Surgical Care Improvement

SCIP Presentation

Presentation adapted from: The Surgical Infection Prevention and Surgical Care Improvement Projects Where we started and where we’re going… Bratzler DW, QIOSC Medical Director -

November 2006, NC Center for Hospital Quality and Patient Safety Annual Patient Safety Conference and the Specifications Manual for National Hospital Inpatient Measures 2009-2010

Needs Assessment:SCIP data is below the 50% for several measures on a consistent basis.

Goals:To improve surgical patient outcomes by increased compliance with national initiative to improve surgical care.

Objectives:1. List 5 evidence based solutions for improving

outcomes in surgical patients 2. Describe 4 examples of how to implement the

necessary improvements .

Surgical Care

What is the problem? What is the solution? How do we do this?

What is the problem?

Surgical Care

At least 30 million major surgeries performed in the US/yr.

1999 IOM Report - 5.4% of patients undergoing surgery suffered complications

~ 1.6 million patients suffer a complication as a result of surgical care

Most Common Surgical Complications

Infections Venous thromboembolic complications Cardiovascular complications

Results of Surgical Complications Length of Stay (LOS)1 - 3 to 11 days longer

Hospital Cost2 Infections costs = $ 1,398Cardiovascular costs = $7,789Respiratory costs = $ 52,466Thromboembolic costs = $18,310

Mortality3 - Independent of perioperative risk, occurrence of a 30 day complication reduced median patient survival by 69%

1. To Err is Human, 1999 IOM Report2. Dimick JB, et al. J Am Coll Surg 20043. Khuri SF, et al. Ann Surg 2005

Who Paid for Surgical Complications?

HospitalReimbursement

$Costs of care

$Profit

$Profit margin

%14266

(uncomplicated)10978 3288 23.0

21911(complicated)

21156 755 3.4

Dimick JB, et al. Who pays for poor surgical quality? Building a

business case for quality improvement. J Am Coll Surg. 2006;202:933-7. Slide: Bratzler DW, QIOSC Medical Director -

November 2006, NC Center for Hospital Quality and Patient Safety Annual Patient Safety Conference

Complications were always associated with an increase in costs to healthcare payors: complications were associated with an average increase in payment of

$7645 (54%) per patient.

Never Events

Medicare announced that it would not pay for care of post op infections

What’s the Solution?

Surgical Improvement 2005 -

Surgical Care Improvement Project (SCIP)

Agency for Healthcare Research and Quality (AHRQ)American College of Surgeons (ACS)American Hospital Association (AHA)American Society of Anesthesiologists (ASA) Association of PeriOperative Registered Nurses (AORN) Centers for Disease Control and Prevention (CDC)Centers for Medicare & Medicaid Services (CMS) Institute for Healthcare Improvement (IHI) Joint Commission on Accreditation of Healthcare Organizations(JCAHO) Veterans Health Administration (VA)

SCIP

Outcomes basedOngoing program to monitor and improve

quality of surgical careEstablished the largest risk adjusted data

base (over 1 million surgical cases to date) Since program inception major surgery

mortality rate decreased by 31%

Surgical Care Improvement Project: Why?

Medicare could prevent* up to:13,027 perioperative deaths271,055 surgical complications

* Major surgical cases

SCIP Components Preventable Complications

Surgical infection preventionCardiovascular complication preventionVenous thromboembolism prevention

Current SCIP Measures

#1 - Proportion of patients who receive antibiotics within 1 hour before surgical incision

#2 - Proportion of patients who receive prophylactic antibiotics consistent with current recommendations

#3 - Proportion of patients whose prophylactic antibiotics were discontinued within 24 hours of Anesthesia end time

Current SCIP measures (cont)

#4 Cardiac Patients with Controlled 6 AM Postoperative Blood Glucose#5 Surgery Patients with Appropriate Hair Removal#6 Urinary catheter removed on Postoperative Day (POD) 1 or POD 2#7 Surgery Patients with Perioperative Temperature Management

Current SCIP Measures (cont)

#8 Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered anytime from hospital arrival to Anesthesia to 24 Hours After Anesthesia end time.#9 Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis within 24 hours prior to Anesthesia Start Time to Anesthesia to 24 Hours After Anesthesia end time.#10 Surgery Patients on Beta-Blocker Therapy Prior to Arrival Who Receive a Beta-Blocker During the Perioperative Period.

SCIP – Inf 1

A goal of prophylaxis with antibiotics is to establish bactericidal tissue and serum levels at the time of skin incision. Prophylactic antibiotics need to be initiated within one hour prior to surgical incision (two hours if receiving Vancomycin or a Fluorquinolone)

SCIP Inf 2

A goal of prophylaxis is to use an agent that is safe, cost-effective, and has a spectrum of action that covers most of the probable intraoperative contaminants for the operation.

SCIP Inf 3

A goal of prophylaxis is to provide benefit to the patient with as little risk as possible. Administration of antibiotics for more than a few hours after the incision is closed offers not additional benefit.

