5Surgical care improvement project SCIP is one of four categories of Core MeasuresThe Surgical Care Improvement Project (SCIP) is a national quality partnership of organizations interested in improving surgical care by significantly reducing surgical complications.Each of the SCIP target areas are advised by a technical expert panel and supported by evidence-based research.
6FY2010 SCIP CORE measuresSCIP INF 1: Patient receives prophylactic antibiotic within minutes prior to surgical incision.SCIP INF 2: Patient receives prophylactic antibiotics consistent with current recommendations identified in published guidelines.SCIP INF 3: Prophylactic antibiotics are discontinued within hours of surgery end time (48 hours for cardiac surgery).SCIP INF 4: Glucose control in cardiac surgery patients.SCIP INF 6: Surgery patients with appropriate hair removal.
7FY2010 SCIP CORE measuresSCIP CARD 2: Beta Blocker therapy prior to Admission who Received a Beta Blocker During the Perioperative PeriodSCIP VTE 1: Surgery patients with recommended VTE prophylaxisSCIP VTE 2: Surgery patients who received appropriate VTE prophylaxis within 24 hours prior to surgery to 24 hours aftersurgery, 48 hours for CABG and other cardiac surgery.SCIP-INF-9: Urinary Catheter Removed on Postoperative Day (POD 1) or by midnight on Postoperative Day 2 (POD 2).SCIP-Inf-10 Surgery Patients with Perioperative Temperature Management.NEWNEW
8SCIP Infection Measure - 9 Measure: Indwelling Urinary Catheter Removed on POD 1 or by midnight on POD 2Science-based rationale: Studies have shown that the longer indwelling urinary catheters remain in patients the greater risk of UTI.Inclusion criteria:Indwelling catheters: Foley catheter 3-Way catheter, Coude catheter, Council tip catheterIntermittent catheters: “in and out” catheterization, Texas catheter, “prn” catheterization for residual urine, self-catheterization, straight catheterization, “spot” catheterizationExclusion criteria: External catheterExceptions to removing catheter:Urological, GYN, Perineal proceduresPlanned return to ORSuprapubic catheter
9Potential Exclusion Criterion Urological, gynecological or perineal procedure performedICU bed and documentation of receiving diureticsOther surgical procedures that occurred within 3 days (4 days for CABG) prior to or after the procedure of interestPhysician documented infection prior to surgical procedureLength of stay < two days postoperativelySuprapubic catheter or had intermittent catheterization preoperativelyNo catheter in place postoperativelyPhysician documentation of a reason for not removing the urinary catheter postoperatively Example: “Foley retained to monitor accurate input and output”
10SCIP Infection Measure - 9 Documentation that the catheter was removed on POD 1 or POD 2 with Anesthesia End Date being POD 0 (POD 2 ends at midnight on the second post-op day)Role of Surgeons:Documentation of the reason why urinary catheter needs to stay in longer than midnight on POD 2.An order to just “continue catheter” will not suffice.Example: The patient required ICU care AND receiving diuretics”.Role of RNs:Check physicians’ orders to discontinue catheter and thendiscontinue catheter asap and document removal.
11SCIP Infection Measure - 10 Measure: Surgery Patients with Perioperative Temperature ManagementScience-based rationale:Studies have shown that hypothermia has been associated with adverse outcomes, including impaired wound healing, adverse cardiac events, altered drug metabolism, increased infection and coagulopathies.Documentation of at least one body temperature greater than or equal to 36° C within the 30 minutes immediately prior to or 15 minutes immediately after Anesthesia End Time (i.e. time associated with the anesthesia providers “signoff” after principal procedure).
12SCIP Infection Measure - 10 Anesthesiologists:Temperature must be 36 degrees or higher by end of surgery, unless “Intentional Hypothermia” is documented in medical record.Document core temperature on anesthesia record 30 minutes before patient is transferred.Physicians/CRNAs need to document “intentional” hypothermia during perioperative period.PACU and ICU RNs:Obtain and document temperature within first 15 minutes after patient arrives in unit.
13Potential Exclusion Criterion Patients whose length of anesthesia was less than 60 minutesPatients who did not have general or neuraxial anesthesiaPatients who received Intentional Hypothermia for the procedure performed.
14Focus on outstanding surgical care Remove urinary catheters by POD 2 SCIP Measure effective NOWSurgeons: Document reason catheter needs to stay in longerExample: “Foley retained to monitor accurate urine output”Exceptions to removing catheter:Urological, GYN, and Perineal proceduresPlanned return to ORIn ICU and receiving diuretic on POD1 or POD2RNs: Check MD orders for the DC Catheter orderAsk MD to document any exceptionsDocument!Document!
15Focus on outstanding surgical care Perioperative Temperature ManagementSCIP Measure effective NOWAnesthesiologists:Temperature must be 36º C /96.8ºF degrees or higher at handoff to PACU/ICU RNs, unless Intentional Hypothermia is documentedDocument End of Anesthesia time & final temperatureDocument use of Bair HuggerPACU and ICU RNs:Temp must be taken and documented within 15 minutes of handoff by AnesthesiologistDocument!Document!
