10 CAHQJournal,Quarter3,2007

T

Surgical Care Improvement Project Compendium:

OperationalApproaches toImproveClinical SCIP

MeasureResults

Compiled by Catherine Carson, BSN, MPA, CPHQ Modified by Kathleen Tornow Chai, RN, PhD, CPHQ, FNAHQ

The Surgical Care Improvement Project (SCIP) is a relatively new

initiative and takes a hospital wide approach not only from the

department of surgery. It takes involvement from the OR, Nurs-

ing, Pharmacy, Infection Control, Administration, Anesthesiolo-

gists, and Surgeons. It is also expected that the Board of Directors,

Medical Staff, and Hospital Administration consider the minimum

requirements of the core measure indicators to reflect evidence-

based medicine and constitute a national standard of care. Frequent

and continuous monitoring of results is required with reporting of

results through medical staff leadership and to the Board of Direc-

tors at least quarterly. It is recommended that the organization share

results by surgery type and by surgeon (individually) and blinded

at Surgery Department meetings, and at Anesthesia Department

meetings.

CAHQJournal,Quarter3,2007 11

How.does.an.organization.implement.

this.initiative?.Start.by.establishing.a.

hospital-wide.focus.for.SCIP.as.a.new.

and.expanded.piece.of.Core.Measures;.

consider.a.“campaign”.to.educate.

about.SCIP.Indicators.and.important.

processes;.develop.a.contest.to.motivate.

staff;.institute.concurrent.open.record.

review.of.all.core.measure.cases.and.

include.results.reporting.into.daily.

operational.activities.such.as.daily.bed.

huddle.meetings;.add.Core.Measure.

Indicator.knowledge.to.Nursing.An-

nual.Skills/Competency.Fair;.include.

an.overview.of.core.measure.indicators.

and.importance.at.all.new.hire.orienta-

tion.education;.use.already.available.

tools.such.as.posters.and.other.materi-

als.at.Health.Services.Advisory.Group.

HSAG.org.

Another.strategy.would.be.to.estab-

lish.a.sub.team.of.the.core.measure.

team.to.“own”.SCIP.processes.and.mea-

sure.results..Membership.might.include.

OR,.Nursing,.Pharmacy,.Infection.

Control,.Anesthesia,.Surgeon(s),.and.

Quality..Have.team.members.subscribe.

to.SCIP.List.serve.for.updates.and.clari-

fications.(To.join.the.SCIP.list.send.an.

e-mail.to:.leigh@qualishealth.org)..

Post.discharge.infection.surveillance.

is.also.important.for.SCIP.success..

Develop.or.enhance.the.current.post.

surgery.surveillance.process..Include.

names.and.dates.of.surgeries,.a.continu-

ous.list.that.can.be.sent.to.surgeons.

monthly.with.check.boxes.to.indicate.

post-operative.infection.and.return.

to.hospital.ICP..Provide.education.to.

hospital.and.medical.staff.on.Wound.

Classifications;.Include.clean,.clean.

contaminated,.contaminated,.and.

dirty/infected.wound.types..Educate.

regarding.post.surgical.prophylaxis.

guidelines.for.antibiotic.selection.by.

surgery.type.and.for.immunocompetent.

adults.in.the.ICU..

It.is.recommended.that.each.failure.

be.analyzed..One.way.to.do.this.is.

to.have.the.clinical.manager.or.qual-

ity.coordinator.perform.an.intensive.

analysis.of.each.measure.failure.within.

3.days.at.the.unit/department.level..Use.

a.simple.cause.and.effect.or.fish-bone.

diagram.to.assist.staff.with.completion..

If.failure.is.related.to.physician.action.

or.inaction.forward.the.information.to.

the.peer.review.process.and.make.sure.

the.physician.receives.notification.of.

the.findings..Review.results.at.the.SCIP.

Team.meetings,.forward.them.to.Infec-

tion.Control.and.Pharmacy/Therapeu-

tic.committees.

Make.sure.references.are.immediately.

available.to.surgeons.and.anesthesi-

ologists..It.is.helpful.to.have.copies.of.

the.peer.reviewed.studies.for.others.

to.learn..Include.specific.studies.on.

normothermia,.glucose.control,.timing.

of.prophylactic.antibiotics.and.duration.

of.prophylactic.antibiotics.and.studies.

specific.to.the.SCIP.applicable.surger-

ies:.colon,.vascular,.cardiac,.total.hip.

and.knee..It.is.also.helpful.to.include.

studies.on.supplemental.oxygen.for.the.

anesthesiologists.

