1. Surgical Care Improvement Project SCIP National Initiatives to Improve Surgical Care

3. 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.

4. WHAT IS SCIP? National quality partnership of organizations focused on improving surgical care by significantly reducing surgical complications.

5. 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

6. 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

7. 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

8. Surgical Care Improvement Project National Goal To reduce preventable surgical morbidity and mortality by 25% by 2010

9. 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

10. 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. 2004;199:531-7.

11. 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.

12. Quality Indicators National 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)

13. Performance Measure Review

14. SCIP Infection Module

15. Prophylactic Antibiotics Antibiotics given for the purpose of preventing infection when infection is not present but the risk of postoperative infection is present

16. Relative Benefit from Antibiotic Surgical Prophylaxis OperationProphylaxis (%)Placebo (%)NNT* Colon4-1224-483-5 Other (mixed) GI4-615-294-9 Vascular1-47-1710-17 Cardiac3-944-492-3 Hysterectomy1-1618-383-6 Craniotomy0.5-34-129-29 Total joint repl0.5-12-912-100 Brst & hernia ops3.55.258

17. Prophylactic Antibiotics Questions Which cases benefit? Which drug should you use? When should you start? How much should you give? How long should antibiotics be continued?

18. 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

19. SCIP Infection 1 Prophylactic antibiotic received within one hour prior to surgical incision (two hours allowed for vancomycin or quinolone)

20. Efficacy Of Prophylaxis Is Independent Of The Specific Antibiotic Age of Lesion at Antibiotic Injection (Hours) Lesion Size, mm (24 Hours) 0 510 Penicillin, 40,000 U Staph + Penicillin Control Chloramphenicol, 0.1 mg/Kg Erythromycin, 0.1 mg/Kg Tetracycline, 0.1 mg/Kg 0246-20246-2 0 510 0 510 0 510Control Control Control Staph + Erythromycin Staph + Tetracycline Staph + Chloramphenicol Burke JF. Surgery. 1961;50:161.

21. Classen. NEJM. 1992;328:281. Perioperative Prophylactic Antibiotics Timing of Administration Infections (%) Hours From Incision 14/369 5/699 5/1009 2/180 1/81 1/41 1/47 15/441

22. Prophylactic Antibiotics Questions When do we start?

23. Antibiotic Timing Related to Incision Bratzler DW, Houck PM, et al. Arch Surg. 2005;140:174-182.

24. SCIP Infection 2 Prophylactic antibiotic selection for surgical patients

25. 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).

26. 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.

27. SCIP Infection 3 Prophylactic antibiotics discontinued within 24 hours after surgery end time (48 hours for cardiac patients)

28. 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.

29. Antibiotic Prophylaxis Duration 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.

30. 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

31. 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

32. SCIP Infection 4 Cardiac surgery patients with controlled 6 a.m. postoperative serum glucose

33. Diabetes, Glucose Control, and SSIs After Median Sternotomy Latham. ICHE 2001; 22: 607-12

34. 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. 2001;22:607 Dellinger. Inf Contr Hosp Epidemiol. 2001;22:604

35. Deep Sternal SSI and Glucose Zerr. Ann Thorac Surg 1997;63:356

36. Glucose Control and Mortality after CABG in 3554 Diabetics Furnary. J Thorac Cardiovasc Surg 2003;125:1007

37. SCIP Infection 5 Postoperative wound infection diagnosed during index hospitalization (OUTCOME)

38. 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

39. SCIP Infection 6 Surgery patients with appropriate hair removal

40. Shaving, Clipping and SSI Cruse. Arch Surg 1973; 107: 206

41. Shaving vs Clipping Cardiac Surgery NumberInfected (%) Shaved99013 (1.3%) Clipped9904 (0.4%) p < 0.03 Ko. Ann Thorac surg 1992;53:301

42. SCIP Infection 7 Colorectal surgery patients with immediate postoperative normothermia

43. Temperature and Tissue O 2 tension Subcut temp increase 4° C Subcut O 2 tension increase 40 torr Linear correlation between temperature and O 2 tension Threefold increase in local perfusion Rabkin. Arch Surg 1987;122:221

44. Local Warming and SSI after Clean Operations Elective hernia repair Varicose vein operation Breast operation, incision > 3cm Pre-op warming > 30 min Whole body forced air - systemic Incision site radiant heat - local Melling. Lancet 2001;358:876

45. 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

46. Can We Prevent SSI’s 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.

47. Surgical Care Improvement Project New Performance measures - Process Surgical infection prevention Glucose 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 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 39

48. SCIP Cardiac Module

49. Prevention of Cardiac Events Introduction 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

50. SCIP Cardiac Module SCIP Card 2: Surgery patients on a beta-blocker prior to arrival that received a betablocker during the perioperative period 45

51. Medication List for Beta Blockers Acebutolol Aerosol Atenolol/chlorthalidone Betapace Betapace AF Betaxolol Bisoprolol Bisoprolol/fumarate Bisopropol/hydro- chlorothiazide 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 Metoprolol/hydrochlorothiazide Metoprolol Tartrate/hydrochlorothiazide Nadolol Nadolol/bendroflumethiazide Normodyne Penbutolol Pindolol Propranolol Propranolol HC1 Propranolol Hydrochloride Propranolol/hydrochlorothiazide Sectral Sorine Sotalol Sotalol HC1 Tenoretic Tenormin Tenormin I.V. Timolide Timolol Timolol Maleate/hydrochlorothiazide Timolol/hydrochlorothiazide Toprol Toprol-XL Trandate Trandate HCl Visken Zebeta Ziac

52. Venous Thromboembolism Prevention 50

53. SCIP VTE Module

54. Prevention of Venous Thromboembolism Introduction 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. 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

55. 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

56. 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° - 72°F PACU Tympanic thermometers were re- calibrated upgraded thermometers purchased

57. SCIP Respiratory Module

58. Why is this Important? PAY FOR PERFORMANCE QUALITY CARE EVIDENCE-BASED PRACTICE PUBLIC INFORMATION HEALTHCARE CONSUMER RIGHTS