16Surgical Care Improvement Project (SCIP) SHC Goal: Increase compliance for the following measures to 90%:SCIP Inf 1—Antibiotic received with one hour prior to incisionSCIP Inf 2—Antibiotic selectionSCIP Inf 3—Antibiotic discontinued within 24 hours after surgery timeSCIP VTE 1—Surgery patients with recommended VTE prophylaxis orderedSCIP VTE 2—Surgery patients who received appropriate VTE prophylaxis within 24 hours prior to surgery to 24 hours after surgery
20Accreditation in Bariatric Surgery CMS National Coverage DeterminationFebruary, 2006CMS will approve and reimburse procedures at a program accredited by one of the two programs:▪ ASBS/ Surgical Review Corporation.American College of Surgeons –Bariatric Surgery Centers
23NSQIP- SSI Observed Rate: 6.96% Expected Rate: 5.14% O/E Ratio: 1.35 Status: Needs Improvement* Includes General and Vascular Surgery Cases
24Semiannual Report, July 2009 American College of SurgeonsNational Surgical Quality Improvement ProgramSemiannual Report, July 2009Dates of Surgery: January 1, 2008 – December 31, 2008Stanford Hospital and Clinics
25A Means For Improvement StanfordCedars SinaiMayo ClinicUniversity of MNSaint Francis OSFNorth Shore – LIJCleveland ClinicNorthwesternAmerican College of SurgeonsTargetedSolutionsToolShare solutions with 16,000 accredited institutionsTargeted Solutions Tool™ (TST) encapsulates the work of the Joint Commission Center for Transforming Healthcare-TST is an application that guides health care organizations through a step-by-step process to accurately measure their organization’s actual performance, identify their barriers to excellent performance, and direct them to proven solutions that are customized to address their particular barriers.TST provides a step-by-step process to measure performance, identify barriers to excellent performance, and implement proven solutionsTST provides accredited hospitals the foundation and framework of an improvement method that, if implemented well, will improve an organization's complianceComplimentary data-driven tool provides validated and customized solutions to address an organization's particular barriers to excellent performanceSelf paced and confidential, the TST offers instantaneous data analysis
26Looked for a procedure/outcome that: Joint Commission Center for Transforming Healthcare - American College of Surgeons Surgical Site Infection ProjectLooked for a procedure/outcome that:Is common across different types of hospitalsComplications have significant, adverse clinical impactHigh variability in performance across hospitalsIdeal Candidate = SSI in colorectal surgery
27Joint Commission Center for Transforming Healthcare - American College of Surgeons Surgical Site Infection ProjectParticipating HospitalsCedars-Sinai, Cleveland Clinic, Mayo Clinic, Northwestern North Shore Long Island Jewish, OSF Saint Francis, StanfordIn August 2010, CTH launched its fourth project in collaboration with ACS on SSINSQIP data on outcomes of surgery are widely regarded as highly reliable, with exemplary risk-adjusted outcomes
28Impact of SSIYear 2008: SSIs generate an average of $28,211 in extra costs per case and comprise 38% of all morbidities.(ACS NSQIP, Business case, 2008)SSI’s add an additional 7-9 excess hospital days per case.(Infection Control Today, 2002)
36New RulesDialogue is almost always a signpost on the road to quality improvementQuality is not a personal virtue; it is an performance expectation that is accountable and rewarded.If you knock one down, you got to put up another oneCAN NOT KEEP DOING THE SAME
37Three trials of 1443Participants compared bar soap with chlorhexidine; when combined there was no difference in the risk of SSIs (RR 1.02, 95% CI 0.57 to 1.84). Three trials of 1192 patients compared bathing with chlorhexidine with no washing, one large study found a statistically significant difference in favour of bathing with chlorhexidine (RR 0.36, 95%CI 0.17 to 0.79).ITS SOAP!!!!
41BMI: Modifiable?2009 Colorectal Cases (All NSQIP Hospitals)Class I obesity ( ): %Class II obesity ( ): %Class III obesity (40): %______________________________________________________________________________40% of Total Population with BMI > 3013.23% of Total Population with Cancer1/3 of our patients could benefit from pre-op surgical weight loss
45Science of SSI (The development of an SSI is a multifactorial and not dependent on perioperative antibiotic administration alone.Prophylactic AntibioticsWound Oxygen Tension (↑O2 = ↓SSI risk)NormothermiaMild hypothermia, 1-2°C, increases wound infection rate.(Kurz, NEJM, 1996)Glucose Control (↑Hyperglycemia = ↑SSI risk)
46What can be the following step? Further multivariate analysis of SSI risk factorsDiabetes*Poor nutritional status*Medications*Body habitusAgeEmergent surgeryPost discharge follow up and care
47What can be the following step? Identify pathogenPattern recognitionOR trafficRedosing
48Surgical Site Infection Prevention Strategies Standardized OR PrepsPreps w/highest efficacy (Chloraprep / Duraprep)Surgery Chlorhexidine GuidelinesOutpatient Clinics: Provide patient with (4%) CHG EZ scrub sponges for Baths/Showers for pre-op skin prep night before surgeryPre Operative Units: If patient does not use (4%) CHG scrub RN to provide (2%) CHG wipes for use day of surgeryInpatient Units Nurses: Provide pre-operative antimicrobial skin prep using (2%) CHG Cloths night before or morning of surgery
49Phase II (May – November 2010) Service Specific Drill DownReview current practice for alignment with evidence based practiceAntibiotic Re-dosing on ORComplex cases & cases longer than 4 hours; define re-dosing timeframeCath Lab / ACS Cases“Small test of Change” pilot for EPS (Pace Maker and ICD cases )Develop measurement and reporting mechanismsAdherence to dispensing of CHG shower/bath prior to surgeryBoarding Pass for compliance with CHG shower/bath prior to surgeryPost Operative Incision Care GuidelinesService specific “Surgical Wound Guidelines”Joint Commission Center for Transforming HealthcareAmerican College of Surgeons NSQIP Project