Measure Specific StrategiesSCIP INF 1: Prophylactic

antibiotic received within one hour prior to surgical incision.

The.antibiotic.infusion.should.be.timed.

so.that.there.is.optimal.concentration.in.

the.serum/tissue.at.the.time.of.incision..

The.measure.focuses.on.a.prophylactic.

antibiotic.infused.one.hour.prior.to.

surgical.incision..The.exception.to.this.

is.2.hours.for.vancomycin.and.fluoro-

quinolones,.e.g..ciprofloxacin,.which.

have.longer.tissue.perfusion.time..One.

key.tip.is.to.synchronize.clocks.in.the.

Pre-op.holding.areas,.Operating.room,.

PACU.etc..Consider.using.atomic.

clocks.for.accuracy..It.is.equally.impor-

tant.to.maintain.the.therapeutic.level.

in.the.serum/tissue.through.out.the.

operation,.so.if.the.surgical.procedure.is.

longer.than.the.half-life.of.the.antibi-

otic,.the.drug.must.be.re-dosed.during.

the.procedure..Refer.to.the.antibiotic.

half.life.table.reference.from.CMS.for.

more.information..The.July.2006.Issue.

of.Medical.Letter.recommends.that.

the.antibiotic.be.given.no.more.than.

30.minutes.before.the.skin.is.incised..

Another.key.to.success.is.to.address.

antibiotic.timing.for.surgeons.with.a.

physician.champion.

As.far.as.the.process.to.be.accom-

plished,.it.is.recommended.that.the.

organization.designate.an.owner.such.

as.the.circulating.nurse.and/or.the.

anesthesiologist,.and.pre-anesthesia.

nurses..Encourage.the.surgical.staff.to.

inquire.about.prophylactic.antibiotics.

during.the.surgical.pause.or.incorporate.

antibiotic.delivery.verification.into.the.

preoperative.time-out..Another.trick.is.

to.remove.all.but.prophylactic.antibiot-

ics.from.the.operating.room..From.an.

orientation.perspective,.include.antibi-

otic.timing.in.all.surgery.staff.orienta-

1� CAHQJournal,Quarter3,2007

tions..For.consistency,.use.standing.or.

pre-printed.orders.specific.to.the.type.

of.surgery.performed.that.include.the.

recommended.prophylactic.antibiotics.

In.addition,.consider.including.the.

antibiotic.on.documentation.forms.

and.add.the.route.of.antibiotic.to.be.

intravenous.

References:

ACOG Practice Bulletin No.

74.(2006). Antibiotic prophylaxis

for gynecologic procedures. Obstetric

Gynecology, 108(1) 225-34.

Bratzler, D.W., Houck, P.M., Rich-

ards, C., & Steele, L. (2005). Use

of Antimicrobial Prophylaxis for

Major Surgery, Archives of Surgery,

140, 174-182.

Lewis, R. T. (2002). Oral versus system-

ic antibiotic prophylaxis in elective

colon surgery: a randomized study

and meta-analysis send a message

from the 1990’s.Canadian Journal of

Surgery, 45(3) 173-80.

Kato D., Maezawa, K., Yonezawa, I.,

Iwase, Y., Ikeda, H., et al. (2006).

Randomized prospective study on

prophylactic antibiotics in clean

orthopedic surgery in one ward for 1

year. Journal of Orthopedic Science,

11(1)20-7.

SCIP INF 2: Prophylactic antibiotic selection for surgical patients.

The.optimal.antibiotic.is.effective.

against.the.organisms.that.are.most.

likely.to.be.encountered.during.the.

type.of.operation.that.planned.is.safe,.

inexpensive,.and.bactericidal,.and.has.

a.long.half-life..It.is.recommended.that.

the.organization.utilize.the.“Updated.

Consensus.Recommendations.of.the.

Surgical.Infection.Prevention.Guideline.

Writers.Workgroup,”.from.the.Nov..17,.

2005.meeting.of.group.representatives.

who.have.published.North.American.

guidelines.for.antibiotic.prophylaxis..

One.way.to.encourage.their.use.is.to.

post.antibiotic.guidelines.prominently.

in.the.operating.room.and.surgeons.

lounges..Pocket.cards.can.be.used.for.

physicians.for.selection.references..One.

example.can.be.found.at.http://www.

medqic.org/dcs/ContentServer?cid=1168

867323122&pagename

Other.key.points:.Involve.pharmacy.

in.the.development.of.the.formulary.to.

include.the.recommended.prophylactic.

antibiotics.and.in.the.correct.selection.

and.delivery.of.antibiotics..Consider.

substitution.policies.for.appropriate.an-

tibiotic.selection.by.surgery.type..Pro-

vide.regular.and.continuous.feedback.

to.surgeons.on.prophylaxis.selection.

compliance.and.infection.rate.data.