Antibiotics

Antibiotics were given within one hour of incision time to 55.7% of patients

Appropriate antibiotic selection occurred in 92.6% of cases

Prophylactic antibiotics were discontinued within 24 hours of surgery end time for only 40.7% of patients

Bratzler. Arch Surg. 2005;140:174-182

SCIP Inf 4

Deep wound infection in diabetic patients undergoing cardiac surgery was reduced by controlling mean blood glucose levels below 200 mg/dL in the immediate post op period.

Perioperative Glucose Control1,000 cardiothoracic surgery patientsDiabetics and non-diabetics with hyperglycemia

Patients with a blood sugar >

300 mg/dL during or within 48 hours of surgery had more than 3X the likelihood of a wound infection!

Latham R, et al. Infect Control Hosp Epidemiol. 2001.

SCIP Inf 6

Studies show that shaving causes multiple skin abrasions that later may become infected. Use depilatory or electric clippers immediately prior to surgery.

Pre-operative shavingShaving the surgical site with a razor induces small

skin lacerationspotential sites for infectiondisturbs hair follicles which are often colonized with S. aureusRisk greatest when done the night beforePatient education

be sure patients know that they should not do you a favor and shave before they come to the hospital!

SCIP Inf 9

It is well-established that the risk of catheter associated urinary tract infection increase with increasing duration of indwelling urinary catheter.

Inf 10

The incidence of surgical site infections among those with mild perioperative hypothermia was 3 times higher than the normothermic patients

Temperature Control200 colorectal surgery patients

control - routine intraoperative thermal care (mean temp 34.7°C)treatment - active warming (mean temp on arrival to recovery 36.6°C)

Resultscontrol - 19% SSI (18/96)treatment - 6% SSI (6/104), P=0.009

Kurz A, et al. N Engl J Med. 1996.

Also: Melling AC, et al. Lancet. 2001. (preop warming)

SCIP VTE 1

VTE is one to the most common postoperative complications and prophylaxis is the most effective strategy to reduce morbidity and mortality

SCIP VTE 2

The frequency of VTE is related to the type and duration of surgery , pt risk factors, duration of post-op immobilization and use or non use of prophylaxis.

Prevention of Venous Thromboembolism

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 dwellingIncidence 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.

Risk of DVT in Hospitalized Patients

Patient group DVT incidenceMedical patients 10 - 20 %Major gyne/urol/gen surgery 15 - 40 %Neurosurgery 15 - 40 %Stroke 20 - 50 %Hip/knee surgery 40 - 60 %Major trauma 40 - 80 %Spinal cord injury 60 - 80 %Critical care patients 15 - 80 %

No prophylaxis + routine objective screening for DVT

SCIP Card 2

Beta Blocker withdrawal is associate with an increased risk of 1 year mortality compared with nonusers.

Prevention of Cardiac Events

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.

Prevention of Cardiac EventsPerioperatively administered beta blockers

have the potential to:Decrease myocardial oxygen demand

Reduced heart rateReduced wall tensionReduced contractility

Decrease myocardial ischemia and adverse cardiac events

Perioperative Beta blockers ACC/AHA Guideline

Beta blockers required in the recent past to control symptoms of angina, symptomatic arrhythmias, or hypertension or other ACC/AHA Class I guideline recommendationsPatients at high cardiac risk owing to the finding of ischemia on preoperative testing who are undergoing vascular surgeryPatients with known coronary artery disease or major risk factors for coronary disease

Fleisher LA, et al. ACC/AHA. http://www.acc.org/clinical/guidelines/perio/periobetablocker.pdf

SCIP Infection•Inf 1: Antibiotic Timing •Inf 2: Antibiotic Selection •Inf 3: Antibiotic Cessation •Inf 4: Glucose Cardiac Surgery•Inf 6: Skin Prep (Hair removal)•Inf 9 Urinary Catheter removal•Inf 10: Maintain Temperature (Normothermia)

SCIP VTE (already NQF endorsed)••VTE 1: ProphylaxisVTE 1: Prophylaxis

OrderedOrdered••VTE 2: Prophylaxis GivenVTE 2: Prophylaxis Given

SCIP Cardiac •Card 2: β-blocker maintained

Public Reporting

Current, and Proposed

Measures for Reporting

73.1

47.6

91.491.4

62.2

40.7

0

20

40

60

80

100

Base

line

2002

Q1

2002

Q2

2002

Q3

2002

Q4

2003

Q1

2003

Q2

2003

Q3

2003

Q4

2004

Q1

2004

Q2

2004

Q3

2004

Q4

2005

Q1

2005

Q2

2005

Q3

Perc

ent

Antibiotic w/in 60 min* Antibiotic selection Antibiotic stopped in 24 hours

Ongoing surveillance of a national sample of Medicare patients having surgery.

