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Lessons learned from the institution of the Surgical Care Improvement Project at a teaching medical center
The American Journal of Surgery (2009) 198, 881– 888
The Southwestern Surgical Congress
Lessons learned from the institution of the Surgical Care Improvement Project at a teaching medical center Bruce Potenza, M.D.*, Michelle Deligencia, R.N., Brenda Estigoy, R.N., Eema Faraday, M.P.H., Andrea Snyder, R.N., Niren Angle, M.D., Alexandra Schwartz, M.D., Leon Chang, M.D., James Hackett, M.D., Anushirvan Minokadeh, M.D., Michael Madani, M.D., Kathryn MacAulay, M.D., Sonia Ramamoorthy, M.D., Lynn Blaner, R.N., Charles James, Pharm.D., Vishal Bansal, M.D., Francesca Torriani, M.D., Raul Coimbra, M.D., Ph.D. Division of Trauma, Critical Care & Burns, University of California, San Diego, 200 W. Arbor Dr., San Diego, CA 921038896, USA KEYWORDS: Surgical care infection project; Surgical site infection; Patient safety; Performance improvement quality measures
Abstract BACKGROUND: The Surgical Care Improvement Project (SCIP) was designed to reduce perioperative complications. We describe our institutional experience in 6 major areas: surgical site infection, venous thromboembolism prevention, use of perioperative -blockade, serum glucose level greater than 200 mg/dL, normothermia, and the use of electric razors for hair removal. METHODS: This was a retrospective review of surgical cases. Evidence-based training and standardization of system and process were undertaken. Compliance with SCIP guidelines was determined. RESULTS: Overall SCIP compliance improved from 80% to 94% over a 2-year period. Standardized antibiotic dosing times improved compliance to more than 90%. Appropriate preoperative antibiotic choice improved to 100%. Cessation of antibiotics postoperatively within 24 hours remains a difficult task. Venous thromboembolism prophylaxis has been difficult to achieve because of postoperative bleeding concerns. Administration of -blockers has remained one of the most difficult problems to correct because of the multiplicity of avenues by which a patient may arrive to the operating suite. CONCLUSIONS: Achievement of the SCIP goals is a formidable, but achievable, process requiring individual, cultural, systems, and institutional changes to achieve success. © 2009 Published by Elsevier Inc.
Patient safety and risk reduction have been important issues for physicians and surgeons over the years. In the early 1900s, a pioneering surgeon from Massachusetts GenPresented at the Southwest Surgical Congress, March 22-25, 2009, San Diego, CA. * Corresponding author. Tel.: ⫹1-619-543-6001; fax: ⫹1-619-543-6003. E-mail address: [email protected] Manuscript received March 25, 2009; revised manuscript August 17, 2009
0002-9610/$ - see front matter © 2009 Published by Elsevier Inc. doi:10.1016/j.amjsurg.2009.08.015
eral Hospital by the name of Earnest Codman introduced the concept of a dedicated morbidity and mortality conference to discuss surgical complications.1 This method of discussion and peer evaluation now is standard in all surgical teaching programs. In 1999, the Institute of Medicine’s report “To Err Is Human” estimated there may be 44,000 to 88,000 potentially preventable deaths in hospitalized patients.2 It acknowledged individual errors of omission and commission, but stressed there is a greater need to explore
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system and process errors that lead to medical and surgical complications. Since this report, numerous patient safety initiatives have been implemented from various private, state, and federal agencies.3 The Centers for Medicare and Medicaid Services are placing an ever-increasing emphasis on reducing medical and surgical complications both for patient safety and to reduce the economic cost of these misadventures. In the United States, surgical complications result in approximately 750,000 cases of surgical site infections annually.4 This translates into 2.4 million excess hospital admission days at an estimated cost of $9.3 billion dollars.5 Each surgical site infection to a surgical inpatient yields, on average, an additional $4,768 in cost.6 To address the issue of surgical infection and safety, a collaborative effort under the direction of the Centers for Medicare and Medicaid Services and the Centers for Disease Control and Prevention was initiated called the Surgical Care Improvement Project (SCIP). SCIP has 9 major areas of concentration that include surgical antibiotic prophylaxis (3 process measures), deep-vein thrombosis prophylaxis (2 process measures), perioperative -blockade, postoperative glucose control, patient temperature control, and surgical site hair removal policies7 (Table 1). The recommendations and process measures that have emerged from this project are a combination of evidence-based and expert opinion. Comparison result data for this project have been available to enrolled hospitals. Recently, many state agencies have been mandating public reporting of the individual hospital results to the SCIP measures. As a result, there is an increased emphasis at each local hospital and medical center to comply and achieve reasonable levels of compliance. This report describes one institution’s experience with the SCIP. It is intended to give the reader a how-to approach Table 1
to what can be a very challenging project. Oftentimes, ideas that seem so simple or based in solid reasoning may have unexpected results. Yet success often is measured by perseverance and a willingness to change.