References:Bratzler, D.W., & Houck, P.M.

(2005). Surgical Infection Preven-

tion Guideline Writers Workgroup,

Antimicrobial prophylaxis for

surgery: an advisory statement from

the National Surgical Infection Pre-

vention Project. American Journal

of Surgery, 189, 395-404.

Prophylactic Antibiotic Regimen Selec-

tion for Surgery. (2006). CMS/

SDPS Memorandum. Retrieved

June 19, 2007 at http://www.cms.

hhs.gov/HospitalQualityInits/Down-

loads/HospitalSDPSMemoRandum.

pdf

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

Two.important.points.need.to.be.made:.

Continuation.of.surgical.prophylaxis.

past.the.24.hour.time.frame.has.not.

been.shown.to.improve.surgical.site.

infection.rates.and.increases.the.cost.of.

care.unnecessarily..The.prolonged.use.

of.prophylactic.antibiotics.is.associated.

with.emergence.of.resistant.organisms..

To.support.the.implementation.of.the.

appropriate.processes,.use.pre-printed.

perioperative.orders.that.include.dis-

continuation.of.prophylactic.antibiotics.

within.24.hours.of.surgery.end.time..

Also,.include.the.surgery.end.time.on.

surgery.documentation.forms.so.that.

timeframes.can.be.tracked..Consider.

limiting.post-op.antibiotics.to.one.

or.two.doses..Address.the.policy.for.

prophylactic.antibiotics.that.includes.

the.first.dose.perioperatively.and.ends.

24.hours.after.surgery.end.time..CMS.

has.a.sample.policy.available..Some.

organizations.have.developed.a.policy.

and/or.assigned.responsibility.for.au-

tomatic.prophylactic.antibiotic.discon-

tinuation.to.the.pharmacy..Another.

way.to.achieve.compliance.is.to.require.

surgeons.to.document.a.reason.for.con-

tinuing.an.antibiotic.beyond.24.hours.

(48.hours.for.cardiac.surgery),.such.as.

treatment.of.an.infection.

Provide.education.to.nursing.and.

pharmacy.on.duration.of.prophylactic.

antibiotic.doses,.as.they.may.not.be.

aware..Include.an.emphasis.on.the.

surgery.end.time.during.PACU.handoff.

CAHQJournal,Quarter3,2007 1�

see SCIP, page 22

communication.to.the.nursing.post.

op.unit..Focus.on.when.the.antibiot-

ics.should.be.discontinued.(24.hours.

hence).rather.than.the.number.of.doses.

to.be.given.

References: Bozorgzadeh, A, Pizzi, W.F., Barie,

P.S., Khaneja, S.C., LaMaute,

H.R., Mandava, N., et al. (1999).

The duration of antibiotic admin-

istration in penetrating abdominal

trauma. American Journal of

Surgery, 177(2)125-31.

Cardiac surgery antibiotic prophylaxis.

(2007). Society of Thoracic Surgeons,

retrieved June 19, 2007 at http://

www.sts.org/sections/aboutthesociety/

practiceguidelines/antibiotic

SCIP INF 4: Cardiac surgery patients with controlled 6 a.m. postoperative serum glucose.

The.degree.of.hyperglycemia.in.the.

postoperative.period.correlates.with.the.

rate.of.surgical.site.infections.in.patients.

undergoing.major.cardiac.surgery..

Patients.with.a.blood.sugar.of.greater.

than.300.mg/dl.during.or.within.48.

hours.of.surgery.had.more.than.3.times.

the.likelihood.of.a.wound.infection.as.

compared.to.those.patients.whose.blood.

sugar.was.less.than.200.mg%.*

Hints.on.avoiding.this.problem.

include:.Use.a.multidisciplinary.ap-

proach.to.address.intra-operative.and.

postoperative.glucose.control..Assign.

responsibility.and.accountability.for.

blood.glucose.monitoring.and.control..

Develop.a.standardized.protocol.for.

intraoperative.and.postoperative.glucose.

monitoring..Identify.hyperglycemia.

prior.to.surgery;.include.glucose.testing.

and.HbA1c.in.pre-op.evaluation.of.

cardiac.surgery.patients..Initiate.glucose.

testing.for.selected.patients,.screening.

for.undiagnosed.hyperglycemia.and.

diabetes..Use.a.standardized.treatment.

protocol.to.maintain.serum.glucose.

tightly.controlled.in.patients.undergo-

ing.cardiac.surgery.(the.CMS.measure)..

