Thirty-eight percent of all hospital-acquired infections are surgical site infections (SSIs), with 4% to 16% being among hospitalized patients, according to the Institute for Healthcare Improvement (IHI).1 This adds up to a cost of approximately $130 to $845 million dollars in the United States.1In 2002, the Centers for Medicare and Medicaid Services (CMS) and the CDC partnered to disseminate evidence on antibiotic use to prevent SSIs. Then known as the Surgical Infection Prevention (SIP) project, the first specification manual had three infection prevention indicators focusing on antibiotic administration: SIP-1, prophylactic antibiotic received within 1 hour of surgery; SIP-2, prophylactic antibiotic selection for surgical patients; and SIP-3, prophylactic antibiotics discontinued within 24 hours after surgery end time.2 In August 2005, the SIP project grew to become a multiyear, national quality partnership of organizations called the Surgical Care Improvement Project, or SCIP, with the goal of decreasing surgical complication by 25% by 2010.
Organizations that sponsor and comprise the SCIP steering committee include the American College of Surgeons, the CMS, the CDC, the American Hospital Association, The Joint Commission, the American Society of Anesthesiologists, the Association of PeriOperative Registered Nurses (AORN), the Agency for Healthcare Research and Quality, the Department of Veterans Affairs, and the IHI. With the contributions of these organizations, the current SCIP measures now address more than antibiotic administration to include nonpharmacologic and pharmacologic interventions.3 The three current focuses being reported for SCIP areas are: infection prevention (administration of antibiotics, monitoring blood glucose levels, appropriate hair removal, removal of urinary catheters, and perioperative temperature management), cardiac care, and venous thromboembolism (VTE) prevention. SCIP core measures lists the SCIP quality measures for patients who are discharged between April 1, 2011 and December 31, 2011.
The quality measures SCIP-INF-1, SCIP-INF-2, and SCIP-INF-3 are further stratified for data collection based on ICD-9-CM codes for overall rate, coronary artery bypass graft (CABG) surgery, other cardiac surgery, hip arthroplasty, knee arthroplasty, hysterectomy, and vascular surgery. Why these specific procedures? According to the National Health Statistic Report Summary, 45 million inpatient procedures were performed in 2007.4 Fifteen percent of reported cases (6,942,000) were cardiovascular procedures; CABG surgeries alone accounted for 3% of cases (232,000). One million of the reported cases were for fractures, and half of these were for hip fractures; more than half of the patients experiencing fractures were age 65 or older. Although a small percentage of all cases, hysterectomy accounted for 517,000 of performed cases.
In this article, I'll review the SCIP core measures and discuss how you can lead your organization to success.
Administration of antibiotics is a true collaborative effort between physicians, pharmacists, and nurses.
- SCIP-INF-2. Although SCIP-INF-2 is listed as the second measure, it starts the process of antibiotic administration by appropriate selection of medication. See Prophylactic antibiotic regimen selection for surgical procedures for a list of recommended antibiotics. It's important for the team to know these recommendations so they're able to discuss the appropriate selection, dosage, and therapeutic monitoring for individual patients.
Your organization can establish a set guideline/protocol with the recommended antibiotics. One way to contribute to your organization's success is to start this process in the physician's office before admission, with the established protocols being easily available. Another opportunity for compliance is creating a pocket guide for the surgical team that can serve as a reminder for staff. Increased compliance is also potentiated if the approved hospital formulary antibiotics are available for administration. Nurses may think they don't influence these decisions, but they do. Other team members rely on nurses to correctly document the patient's allergies, height and weight, and perform the six rights of medication administration at the point of delivery.
- SCIP-INF-1. After the antibiotic is ordered, nursing can have one of the greatest impacts on timeliness of medication administration. SCIP-INF-1 requires the antibiotic to be administered within 1 hour of cut time (any time skin integrity is disrupted, such as in laparoscopic procedures), with the belief that it provides opportunity for the medication to travel through the body and be available at the surgical site at the time of incision. The exception to this time frame is when vancomycin or a fluoroquinolone is ordered; these medications should be administered within 2 hours due to longer administration times.3
A retrospective study reviewing elective hip arthroplasty patients showed that 2.6% of the patients who received antibiotics after the initial incision experienced an SSI.5 Although the literature demonstrates the importance of timely antibiotic administration, facilities struggle to accomplish this. There are contributing factors that may lead to noncompliance, such as availability of medication in pre-op holding areas, surgical delays due to emergent cases, or a patient not arriving on time.
Hospitals can implement several processes to ensure meeting the SCIP-INF-1 measure. One technique that can be implemented to address antibiotic accessibility in pre-op areas is to send the medication with the patient from the inpatient unit. This avoids the inpatient unit administering the medication too early if there's a delay. Another tactic is to add the verification of administration into the "time out" the team conducts immediately before incision as required by The Joint Commission National Patient Safety Goal (UP.01.01.01).6 Assigning a particular team member to administer the medication and document the administration may also increase accountability.