Methods SCIP was designed to decrease surgical complications and surgical site infections, enhance patient safety, and to bring our institution into compliance with the guidelines that were mandated by state and federal agencies. The specific aim of this study was to determine compliance with the SCIP process measures. Secondary aims were to define barriers and bridges to achieve compliance. This project was a retrospective chart review of surgical patients who underwent selected surgical procedures at the University of California San Diego Medical Center during July 2006 through September 2008. The University of California San Diego Medical Center is a 325-bed teaching institution. The selected surgical procedures were delineated by SCIP to form the core group of surgical patients for the project. These surgical categories included colorectal, vascular, cardiovascular (coronary artery bypass surgery and noncardiac), orthopedic (knee and hip arthroplasty), gynecology (hysterectomy), and patients undergoing other selected major surgical procedures. The SCIP team members consisted of representative members of each of the specialties, as well as nursing and pharmacy. There was a lead performance improvement nurse and data analyst who were key members for technical and logistical organization, data abstraction, and analysis.
Surgical Care Improvement Project Quality Measures
SCIP infection—antibiotics given preoperatively Prophylactic antibiotic received within 1 hour before surgical incision SCIP infection—appropriate antibiotic choice Prophylactic antibiotic selection for surgical patients SCIP infection—antibiotic discontinuation Prophylactic antibiotics discontinued within 24 hours after surgery end time (48 hours for cardiac patients) SCIP infection—shaving Surgery patients with appropriate hair removal SCIP infection—normothermia Colorectal surgery patients with immediate postoperative normothermia (ⱖ96.8°F) within the first 15 minutes after leaving the operating room SCIP cardiac Surgery patients on a -blocker before arrival who received a -blocker during the perioperative period, defined as 24 hours before surgical incision through discharge from the postanesthesia care unit SCIP cardiac Cardiac surgery patients with controlled 6 am postoperative serum glucose level ⱕ 200 mg/dL VTE prophylaxis Surgery patients with recommended VTE prophylaxis ordered anytime from hospital arrival to 48 hours after surgery end time VTE prophylaxis Surgery patients who received appropriate VTE prophylaxis within 24 hours before surgical incision time to 24 hours after surgery end time Adapted from the Specifications Manual for National Hospital Inpatient Quality Measures for the Surgical Care Improvement Project Discharges October 1, 2008, through March 31, 2009.
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The core members of the team met monthly to review specialty-specific data and the entire team met on a quarterly basis. Charts were reviewed to determine compliance with 9 SCIP guidelines delineated in Table 1. Data abstracted included all the mandated SCIP elements and general demographic and therapeutic information. Analysis of data included determination of compliance rates for each process measurements. Comparison of compliance rates at the beginning of the study (2006 vs 2008) was performed for each of the SCIP process measures. Trends were analyzed for compliance to SCIP by determining the chi-square statistic for trends. Significance was set at a P value of .05 or less.