SCIP - Data

Slide: Bratzler DW, QIOSC Medical Director -

November 2006, NC Center for Hospital Quality and Patient Safety Annual Patient Safety Conference

87.9

7581.9

90.5

69.1

96.7 98.9 95.186.1

0

20

40

60

80

100

Antibiotics w/in 1 hour Correct Antibiotic Antibiotic DCed w/in 24hours

Perc

ent

North Carolina Average* Benchmark

•Based on medical record abstraction from the charts of patients discharged in the 3rd quarter of 2005. Benchmark rates were calculated for all HQA reporting hospitals (N=1609) in the US based on discharges during the 3rd quarter of 2005 using the Achievable Benchmarks of CareTM methodology (http://main.uab.edu/show.asp?durki=14527).

SCIP Data - 44 NC Hospitals Reporting Hospital Voluntary Self-Reporting, Qtr. 3, 2005

INF9 Catheter Removal Monthly Trends

70%

73%

75%

78%

80%

83%

85%88%

90%

93%

95%

98%

100%

Oct_09 Nov_09 Dec_09 Jan_10 Feb_10

Com

plia

nce

Per

cent

ALL NCSCIP NCSCIP Tier 1 NCSCIP Tier 2

SCIP8 Optimal Care Monthly Trends

70%

73%

75%

78%

80%

83%

85%

88%

90%

93%

95%

98%

100%

Sep_09 Oct_09 Nov_09 Dec_09 Jan_10 Feb_10

SC

IP8

OC

Com

plia

nce

Per

cent

All NCSCIP NCSCIP Tier 1 NCSCIP Tier 2

Surgical Care Improvement Project (SCIP)

National Goal:To reduce preventable surgical morbidity and mortality by 25% by 2010

What can be done and how do we do

this?

Improve Antibiotic Delivery

Assigned responsibility for administration and documentation of antibiotic prophylaxis

Often involved transfer of ownership of the process to anesthesiaEnsuring the delivery of the antibiotic near or in the ORUse of preprinted protocols for antibiotic selection and durationAntibiotics available in the ORSome incorporated into the ‘time out’Revision of forms to require documentation of antibiotic dose and time

Eliminate Razors

Many hospitals physically removed razors from the operating rooms and holding areas or required them to be signed out

Clippers had to be readily available and training provided

Other departments – e.g., preoperative ECGs

Improve Glycemic Control

Multidisciplinary teams to address blood sugar control in intensive care units

Most hospitals did not limit this work to cardiac surgery patientsRequired considerable education on the risk of infections and adverse outcomes versus the lower risk of hypoglycemiaIV insulin infusions essential – frequent FSBS and issues of use outside of the ICUAdoption of other published protocols.

Ensure Normothermia for PatientsEducation on the risks of hypothermia

Increased infection rates, increased cardiac arrhythmias, increased transfusion requirements

Warming of the OR (some surgeons needed cooling vests)

Attention to body temperature prior to going to the ORMany hospitals found that patients were already dropping their body temperature prior to the OR

Host of mechanical methods to warm patient-we use the LMA PerfecTemp

Attention to consistent mechanism of documenting body temperature

Foley Catheter

Develop policies and protocols for urinary catheter removal

Ensure Perioperative Beta Blocker Administration

Assign responsibility for ordering pre and postoperative beta blocker administration

Implement or revise guidelines for pre and postoperative cardiac risk assessment

Include cardiac risk assessment with physician preoperative order set during preoperative assessment

Add a check box to perioperative assessment form for beta blocker use include date, time of last dose

Improve VTE Prophylaxis

Hospital policy of risk assessment for all admitted patients

Most will have risk factors for VTE and should receive prophylaxisPreprinted protocols for surgical patients

What Can You Do?

Assist the SCIP Team by……1. Becoming involved in process

improvement2. Educate your peers 3. Communicate to others4. Be informed on projects progress

When Do We Start?

TODAY!

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Surgical Care Improvement Needs Assessment:Surgical Care What is the problem? Surgical CareMost Common Surgical Complications Results of Surgical Complications Who Paid for Surgical Complications?Never EventsWhat’s the Solution? Surgical Improvement SCIPSurgical Care Improvement Project: Why?SCIP Components Current SCIP MeasuresCurrent SCIP measures (cont)Current SCIP Measures (cont)Slide Number 18SCIP – Inf 1SCIP Inf 2SCIP Inf 3Antibiotics SCIP Inf 4Perioperative Glucose ControlSCIP Inf 6Pre-operative shavingSCIP Inf 9Inf 10Temperature ControlSCIP VTE 1SCIP VTE 2Prevention of Venous ThromboembolismSlide Number 33SCIP Card 2Prevention of Cardiac Events�Prevention of Cardiac Events�Perioperative Beta blockers�ACC/AHA GuidelineSlide Number 38Slide Number 39SCIP Data - 44 NC Hospitals Reporting �Hospital Voluntary Self-Reporting, Qtr. 3, 2005Slide Number 41Slide Number 42Surgical Care Improvement Project (SCIP)�What can be done and how do we do this?Improve Antibiotic DeliveryEliminate Razors Improve Glycemic ControlEnsure Normothermia for PatientsFoley Catheter�Ensure Perioperative Beta Blocker Administration Improve VTE ProphylaxisWhat Can You Do?When Do We Start?Slide Number 54