A.blood.glucose.greater.than.110mg/

dl.is.associated.with.increased.compli-

cations..Glucose.monitoring.is.a.chang-

ing.field.and.we.should.all.be.diligent.in.

staying.current.with.the.literature..

References: Furnary, A.P., Zerr, K.J., Grunkemei-

er, G.L. & Starr, A. (1999). Con-

tinuous intravenous insulin infusion

reduces the incidence of deep sternal

wound infection in diabetic patients

after cardiac surgical procedures.

Annuals of Thoracic Surgery, 67,

352-360.

* Latham, R., Lancaster, A.D., Cov-

ington, J.F., Pirolo, J.S., & Thomas,

Jr, C.S. (2001). The Association of

Diabetes and Glucose Control With

Surgical-Site Infections Among

Cardiothoracic Surgery Patients.

Infection Control Hospital Epidemi-

ology, 22, 607-612.

McAlister, F.A., Man, J., Bistritz, L.,

Amad, H., & Tandon, H. (2003).

Diabetes and Coronary Artery

Bypass Surgery. Diabetes care, 26,

1518-1524.

Van den Berghe, G. (2001). Intensive

insulin therapy in critically ill

patients. New England Journal of

Medicine, 345, 1359-67.

Van den Berghe, G., Wilmer, A., Her-

mans, G., Meerssman, W.,Wouters,

P.J., et al. (2006). Intensive insulin

therapy in the medical ICU. New

England Journal of Medicine, 354,

449-461.

SCIP INF 6: Surgery patients with appropriate hair removal.

Removal.of.surgical.site.hair.is.not.con-

sidered.effective.as.a.preventive.measure.

for.surgical.site.infection..The.decision.

to.remove.hair.includes.consideration.

of.potential.access.to.the.surgical.site.

and.the.field.of.view..Hair.removal.with.

clippers.is.found.to.be.safer.and.results.

in.a.lower.incidence.of.surgical.site.in-

fections.than.shaving.with.a.razor.blade.

regardless.of.the.timing.of.hair.removal..

A.number.of.steps.are.recommended.to.

assure.appropriate.hair.removal.is.done:

Remove.all.razors.from.operat-

ing.room.suites.and.surrounding.

patient.support.areas.and.eliminate.

razors.from.surgical.prep.kits.

Consider.removing.razors.entirely.

from.the.hospital.via.materials.

management.

Institute.a.policy.to.avoid.shaving.

surgical.sites,.and.if.hair.removal.

is.necessary,.perform.hair.removal.

with.clippers.only.before.surgery.

Revise.documentation.forms.to.

include.selection.of.hair.removal.

technique:.no.hair.removal,.clip-

per,.or.depilatory,.remove.shaving.

option.

Educate.surgeons,.invasive.pro-

cedure.operators,.and.staff.on.ap-

propriate.hair.removal.techniques:.

clipper.or.depilatory.

Educate.patients.to.not.shave.the.

surgical.site.before.surgery.and.add.

•

•

•

•

•

•

�� CAHQJournal,Quarter3,2007

information.to.preoperative.educa-

tional.materials.

Utilize.posters.highlighting.“No.

Shave.Zone”.throughout.the.

hospital.

References:Joanna Briggs Institute. (2003).

The Impact of Preoperative Hair

Removal on Surgical Site Infection,

Best Practice, 7(2), Retrieved online

June 10, 2007 at http://www.joan-

nabriggs.edu.au/pubs/best_practice.

php?pageNum_rsBestPractice=1&to

talRows_rsBestPractice=51

Small, S.P. (1996). Preoperative hair

•

removal: A case report with implica-

tions for nursing. Journal of Clinical

Nursing, 5, 79-84.

Tanner, J., Woodlings, D., & Mon-

caster, K. (2006). Preoperative hair

to reduce surgical site infection. The

Cochrane Database of Systematic

Reviews, 2.

SCIP INF 7: Colorectal surgery patients with immediate postoperative normothermia.

The.overall.incidence.of.surgical.wound.

infection.is.between.1-3%.except.for.

post.colon.surgery,.where.the.incidence.

has.continued.to.be.10%.for.many.

years..Keeping.the.patient.warm.during.

surgery.significantly.reduces.the.risk.of.

a.surgical.site.infection..Mild.periopera-

tive.hypothermia,.common.during.sur-

gery,.promotes.surgical.site.infections.

by.triggering.vasoconstriction,.which.

decreases.subcutaneous.oxygen.tension..