Results There were 8,989 patients who met criteria for entry into this project. A total of 1,359 patients (15%) met sampling criteria outlined by the SCIP protocol. The surgical case breakdown included 305 cardiothoracic cases, 329 colorectal, 359 hip arthroplasty, 266 knee arthroplasty, 344 hysterectomy, 103 vascular surgery, and 358 major surgical cases (Table 2). All 9 SCIP process measures were evaluated. The mean compliance rates across all 9 SCIP measures improved from the baseline rate of 80% (2006) to 94% (2008), a 14% improvement (P ⫽ .01). There were 3 process measures showing a 90% or better compliance rate during the beginning of the study. These included the following: (1) hair removal with a shaver (100%), (2) glucose control of 200 mg/dL or less (100%), and (3) normothermia of colorectal patients in the postanesthesia recovery unit (91%). At the conclusion of the data collection there were 8 of 9 process measures that achieved a 90% or higher compliance rate. The only measure that failed to meet this goal was the administration of perioperative -blockade in selected patients (77%) (Table 3). Most process measures showed gradual improvement in compliance over the study period. The 3 SCIP process measures that showed the most improvement included the
Table 2
Table 3
Rates of compliance 2006
Overall compliance with all SCIP measures Preoperative antibiotic administered within 1 h of incision Appropriate choice of antibiotic Cessation of prophylactic antibiotic therapy in ⬍24 or ⬍48 h for cardiac surgery Glucose control ⱕ200 mg/dL Appropriate hair removal with clippers, not a razor Normothermia in PACU (only colorectal patients) -blockade administered Venous thromboprophylaxis ordered Venous thromboprophylaxis administered
80%
2008
P value
94% .01
81% 98% .02 89% 100% .01
58% 100%
91% .01 91% .19
100% 100% NA 91% 47% 82%
94% .73 77% .01 97% .02
69%
96% .01
following: (1) cessation of antibiotic therapy within 24 hours of surgery (33% improvement: P ⫽ .01), (2) administration of -blockade to selected patients (30% improvement: P ⫽ .01), and (3) administration of venous thromboprophylaxis (27% improvement: P ⫽ .01). There was a decrease in compliance (of 9%) of adequate glucose control of less than 200 mg/dL, which was not significant (P ⫽ .19). Temporal variation of compliance was shown in multiple SCIP guidelines. For example, the process measure for cessation of antibiotic therapy in less than 24 hours showed a compliance rate that ranged from 58% at the beginning of the study (late 2006) to 87% (early 2007), decreasing to 76% (mid-2007), and then improving at the end of the study to 91% (2008). Compliance with perioperative -blockade remained variable throughout the study period. It was low for the entire first half of the project period (range, 35%– 56%), with improvement for the last quarter of 2008 of 77%. -blockade remains the lowest compliance indicator to date.
Patient sampling by surgical procedure
CABG Other cardiac surgery Colorectal Hip arthroplasty Knee arthroplasty Hysterectomy Vascular surgery Major surgery Total
Patients sampled
Eligible patients
Sampled/eligible,%
Percentage of all patients sampled
142 114 155 156 154 156 97 385 1,359
207 128 329 359 266 344 103 7,253 8,989
69 89 47 43 58 45 94 5.3 15
10.4 8.4 11.4 11.5 11.3 11.5 7.2 28.3 100
CABG ⫽ coronary artery bypass graft.
