WHAT IS SCIP UNSCRAMBLING THE SURGICAL CARE IMPROVEMENT

WHAT IS SCIP? UNSCRAMBLING THE SURGICAL CARE IMPROVEMENT PROJECT MEASURES PART 1 PREVENTING SURGICAL INFECTIONS Developed by Kathy Wonderly RN, BSPA, CPHQ Performance Improvement Coordinator Developed: October 2009 Most recently updated: September 2013

OBJECTIVES To recognize the importance of the timing of preoperative prophylactic antibiotic administration. To identify the need to discontinue the antibiotics within 24 hours of end of surgery. (48 for cardiac surgery) To demonstrate understanding of the need to remove Foley catheters by post-op day 2. To identify the risks of hypothermia during surgery. To identify the increased risks for CABG patients who have hyperglycemia postoperatively.

THE FOCUS OF SCIP The SCIP measures have been developed to reduce surgical complications. They focus on two areas, preventing surgical site infections and reducing the chance of developing either a deep vein thrombosis (DVT) or a pulmonary embolism (PE) along with 1 cardiac measure. Note: changes for January through September 2014.

WHAT TYPE OF SURGERIES ARE INCLUDED IN THE SCIP MEASURES FOR INPATIENTS This is a very general list. The procedures are identified by specific ICD-9 -CM code. • Cardiac surgery including CABG • Hip arthroplasty procedures • Knee arthroplasty • Colon surgery • Hysterectomy • Vascular surgery • Other major surgeries that include brain procedures, lung procedures, laparoscopic assisted approaches or totally laparoscopic procedures for any of the above categories

SCIP PREVENTING SURGICAL INFECTIONS In this section there are 7 measures. The first three deal with prophylactic use of antibiotics. It is the surgeons responsibility to order the appropriate antibiotic. Anesthesia, Nursing, and Pharmacy must be sure the time for start and discontinuation are correct.

SCIP Preventing Surgical Infections PROPHYLACTIC ANTIBIOTIC WITHIN 1 HOUR OF SURGICAL INCISION This measure requires that the prophylactic antibiotic be received within one hour prior to surgical incision. This is measured by checking the earliest documented start time for the ordered antibiotic and comparing it to the Surgical incision date and time for the procedure. To meet the measure the time cannot exceed 60 minutes.

SCIP Preventing Surgical Infections Prophylactic Antibiotic within 1 Hour of Surgical Incision There are two exception to this rule. Vancomycin or a fluoroquinolone may be started 2 hours prior to surgery as many patients experience side effects it the medication is administered too fast. The approved prep for colon surgery includes some oral antibiotics which are taken the evening before surgery.

SCIP-Preventing Surgical Infections APPROPRIATE SELECTION OF ANTIBIOTIC • • • This measure requires the surgeon to order an acceptable antibiotic for the procedure he/she is doing. In general, the approved antibiotics are cephalosporins with vancomycin if the patient is allergic to the cephalosporins. The oral prep for colon surgery is neomycin or erythromycin + metronidazole (Flagyl) There are some cases in which clindamycin can be used for patients with allergies to cephalosporins. The quinolones such as Cipro are also used for specific procedures. (See the following slides for antibiotic recommendations)

Prophylactic Antibiotic Regimen Selection for Surgical Procedure PROCEDURE CATEGORY ANTIBIOTICS CABG, Other Cardiac or Vascular APPROVED Cefazolin, Cefuroxime OR Vancomycin** * If β-lactam allergy: Vancomycin OR Clindamycin

Prophylactic Antibiotic Regimen Selection for Surgical Procedure Category Hip/Knee Arthroplasty Approved antibiotics Cefazolin or Cefuroxime OR Vancomycin ** If β-lactam allergy: Vancomycin OR Clindamycin

Prophylactic Antibiotic Regimen Selection for Surgical Procedure category Colon SSI ca generation clep Approved antibiotics Cefotetan, Cefoxitin, Ampicillin/Sulbactam , or Ertapenem † A single dose of ertapenem (Invanz) is recommended for colon procedures. OR Cefazolin or Cefuroxime + Metronidazole If β-lactam allergy: Clindamycin + Aminoglycoside OR Ceftriazone + Metronidazole ( for hospitals having SSI’s caused by gram – organisms resistant to 1 st or 2 nd cephalosporins. OR Clindamycin + Quinolone , or Clindamycin + Aztreonam OR Metronidazole + Aminoglycoside OR Metronidazole + Quinolone