Reduced.levels.of.oxygen.in.tissue.

impair.oxidative.killing.by.neutrophils.

and.decrease.the.strength.of.the.healing.

wound.by.reducing.the.deposition.of.

collagen..Hypothermia.also.directly.

impairs.immune.function..Patients.

who.are.only.1.9.degrees.C.hypother-

mic.were.3.times.as.likely.to.develop.

surgical.wound.infections.as.those.kept.

normothermic.(Kurtz,.et.al.).

SCIPcontinued from page 13

see Communication page 39

with.interesting.visuals,.videos,.

or.models..Use.visual.aids.such.

as.posters.and.learning.models.to.

demonstrate.concepts,.procedures,.

or.conditions.22.Visual.aids.such.as.

brief.video.segments,.photographs,.

fotonovelas.(booklets.with.photos.

that.tell.a.story),.illustrations,.or.

comic.books.can.help.to.illustrate.

a.medical.explanation.

b).Use.simple.education.brochures..

Choose.multilingual.educa-

tional.materials.that.feature.plain.

language,.a.large.typeface,.and.il-

lustrations.to.support.the.message..

Material.design.should.be.easy-to-

read.and.visually.appealing.21,.22,.

24.Educational.brochure.content.

should.be.limited.to.a.specific.

objective.

c).Avoid.literal.translations..Use.

bilingual.flyers.and.brochures.that.

have.been.pre-tested.for.language.

and.cultural.acceptability.with.

your.target.audience..When.devel-

oping.your.own.materials,.involve.

patients.in.the.review.and.pre-test.

for.clarity,.comprehension,.appeal,.

affect,.and.cultural.relevance..

When.translating.materials,.use.a.

universal.broadcast.Spanish.and.

cultural.adaptations,.avoiding.

word-by-word.translations.25

IV. Support Self-Management Many.Hispanics.have.more.difficulties.

with.goal.setting.and.action.planning,.

two.critical.elements.of.chronic.disease.

self-management..They.do,.however,.en-

joy.the.benefit.of.strong.family.support,.

which.has.been.shown.to.play.a.central.

role.in.effective.self-management.

activities.5.The.following.techniques.can.

enhance.the.physician’s.support.for.his.

or.her.Hispanic.patients.in.these.areas..

Table.2.(page.41).summarizes.strategies.

presented.in.this.section.

a).Check.patient’s.understanding.

using.“teach.back”.to.ensure.com-

prehension..The.physician.encoun-

ter.is.a.valuable.opportunity.to.

both.educate.patients.and.ensure.

their.comprehension.of.treatment..

Involve.patients.in.an.interactive.

way.by.asking.them.to.show,.say,.

or.do.something.to.demonstrate.

understanding.of.your.instruc-

tions.12.One.helpful.technique.is.

to.ask.the.patient.to.summarize.

(“teach.back”).the.actions.to.be.

taken.or.care.instructions.you.give.

to.them.23

b).Focus.on.patient.goal.setting.and.

action.plans..Educate.patients.to.

set.goals.for.managing.chronic.

disease,.and.support.them.in.the.

creation.of.a.treatment.plan.to.

CAHQJournal,Quarter3,2007 ��

It.is.recommended.that.the.organi-

zation.standardize.methods.of.tem-

perature.measurement.to.centigrade.

using.core.temperature.measures..In.

200.colorectal.surgery.patients,.the.

normothermic.patients.(36.6.+-.0.5).

had.an.incidence.of.infection.of.6%.

with.LOS.of.12.1.+-.4.4.days.compared.

with.hypothermic.patients.(34.7.+_.0.6).

with.an.infection.rate.of.19%.with.a.

LOS.of.14.7+_.6.5.days.–.a.13%.reduc-

tion.in.infection.rate.(Melling,.Lancet.

2001;358:876).

Thermal.preoperative.management.

should.include.identification.of.risk.

factors.for.hypothermia.including.

extremes.of.age,.major.surgery.in.adults.

greater.than.1.hour,.use.of.general.

or.regional.anesthesia,.preexisting.

conditions.such.as.peripheral.vascular.

disease,.endocrine.disease,.pregnancy,.

burns,.or.open.wounds..If.the.patient.is.

normothermic.preoperatively,.institute.

passive.insulation.warming.measures.

(warm.blankets,.socks,.head.covering,.

and.limit.skin.exposure)..If.patient.is.

hypothermic.preoperatively,.institute.

active.warming.measures.(forced.air.

warming.system,.passive.insulation)..

Limit.body.exposure.to.prevent.heat.

loss.in.patients.prior.to.the.operative.

procedure.