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Comments Identification of barriers and bridges to compliance with SCIP guidelines There were a number of barriers to overcome and bridges to be built before we were able to improve our compliance rates. For illustration they have been divided into 3 main areas: people, process, and systems issues. Our first task was to educate our staff about the project. The first task to initiate SCIP was to inform our surgical attending, house staff, and nursing staff of the project-specific goals and objectives. Equally important was to build a case for the need to attempt a quality project of this magnitude that would standardize our approach to some of the basic issues of surgical practice. This required an informational roll-out of the project at many different venues. Each time it was necessary to defend the conceptual rubric that supported the use of standardized surgical practices to decrease surgical complications. Evidence-based discussions were conducted throughout the surgical specialties, anesthesia, and nursing to build a foundation for this project. Examples of our institution-specific quality benchmark successes and challenges were presented to staff. These local examples proved to be one of the best learning tools. A group practice model appeared to be the best method to achieve compliance with the SCIP process measures. Initially, this was difficult to promote because our staff showed a strong sense of individuality with their surgical practice. Many surgeons practiced good evidence-based medicine, but the actual practice patterns were different from those prescribed by SCIP. These surgeons needed to be reassured that the practice change would be as efficacious as their present practice and convinced that a group practice model was necessary for the organization to move forward. The 2 most contentious areas to secure agreement concerned the use of prophylactic antibiotics and venous thromboembolic prophylaxis. Over time, through the educational venues such as morbidity and mortality conferences, there was a gradual agreement by key surgical personnel that led the effort of change. Some staff needed extra attention to improve compliance. Some noncompliance issues were caused by omission whereas some were caused by a resistance to change, but oftentimes it centered on a misunderstanding of the process measure. Individual discussions with these surgeons, peer pressure, as well as Department of Surgery and Anesthesiology Chair encouragement seemed ultimately to win out. Process problems consisted of issues related to how to best perform specific tasks. Once there is institutional and staff buy-in for the project we needed a mechanism to achieve the SCIP goals. This involved setting up a process by which all the SCIP measures were addressed with each patient. An initial effort to develop surgical specialty order sets led to multiple parallel ordering systems that always seemed to find a way around one of the SCIP guidelines.
Developing more central order sets that funnel all subspecialty groups into common pathways with specific subspecialty recommendations for prophylactic antibiotics and venous thromboembolism orders were the most challenging to develop. Glucose control proved to be difficult because of the inherent problems of weaning from an insulin drip to daily glycemic control measures. New insulin protocols were developed, piloted, modified, and then implemented into our general practice. Many documentation forms for the SCIP measures needed modification or clarification so the SCIP abstraction of data analysis would be simplified. Additional modifications were added to forms to serve as prompts for the staff to perform certain duties during the perioperative period. Simple additions to the anesthetic record to accentuate the administration of the preoperative antibiotic and document the timing and the route of administration improved our compliance. System problems were identified during the entire study period. In fact, we are certain that we have not yet identified all the potential system problems or developed the best solutions for the problems encountered to date. Unfortunately, ideas that seemed good in the planning stage actually resulted in a worsening of some of the performance measures. The most egregious example was when we decided that all preoperative antibiotics were to be administered in the preoperative holding area. This resulted in our lowest compliance with a preoperative antibiotic dose administration less than 60 minutes before incision because of an inability to predict when the patient would move to the operating room to start the case. Another area that resulted in preoperative antibiotic administration given outside the 60-minute window was shown in operating rooms where there was a long anesthesiology preparation time. Patients who needed central lines, arterial lines, special positioning, or bronchoscopy fell into this group. The antibiotics were not administered within the 60-minute window, but fell into the 61- to 75-minute window in 50% of the noncompliant cases. This was remedied by setting a standard policy of when to administer the preoperative antibiotics in these types of cases. Unless indicated for any other procedure the antibiotics were given as the last step before the surgery began. System issues for the pharmacy to deliver adequate supplies of approved drugs and for anesthesia to stock them on their carts needed to be worked out. Making sure that rotating ancillary support personnel kept up with all of our policies and practices was very challenging. Eventually, the new policies became the norm for everyone and the compliance began to improve.
