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