Intraoperative.management.should.

include.passive.insulation.measures,.

active.forced.air.warming.system,.

warm.intravenous.fluids.and.irrig-

ants..It.is.expected.that.the.patient’s.

core.temperature.be.maintained.at.36.

C.or.above.during.the.intraoperative.

phase.unless.hypothermia.is.indicated..

Another.important.key.is.to.standardize.

the.operative.suite.ambient.tempera-

ture,.and/or.assure.engineering.controls.

to.allow.surgical.staff.to.control.room.

temperature.and.increase.the.ambi-

ent.room.temperature.in.the.operating.

room.along.with.the.humidity..This.

may.require.cooling.vests.for.use.by.the.

surgeons.and.other.personnel..

In.addition,.it.is.important.to.educate.

staff.on.the.relationship.between.hypo-

thermia.and.increased.risk.of.surgical.

infections..Work.closely.with.anesthesi-

ologists.to.designate.responsibility.and.

accountability.for.thermoregulation,.

including.interval.measurement.and.

documentation.of.intra-.and.postopera-

tive.temperatures.

References:Dellinger, E. P. (2006). Roles of

temperature and oxygenation n

prevention of surgical site infection.

Surgical Infection, 7,Supplement 3,

s27-32.

Flores-Maldonado, A., Medina-Esobe-

do, C.E., Rios-Rodriguez, H.M., &

Fernandez-Dominguez, R. (2001).

Mild hypothermia and the risk of

wound infection, Archives of Medi-

cal Research, 32(3), 227-31.

Kurz, A., Sessler, D.I., & Lenhardt,R.

(1996). Perioperative Normothermia

to Reduce the Incidence of Surgical-

Wound Infection and Shorten Hos-

pitalization. New England Journal

of Medicine, 334, 1209-1216.

SCIP CARD 1: Non-cardiac vascular surgery patients with evidence of coronary artery disease who received beta-blockers during the perioperative period.

This.measure.is.under.consideration.and.

study.by.CMS,.but.is.not.yet.reported.

on.Medicare.patients.

SCIP CARD 2: Surgery patients on a beta-blocker prior to arrival that received a beta-blocker during the perioperative period.

Perioperative.beta.blockers.offer.signifi-

cant.protection.against.cardiac.mortal-

ity.in.patients.undergoing.non-cardiac.

surgery..For.every.100.patients.treated.

with.beta.blockers:.13.will.be.prevented.

from.having.intra.or.postoperative.

ischemia,.4.will.not.have.an.MI,.and.3.

deaths.will.be.prevented..As.preventa-

tive.measures,.it.is.recommended.that.

the.organization.develop.a.policy.for.

universal.cardiac.risk.assessment.of.all.

patients.during.preoperative.assess-

ment.and.provide.alert.when.patient.is.

eligible.for.beta.blocker.administration..

Also,.develop.standardized.orders.to.

incorporate.beta.blocker.administra-

tion/continuation.for.eligible.patients..

In.conjunction,.provide.education.to.

staff.on.adverse.cardiovascular.com-

plications.for.surgical.patients..Try.to.

engage.a.physician.champion.to.address.

beta.blocker.usage.with.surgeons.and.

provide.regular.feedback.to.surgeons.on.

beta.blocker.usage.

The.Agency.for.Healthcare.Research.

and.Quality.(AHRQ).identified.11.of.

79.safety.practices.reviewed.as.hav-

ing.the.strongest.evidence.supporting.

widespread.implementation.in.2001.

and.are.listed.in.descending.order.with.

the.most.highly.rated.listed.first..The.

number.two.of.these.11.practices.is:.use.

of.perioperative.beta-blockers.in.appro-

�� CAHQJournal,Quarter3,2007

priate.patients.to.prevent.perioperative.

morbidity.and.mortality.

References:Stevens, R.D., Burri, H., & Tra-

mer, M.R. (2003). Pharmacologic

myocardial protection in patients

undergoing non-cardiac surgery:

A quantitative systematic review.

Anesthesia Analgesia, 97, 623-633.

The ACC/AHA Guideline for use of perioperative beta blockers:

Class.I.Recommendation:.Beta.block-

ers.required.in.recent.past.to.control.

symptoms.of.angina,.symptomatic.ar-

rhythmias,.or.hypertension.and.patients.

at.high.cardiac.risk.due.to.the.finding.

of.ischemia.on.preoperative.testing.who.

are.undergoing.vascular.surgery.

Class.IIa.Recommendation:.Patients.

with.known.coronary.artery.disease.or.

major.risk.factors.for.coronary.disease.