Institutional roll-out of SCIP and other patient safety projects The introduction of the SCIP came at a time when similar patient safety and practice guideline projects were coming online at the medical center. A perioperative
B. Potenza et al. Table 4
Lessons learned from SCIP
Surgical briefing and time out
Sign in all team members Surgeon, anesthesia, and operating nurse verify Correct patient Correct site Correct procedure Allergies Patient position Brief discussion of plan of surgery Anticipated needs or special equipment available in the operating room Anticipated need for blood products (none needed, screened, cross-matched) Antibiotics needed and administered VTE prophylaxis Any concerns or clarifications from any team members Modification of this briefing and time-out can be made to fit local needs.
safety initiative entitled “Crew resource management” was a mandatory requirement for all surgeons and operating room personnel.8 This project centered on a “team responsibility” for patient safety, recognized individual clinical judgment fallibility, and promoted peer monitoring. Fundamental to the project was an operating room team approach philosophy.9 This collective mind set was designed limit potential errors, recognize errors as they occur, and mitigate the consequences of these errors before major harm was done. One of the key constructs of the project was to have a preoperative briefing and a final surgical time-out (Table 4). During these collective moments of group thinking we were able review and enforce SCIP process measures before the start of the case. The circulating nurse was empowered to initiate the preoperative checklist and to delay the start of the surgery if all requisite checks were not complete.10,11 In each surgical case a series of questions were raised. They included verification of the patient, procedure, surgical site, patient allergies, special equipment requests, availability of blood products, venous thromboembolism (VTE) prophylaxis, and preoperative antibiotics. By using the crew resource management process there was an increase in the institutional awareness of the SCIP project as well as an infrastructure to promote SCIP performance measures.
Changing practice patterns The SCIP committee began a series of informational and educational events to introduce the faculty and resident surgical house staff to the project. The educational programs were important in changing this perspective and enlisting key clinical staff members to the project. Grand rounds, small didactic meetings, faculty meetings, and informal discussions were used to present the evidence for a standardized approach to surgical infection prophylaxis. Surgical literature was reviewed at these conferences describing
885 the surgical principles for the timing of prophylaxis and the choice and duration of prophylaxis in the various specialty target areas.12,13 In an effort to assist the clinician, standardized preoperative order sets were developed. All the surgical service order sets now go through a centralized antibiotic and venous thromboembolic prophylaxis ordering program to help direct the clinician to the appropriate management choices. Surgical house staff and faculty were given laminated cards with the SCIP guidelines including antibiotic choices. All operating rooms have prophylactic antibiotic listings by surgical specialty for quick reference. Key partners in this phase of the SCIP program were our anesthesiologists. They were directly responsible for administering the prophylactic antibiotics, therefore, during the surgical briefing and again at the surgical time-out they asked if antibiotics were indicated. They were empowered to question the choice of antibiotics if they did not meet the guidelines. They have been the driving force for antibiotic administration within the 60 minutes before incision as well as the choice of antibiotics. They were vigilant about antibiotic redosing during long cases. The anesthetic worksheet also was revised to improve SCIP documentation. The simple expansion of the antibiotic section and listing modes of drug administration improved documentation.
