 1973 107 206
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Shaving vs ClippingCardiac Surgery

• Number Infected ()
• Shaved 990 13 (1.3)
• Clipped 990 4 (0.4)
• p lt 0.03

Ko. Ann Thorac surg 199253301
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SCIP Infection 7

• Colorectal surgery patients with immediate
  postoperative normothermia

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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 1987122221
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Local Warming and SSI after Clean Operations

• Elective hernia repair
• Varicose vein operation
• Breast operation, incision gt 3cm
• Pre-op warming gt 30 min Whole body forced air -
  systemic Incision site radiant heat - local

Melling. Lancet 2001358876
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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

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Can We Prevent SSIs in the Operating Room?

• Oxygenation
• Temperature
• Fluid Management
• Antibiotics
• Glucose
• Shaving
• ?Other
• The period of maximum influence on SSI risk
  begins and ends in the operating room.

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Surgical Care Improvement ProjectNew Performance
measures - Process
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• 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

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SCIP Cardiac Module
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Prevention of Cardiac EventsIntroduction
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• 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.
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SCIP Cardiac Module
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• SCIP Card 2
• Surgery patients on a beta-blocker prior to
  arrival that received a betablocker during the
  perioperative period

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Medication List for Beta Blockers
Acebutolol Aerosol Atenolol/chlorthalidone
Betapace Betapace AF Betaxolol Bisoprolol
Bisoprolol/fumarate Bisopropol/hydro-chlorothiazi
de Blocadren Brevibloc Carteolol
Cartrol Carvedilol Coreg Corgard Corzide
40/5 Corzide 80/5 Esmolol
Inderal Inderal LA Inderide Inderide LA
Kerlone Labetalol Levatol Lopressor Lopressor
HCT Lopressor/hydrochlorothiazide Metoprolol Metop
rolol/hydrochlorothiazide Metoprolol
Tartrate/hydrochlorothiazide Nadolol Nadolol/bendr
oflumethiazide Normodyne Penbutolol Pindolol Propr
anolol Propranolol HC1 Propranolol
Hydrochloride Propranolol/hydrochlorothiazide
Sectral Sorine Sotalol Sotalol HC1 Tenoretic
Tenormin Tenormin I.V. Timolide Timolol Timolol
Maleate/hydrochlorothiazide Timolol/hydrochlorothi
azide Toprol Toprol-XL Trandate Trandate HCl
Visken Zebeta Ziac
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Venous Thromboembolism Prevention
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SCIP VTE Module
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Prevention of Venous ThromboembolismIntroduction
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• 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.
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SCIP VTE Module
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• 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

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Orthopedic Intra-operative Thermal Management

• Anesthesia record revised for documentation of
  interventions
• Fluids
• Blanket
• H recorded in ORME ( Heat Moisture Exchange)
• Core Temperature

• Engineering
• Confirmation maintenance of all thermostats in
  OR Suites
• OR rooms being maintained at
• 68 - 72F
• PACU
• Tympanic thermometers were re-calibrated
• upgraded thermometers purchased

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SCIP Respiratory Module
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Why is this Important?PAY FOR
PERFORMANCEQUALITY CAREEVIDENCE-BASED PRACTICE
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