SCIP CARD 3: Intra- or postoperative acute myocardial infarction (AMI) diagnosed during index hospitalization and within 30 days of surgery (outcome).

This.indicator.is.still.under.consider-

ation.by.CMS.for.reporting.on.Medi-

care.patients.

SCIP VTE 1: Surgery patients with recommended venous thromboembolism prophylaxis ordered.

Recent.research.has.shown.that.the.

incidence.of.deep.vein.thrombosis.and.

pulmonary.embolism.(both.are.referred.

to.as.VTE.–.venous.thromboembolism).

are.more.than.100.times.greater.among.

hospitalized.patients.than.those.in.the.

community..Pulmonary.embolism.

is.responsible.for.10%.of.all.hospital.

deaths,.and.is.largely.preventable..This.

condition.remains.the.most.common.

preventable.cause.of.hospital.deaths..

Current.estimates.suggest.that.less.than.

50.percent.of.patients.diagnosed.and.

hospitalized.with.DVT.had.received.

prophylaxis.

In.2003.the.National.Quality.Foun-

dation.(NQF).endorsed.Safe.Practice.

17:.Evaluate.each.patient.upon.admis-

sion,.and.regularly.thereafter,.for.the.

risk.of.developing.DVT/VTE..Utilize.

clinically.appropriate.methods.to.

prevent.DVT/VTE.and.Safe.Practice.

18:.Utilize.dedicated.anti-thrombotic.

(anticoagulation).services.that.facilitate.

coordinated.care.management..This.

project.builds.on.Safe.Practices.17/18.

by.developing.and.endorsing.consensus.

standards.in.DVT/VTE.prevention.and.

care.

The.Agency.for.Healthcare.Research.

and.Quality.(AHRQ).identified.11.of.

79.safety.practices.reviewed.as.hav-

ing.the.strongest.evidence.supporting.

widespread.implementation.in.2001.

and.are.listed.in.descending.order.with.

the.most.highly.rated.listed.first..The.

number.one.of.these.11.practices.is:.ap-

propriate.use.of.prophylaxis.to.prevent.

venous.thromboembolism.in.patients.

at.risk..

The.American.College.of.Chest.

Physicians.listed.15.risk.factors.for.VTE.

in.Chest.2004;.major.surgery,.includ-

ing.abdomen.and.pelvis.was.included..

All.patients.undergoing.major.surgery.

are.at.risk.for.VTE..Therefore,.it.is.

recommended.that.physicians.include.

VTE.risk.assessment.with.the.pre-

op.order.set.to.be.completed.during.

pre-op.evaluation.or.complete.VTE.

assessment.during.preoperative.anes-

thesia.evaluation..Include.pharmacy.in.

VTE.prophylaxis.planning.so.that.the.

organization.can.develop.a.standard.

protocol.or.standing.order.set.to.ad-

minister.VTE.prophylaxis.based.upon.

identified.patient.risk.factors..Imple-

ment.a.DVT/PE.awareness.campaign.

and.education.for.clinical.staff..Provide.

regular.feedback.to.all.surgeons.on.

VTE.prophylaxis.usage.monthly.

References:Colwell, C.W., Kwong, L,M, Tur-

pie, A., & Davidson, B. (2006).

Flexibility in administration of

fondaparinux for prevention of

symptomatic venous thromboembo-

lism in orthopedic surgery. Journal

of Arthroplasty, 21(1), 36-45.

Geerts, W. H., Pineo, G.F., Heit,

J.A., Bergqvist, D., Lassen,M.R., et

al.(2004).

Prevention of Venous Thrombo-

embolism: The Seventh ACCP

Conference on Antithrombotic and

Thrombolytic Therapy. Chest 126,

338S-400S.

Making Health Care Safer: A Critical

Analysis of Patient Safety Practices.

(2001). AHRQ Publication No.

01-E057.

Martino, M.A., Borges, E., William-

son, E., Siegfried, S., Cantor, A.B.,

et al. (2006). Pulmonary embolism

after major abdominal surgery in

gynecologic oncology. Obstetrics &

Gynecology, 107(3), 666-671.

Venous Thromboembolism Prophylaxis.

CAHQJournal,Quarter3,2007 ��

(2006). National Guideline Clear-

inghouse. Retrieved June 10, 2007 at

http://www.guideline.gov/summary/

summary.aspx?doc_id=9625

SCIP VTE 2: Surgery patients who received appropriate venous thromboembolism prophylaxis within 24 hours prior to surgery to 24 hours after surgery.

For.evidence.regarding.utilization.and.

for.success.strategies,.refer.to.SCIP.