- SCIP-INF-3. The discontinuation, or stop date, of antibiotics after surgery is also important to outcomes. SCIP-INF-3 requires antibiotics to be stopped 24 to 48 hours after incision time, depending on the surgical procedure. Patients undergoing a CABG procedure or other cardiac surgeries need to have their antibiotics discontinued by the 48-hour deadline, according to the ICD-9-CM codes.
As previously mentioned, the development of an approved protocol that allows the pharmacy or nursing to automatically discontinue the antibiotic can assist in meeting the third measure. Another prospect for reminding staff of antibiotic stop time is the use of clinical pathways or best practice alerts. Medication administration records, whether in paper or electronic format, need to make clear to the nurse the stop date and time for the specific antibiotic. The CMS regulation §482.23 (c)(1) for medications to be administered within 30 minutes of the scheduled administration time doesn't apply for SCIP-INF-1 and SCIP-INF-3.7 When the antibiotic is administered 1 minute outside the time window identified in the measure, it doesn't contribute to the success of the organization.
Controlling blood glucose levels
There's further concern with infection in cardiac surgery patients. A prospective study of 411 patients with a history of diabetes undergoing coronary artery surgery showed that patients with hyperglycemia were progressively at higher risk for infection.8 The study recommended physicians consider maintaining or keeping patient glucose levels at or below 200 mg/dL. Further studies demonstrate that the control of blood glucose contributes to better outcomes in critically ill and surgical patients.9–12
- SCIP-INF-4. This measure addresses the cardiac surgery patient's post-op 6 a.m. serum blood glucose level. Early identification of patients with hyperglycemia before surgery will assist in the management of the patient's blood glucose levels throughout the surgical process.
The adoption of standard glucose management protocols can assist in the monitoring and management of patients with a preexisting diagnosis of diabetes and those having cardiac surgery. A nurse who's able to adjust insulin based on protocol avoids delays in treatment, such as waiting for the practitioner to call back or delivery of medication, and allows the patient to achieve acceptable glucose levels quicker.
Appropriate hair removal
The literature shows there's an increase in SSIs when hair is removed from the surgical site.13–16 When the surgical site is shaved with a razor, small cuts and disruption in the hair follicle may occur, creating the optimal portal of entry and environment for bacteria proliferation.
- SCIP-INF-6. This measure requires appropriate hair removal at the surgical site. A review of the literature demonstrates there's a decreased incidence of SSIs when hair is removed from the surgical site with clippers or depilatory creams.13–16 The AORN recommendations state that hair at the surgical site should be left in place whenever possible.17 If hair must be removed, remove only the hair at the surgical site. This should be done outside of the surgical suite, as close to incision time as possible.
Inpatient units can assist in meeting this measure by adding hair removal to a surgical checklist, as well as making electrical clippers available for use. Decreasing access to razors will decrease the temptation to use them. If patients are being admitted the day of surgery and instructed to remove the hair themselves using a depilatory cream, they need to test an area first to check for irritation or allergic reaction, which may delay the surgical procedure.
Removal of urinary catheters
Until the recent catheter-associated urinary tract infection (CAUTI) guidelines were put into place, hospitals hadn't focused on CAUTI because it's associated with lower morbidity and mortality than other hospital-acquired infections. As noted with shaving patients, the indwelling catheter offers a portal of entry for bacteria and a surface for colonization. Approximately 80% of CAUTIs are associated with indwelling catheters, and many of these catheters are said to be placed inappropriately.18–20
- SCIP-INF-9. This measure addresses timely removal of urinary catheters within 1 to 2 days after the day of surgery. In 2006, a study demonstrated a 60% reduction of CAUTIs using a multifaceted intervention for orthopedic surgery patients.21 An early intervention in the study was to remove indwelling catheters by post-op day 2 for total hip replacements and day 1 for total knee replacements. The study noted that there was an 82% compliance rate with the intervention.
The implementation of such an intervention into approved protocols can assist in meeting the SCIP-INF-9 measure by allowing the nurse to remove the catheter as soon as possible and decrease the risk of patient infections. Other interventions nurses can implement to assist in the decrease of infection are listed by the Wound, Ostomy and Continence Nurses Society in its fact sheet to address CAUTI, which includes sterile technique, use of the smallest lumen possible, use of a closed system, keeping the catheter below the level of the bladder, securing the catheter to reduce tension and traction, and routine perineal care.22
Perioperative temperature management
One study found that patients who experienced mild hypothermia during surgery were three times more likely to have positive cultures from the surgical site.23 In this study, there was delayed healing and prolonged hospitalization associated with hypothermia.