Prophylactic Antibiotic Regimen Selection for Surgical Procedure category Hysterectomy OR Approved antibiotic Cefotetan, Cefazolin, Cefoxitin, Cefuroxime, OR Ampicillin/Sulbactam If β-lactam allergy: Clindamycin + Aminoglycoside Or Clindamycin + Quinolone or Clindamycin + Aztreonam OR Metronidazole + Aminoglycoside or Metronidazole + Quinolone OR Vancomycin + Aminoglycoside or Vancomycin + Azetreonam or Vancomycin + Quinolone

HYSTERECTOMY WITH ANOTHER PROCEDURE INVOLVING COLON SURGERY Approved antibiotics: Cefotetan, Cefazolin, Cefoxitin, Cefuroxime, OR Ampicillin/Sulbactam OR Ertapenem If β-lactam allergy: Clindamycin + Aminoglycoside OR Clindamycin + Quinolone OR Clindamycin + Aztreonam OR Metronidazole + Aminoglycoside OR Metronidazole + Quinolone

Special Considerations *For cardiac, orthopedic, and vascular surgery, if the patient is allergic to β-lactam antibiotics, Vancomycin or Clindamycin are acceptable substitutes. **Vancomycin is acceptable with a physician/APN/PA/ pharmacist documented justification for its use Reference: Specifications Manual for National Hospital Inpatient Quality Measures Discharges 01 -01 -14 (1 Q 14) through 9 -30 -14(3 Q 14)

EXCLUDED PATIENTS Patients who had other procedures requiring general or spinal anesthesia that occurred within 3 days ( 4 days for cardiac surgery) prior to or after the procedure (during a separate surgical episode but during the same hospital stay) are excluded from the appropriate antibiotic prophylaxis measure. Patients who were receiving antibiotics more than 24 hours before surgery.

SCIP- PREVENTING SURGICAL INFECTIONS • • Research shows that the success of the prophylactic antibiotics lies with maintaining a drug blood level during surgery. If the procedure is long (over 4 hours) a second dose may need to be given.

SCIP-PREVENTING SURGICAL INFECTIONS DISCONTINUE THE ANTIBIOTIC WITHIN 24 HOURS • • • The prophylactic antibiotic must be discontinued within 24 hours after Anesthesia end time. The 24 hour clock starts from the anesthesia end time recorded in the medical record. If your facility uses standardized medication administration times you will have to be sure that the antibiotics that are ordered q 6 x 4 doses or q 8 hours x 3 doses do not exceed the 24 hour limit.

SCIP- PREVENTING SURGICAL INFECTIONS DISCONTINUE THE ANTIBIOTIC WITHIN 24 HOURS There is no evidence that administering antibiotics for more that a few hours after the incision is closed offers additional benefit. Based on this many surgeons are not ordering any prophylactic antibiotics post –op or order just one dose to be given before the patient leaves PACU.

SCIP- PREVENTING SURGICAL INFECTIONS DISCONTINUE THE ANTIBIOTIC WITHIN 24 HOURS There is one exception to this indicator. The antibiotics need to be discontinued within 48 hours for cardiac surgery.

REASONS TO EXTEND POST-OP ANTIBIOTICS There are some approved reasons for extending the antibiotics beyond the 24 hour (48 hr for cardiac surgery) timeframe. These are: 1. Erythromycin administered for the purpose of increasing gastric mobility 2. For treating hepatic encephalopathy 3. Prophylaxis for Pneumocystis pneumonia (PCP) 4. If the patient has an infection 5. If the patient has a current malignancy of the lower extremity involving the same extremity as the joint revision surgery. 6. If a culture of the operative site is taken after incision but prior to the administration of prophylactic antibiotic for a joint revision surgery.

REASONS TO EXTEND POST-OP ANTIBIOTICS The practitioner must document the very specific reason for the antibiotic extension. This must be either written or dictated after the incision but within 2 days (3 days for cardiac surgery) after the anesthesia end time.

SCIP- PREVENTING SURGICAL INFECTIONS GLUCOSE CONTROL IN CARDIAC SURGERY PATIENTS This measure is for cardiac surgery only. It requires that the patient has a controlled (<180 mg/d. L) blood glucose at 18 to 42 hours after anesthesia end time.

SCIP- PREVENTING SURGICAL INFECTIONS GLUCOSE CONTROL IN CARDIAC SURGERY PATIENTS Evidence based medicine has shown that both diabetic and non-diabetic patients who have hyperglycemia in the immediate post-op phase have an increased chance of developing a deep wound infection or acute renal failure, requiring additional blood transfusions and post-operative mortality.