VTE.1..

References:Morris, R.J., & Woodcock, J.P. (2004).

Evidence based compression preven-

tion of stasis and deep vein thrombo-

sis. Annals of surgery, 239, 162-171.

Snow, V., Qaseem, A., Barry, P.,

Hornbake, E. R., Rodnick, J.E., et

al. (2007). Management of Venous

Thromboembolism: A Clinical Prac-

tice Guideline from the American

College of Physicians and the Ameri-

can Academy of Family Physicians.

Annals of Internal Medicine, 146,

204-210.

Additional clinical focus items not specific to each measure:

Optimize.Oxygen.Tension.–.Adequate.

oxygen.level.is.necessary.for.optimal.

bactericidal.effect.at.the.tissue.level.

along.with.normothermia..A.study.

in.2000.by.Grief.et.al.showed.“that.

supplemental.oxygen.in.the.periopera-

tive.period.reduced.the.risk.of.SSI,.pre-

sumably.by.promoting.the.bactericidal.

effect.of.derived.reactive.oxygen.species.

in.the.surgical.wound.”

Oxidative.killing.is.the.primary.

defense.against.surgical.pathogens..

Oxygen.is.transformed.into.superoxide.

radical..Thermoregulatory.vasoconstric-

tion.decreases.subcutaneous.oxygen.

tension,.and.local.warming.increases.

subcutaneous.oxygen.tension..(Akca,.

Ozan,.Assistant.Professor,.Depart-

ment.of.Anesthesiology,.University.of.

Louisville)

Supplemental.80%.FIO2,.during.

and.for.six.hours.after.major.colorectal.

surgery.reduced.postoperative.wound.

infection.risk.by.a.factor.of.2..Supple-

mental.oxygen.adds.little.risk.to.the.

patient,.has.little.associated.cost,.and.

should.be.considered.part.of.ongoing.

quality.improvement.related.to.surgical.

care.

Obstacles.to.oxygen.delivery.include.

hypoxemia.PO2.(<.40mm.Hg).that.is.

due.to.lung.disease,.drug-induces.or.

pain-induced,.decreased.perfusion.due.

to.effects.of.the.sympathetic.nervous.

system.due.to.pain,.cold,.dehydra-

tion.and.fear,.vasoactive.drugs,.etc..

Thermoregulation.will.improve.wound.

oxygen.tension..Thus.efforts.to.promote.

normothermia.need.to.be.accompanied.

by.supplemental.oxygen.(80%).to.maxi-

mize.the.effects.of.both.on.preventing.

surgical.site.infections..There.is.no.

evidence.that.80%.perioperative.oxygen.

causes.atelectasis.or.any,.decrement.in.

pulmonary.function..It.does.activate.

alveolar.immune.defenses.and.reduces.

the.incidence.of.postoperative.nausea.

and.vomiting.

Develop.with.Anesthesia.and.

administer.a.protocol.for.supplemen-

tal.oxygen,.defined.as.intra-operative.

FIO2.>.80%.in.the.intubated.patient.

or.a.non-rebreathing.face.mask.at.>12.

l/min.fresh.gas.flow.in.the.non-intu-

bated.patient..Provide.copies.of.clinical.

research.to.the.Anesthesia.Department.

and.OR.staff.to.facilitate.acceptance.

and.understanding..Revise.the.Anes-

thesia.Record.to.include.an.area.for.

documentation.of.FIO2.during.surgical.

procedures..Provide.profiled.anesthesia.

data.including.post.operative.surgical.

wound.infection.rates.

References:

Denault, A., Fréchette, D., & Skrobik,

Y. (2001). Best evidence in anesthetic

practice – supplemental oxygen

reduces the incidence of surgical

wound infection. Canadian Journal

of Anesthesia, 48,844-846.

Greif, R., Akca, O., Horn, E.P., Kurz,

A., & Sessler, D.I. (2000). Supple-

mental perioperative oxygen to re-

duce the incidence of surgical wound

infection. New England Journal of

Medicine, 342,161-7.

Additional ReferencesBelda, F.H., Aguilera, L., García de la

Asunción, J., Alberti, J., Vincente,

R. (2005). Supplemental periopera-

tive oxygen and the risk of surgical

wound infection: a randomized

controlled trial. Journal of the

American Medical Association, 294,

2035-42.

Bratzler, D. W., & Houk, P.M.

(2004). Antimicrobial Prophylaxis

for Surgery: An Advisory Statement

from the National Surgical Infection

Prevention Project. Clinical Infec-

tious Disease, 38, 1706-15.

✦For CEU post test see page 51