- SCIP-INF-10. This measure addresses perioperative temperature management. Risk factors for unintentional hypothermia include extremes in age, hypotension, gender (female), low body mass index, length of time of surgical procedure, body surface exposure during procedure, duration of anesthesia, and preexisting metabolic disorders such as diabetes.24 Nurses need to assess patients for these risks. The recommendations for practice state that the core temperature of a patient at risk for hypothermia be monitored throughout the surgical process.17,25 This entails the inpatient unit obtaining a baseline temperature for the patient at admission and before surgery, as well assessing for signs and symptoms of hypothermia during the procedure.
Interventions that assist in maintaining patient normothermia include implementation of prewarming before surgery, utilization of insulated blankets, and forced air warming. Another intervention is to adjust the OR temperature between 68° F and 77° F. Communication is vital between staff members monitoring the patient's temperature and the physician in case other techniques such as warmed I.V. fluids are needed.
Although there's literature to support each of the individual infection prevention interventions, a recent retrospective study reviewing discharges from July 6, 2006 to March 1, 2008, found that there was no statistically significant association between reported SCIP adherence rates using individual measures. However, an all-or-none infection prevention measure did show a lower probability for infection.26
SCIP measures addressing cardiac care have been decreased; in 2011 there's only one.
- SCIP-CARD-2. This measure addresses surgical patients on a beta-blocker before arrival receiving a beta-blocker during the perioperative period (defined as 24 hours before the surgical incision through discharge from the post-op area). The literature demonstrates that patients who are maintained on beta-blockers are at lower risk for post-op myocardial infarction and have decreased mortatlity.27,28 The neurohormonal stress with surgery causes increased heart rate, myocardial contractility, and oxygen demand. Beta-blockers decrease the myocardial oxygen demand, which reduces heart rate, wall tension, and contractility. Patients maintained on beta-blockers, without complications that might warrant discontinuation, are good candidates for continuation of beta-blockers through the perioperative period. The goal is to maintain a tight control on the patient's heart rate.
Development of hospital protocols that require standing orders for beta-blockers for eligible patients helps reach this measure. One of the most important interventions that nursing and pharmacy can contribute to this measure is an accurate patient history related to beta-blockers and a completed review and update of home medication reconciliation.
VTE is experienced by approximately 1 million hospitalized Americans yearly and is the most common preventable cause of death in hospitals. VTE includes both deep vein thrombosis and pulmonary embolism. There are two SCIP measures addressing VTE.
- SCIP-VTE-1. This measure states that surgery patients will have recommended VTE prophylaxis ordered. VTE prophylaxis starts with identification of risk factors, including the patient having surgery (higher risk with hip or knee surgery), trauma to lower extremities, increasing age (older than age 40), hormonal therapy, chemotherapy, central line catheter placement, immobility, obesity, varicose veins, and pregnancy (antepartum and postpartum).29–31 There are a number of risk assessment scoring tools available to assist in the determination of patient risk severity. Determining if the patient is at low, moderate, or high risk for VTE will guide the team to select the prophylactic treatment. As soon as a patient is admitted to the inpatient unit or is known to be staying more than 24 hours, a risk assessment needs to be completed. After the risk level is assigned, the appropriate intervention can be ordered and implemented.
Interventions are separated into two categories: nonpharmacologic and pharmacologic. The first intervention is frequent and early ambulation. The second nonpharmacologic intervention is the use of graduated compression stockings or intermittent pneumatic compression devices. Nurses need to know the importance of applying and using these devices for patients with limited mobility. Patients identified as moderate or high risk will also receive pharmacologic intervention of a low-dose unfractionated or low-molecular-weight heparin.
- SCIP-VTE-2. This measure states that surgical patients will receive appropriate VTE prophylaxis within 24 hours before surgery to 24 hours after surgery. Again, the timing of post-op medication administration is important. Organizations using best practice alerts may improve their outcomes by getting prophylaxis ordered and implemented early.
A positive impact
In the fiscal year 2009, 96% of hospitals participated successfully in the SCIP reporting program and received the full-market basket update for 2010.32 It's evident that SCIP is impacting healthcare when so many organizations are collaborating and reporting information. Nurses need to be educated about SCIP and made aware of their impact on patient outcomes through the sharing of SCIP core measure results.
1. Institute for Healthcare Improvement. Case for improvement
2. QualityNet. Specifications Manual, Version 1.0. Discharges 01/01/2005 to 06/30/2005
3. QualityNet. Specifications Manual, Version 3.3. Discharges 04/01/2011 to 12/31/2011
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7. Centers for Medicare and Medicaid Services. State Operations Manual. Appendix A—Survey Protocol, Regulations and Interpretive Guidelines for Hospitals
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32. Centers for Medicare and Medicaid Services. Reporting hospital quality data for annual payment update