PREVENTING SURGICAL INFECTIONS APPROPRIATE HAIR REMOVAL • • • This measure is no longer required by CMS but remains a Joint Commission measure. driven. Surgery patients should have appropriate hair removal. This includes no hair removal or the use of clippers or depilatory. The key to meeting this measure is clear documentation which must include the device used. Many times the word “shaved” is used meaning with clippers and is interpreted as using a razor.

SCIP- PREVENTING SURGICAL INFECTIONS URINARY CATHETER REMOVAL This measure requires that the patient have their urinary catheter removed by post-op day two. Exceptions to this measure are patients who had urological, gynecological or perineal procedures performed or patients who had a urinary diversion or urethral catheter in place or were being intermittently catheterized preoperatively or prior to hospital arrival.

SCIP- PREVENTING SURGICAL INFECTIONS URINARY CATHETER REMOVAL • This measure is related to the well established infection control data that shows the risk of catheter related urinary tract infection (UTI) is directly related to the length of time a catheter remains in place.

SUPPORTING STUDIES • Some studies show that 24% of patients will develop a symptomatic UTI and 3. 6% will develop bacteremia when a catheter remains in place from 2 -10 days. • Other studies demonstrated that surgical patients who have a urinary catheter in place for more than 2 days were twice as likely to develop a UTI prior to discharge.

SCIP- PREVENTING SURGICAL INFECTIONS URINARY CATHETER REMOVAL • A 2006 study reports that in Orthopedic patients it was found that limiting the use and duration of indwelling catheters resulted in a 60% reduction in UTI’s.

SCIP- PREVENTING SURGICAL INFECTIONS URINARY CATHETER REMOVAL This measure is both practitioner and nursing driven and requires clear documentation. The date and time the catheter is removed must be documented. If the catheter is not removed, at the time of the decision(before the end of p. o. day 2) the practitioner must document the specific reason for continued urinary catheterization.

GENERAL REMINDER • • Any time there is duplicate documentation in the medical record there is a risk for error and duplication wastes time for many care providers. It is important that the team members coordinate their documentation so that there are not multiple times for the same intervention. CMS has a standing rule that the chart abstractor must use the earliest time for the start measures and the latest documented time for the stop measures.

SCIPMAINTAINING A NORMAL TEMPERATURE DURING SURGERY Hypothermia has always been a concern for patients undergoing general surgery. Research shows that there is an increased risk for impaired wound healing, adverse cardiac events as well as altered drug metabolism and coagulation responses. These complications have led to unanticipated admissions to ICU, mechanical ventilation and the increased need for blood product administration.

SCIP- MAINTAINING A NORMAL TEMPERATURE DURING SURGERY Nursing can take the lead with this measure by being sure that their patients undergoing general anesthesia lasting more than 60 minutes have active warming (forced air warming or warm water garment) during the procedure to maintain a body temperature of greater than 96. 8 F/36 C. If some procedures hypothermia is intentially maintained. In these cases intentional hypothermia must be documented in the medical record.

SCIP- PREVENTING SURGICAL INFECTIONS MAINTAINING A NORMAL TEMPERATURE DURING SURGERY The perioperative time is from 30 minutes immediately prior to or 15 minutes immediately following the anesthesia end time. Is not only necessary to monitor the patient’s temperature during the perioperative period. It is also necessary to document the date, time and the temperature in the medical record

THE WRAP-UP FOR PART 1 • • The SCIP measures are complicated and require good team work and communication between care givers. Many facilities and surgeons have preestablished orders for all of their patients that include the SCIP measures we reviewed in this session.

TEST YOUR KNOWLEDGE 1. Any antibiotic is acceptable to be used for surgical prophylaxis. A. True B. False

TEST YOUR KNOWLEDGE 2. The 24 hour clock for discontinuing prophylactic antibiotics starts with the_________ end time. A. Incision B. Anesthesia C. Room charge

TEST YOUR KNOWLEDGE 3. Hyperglycemia has been associated with increasing the risk of ________ for patients undergoing CABG surgery. A. B. C. D. E. infection mortality acute renal failure increased blood transfusions all of the above

TEST YOUR KNOWLEDGE 4. To reduce the risk of developing a post surgical urinary track infection, the urinary catheter should be removed before or on post-op day two even if the patient had it in use before the perioperative period. A. True B. False

TEST YOUR KNOWLEDGE 5. Hypothermia during surgery can lead to an increased risk for __________. A. Impaired wound healing B. Adverse cardiac events C. Seizures D. A & B

THIS CONCLUDES SCIP PART I SCIP Part II is on the Power. Point presentation SCIP-VTE