Specific SCIP Process Measure Challenges Obtaining surgical staff support for prophylactic antibiotic use was one of the most difficult tasks in the early portion of the study. Additional issues developed when newer antibiotics were described in the literature to be effective for prophylaxis in some of the surgical specialties. SCIP lags in the adoption of some of these antibiotics and practices. It was necessary to remind our staff not to use the drugs until there was approval from the SCIP experts. If we were not reviewing our data monthly we might not have caught some of these practice changes that were not SCIP compliant. When non-SCIP antibiotics were requested by a surgeon, the anesthesiologist or the circulating nurse were empowered to ask why these drugs were being used in lieu of SCIP-approved antibiotics.14 In this manner there was a chance to correct the mistake and administer the correct drug. Glucose control was addressed using insulin protocols and new methods to convert patients from an insulin drip to daily intermittent dosing. In the outpatient clinic we attempted to identify potential patients with hyperglycemia by screening for an increased hemoglobin A-1C level in highrisk patients. The patients were stratified to appropriate glucose control measures based on this information. VTE was a challenging problem Individual surgeons showed wide variation in their interpretation of the VTE prophylaxis guidelines. To counter
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this, VTE prophylaxis recommendations from the American College of Chest Physicians were e-mailed to all staff were discussed at surgical grand rounds and morbidity and mortality conferences when applicable.15 Our compliance improved from 82% to 97% by the end of the study. The use of a -blocker within 24 hours of the start of the procedure to the time of discharge from the postanesthesia recovery unit has continued to be the most difficult guideline to achieve. We identified multiple areas where this process measure was not followed. These included the following: (1) improper preoperative instructions from surgical staff or medical consultants, (2) misunderstanding of what medications the patient may take the night before or the morning of surgery, (3) forgetfulness on the part of the surgical staff to administer the -blocker if there is no contraindication to do so, and (4) not documenting why the drug was not administered when there was a clinical reason not to administer the drug. We now have designated the anesthesia preoperative clearance visit as the time when all patient medications were reviewed and final patient instructions were given in both verbal and written form. The surgical removal of hair without the use of a razor was a simple guideline to meet. All razors were removed from the operating room and replaced with electric shavers. This was a relatively easy process measure to meet. For some surgeries that require a very close shave, such as neurosurgery, more expensive and better electric shavers are provided. If a surgeon needed a razor they need to ask for it and document in the chart why they are using it. Achieving near-100% compliance should be the norm. Achieving normothermia in colorectal patients has been a minor problem. In those cases that were noncompliant, the mean value below the minimum temperature of 96.8°F that we found our cases to be was 0.5°F. To combat this we now encourage total abdominal preparation and then covering the patient quickly with sterile towels and drapes, using warm lavage fluid, use of the warming blanket, and warming up the operating rooms. The latter idea of warming operating rooms still is met with resistance.
Limitations This study was an accurate representation of the compliance to SCIP guidelines at a university teaching institution. Our faculty is predominantly a closed panel. All faculty attend weekly surgical conferences where SCIP information is disseminated. We do not have an inpatient electronic medical record system that would afford a seamless data entry, order, and retrieval system. All of our data abstraction is performed by hand, which makes concurrent data collection challenging. We are 1 to 1.5 quarters behind in data analysis and in physician notification of SCIP compliance problems.
Conclusions The SCIP is one of the largest surgical patient safety and surgical site infection initiatives in the county. The stated goal is to reduce preventable surgical morbidity and mortality by 25% by 2010. We have shown at our universitybased teaching hospitals that it is possible to implement a project such as SCIP and achieve good results. SCIP necessitates some fundamental changes in the way surgeons practice and institutions function in the care of surgical patients. Most importantly, SCIP requires all of us to practice in a standardized evidence-based fashion in an effort to improve patient care.16 Surgical quality and performance improvement projects already have shown a reduction in surgical site infections in colorectal and cardiothoracic patients by following evidence-based practices.17–19 The savings in surgical morbidity and mortality should be well worth this intense effort. The Centers for Medicare and Medicaid Services estimates a reduction in surgical mortality of 13,000 lives and more than 270,000 complications if these measures are followed. These are underestimates of potential lives saved because the estimates are based on patients enrolled by Medicare and do not consider other surgical patients. The imperative is on the surgical profession to show an ability to take on these projects in the interest of good, safe patient care. By giving up a small amount of autonomy of individual practice, there are huge benefits to be accrued for the greater good. We now live in an era during which local and regional differences in patient care and outcomes will begin to diminish as we embrace common evidence-based surgical practice. If we do not take up the public health, best practice approach, we may find a more punitive payment methodology forced on us to use patient safety measures such as SCIP.19 It is time to move forward and embrace those practices that unite us and serve to provide for the optimal care of the surgical patient.
References 1. Codman EA. A study in hospital efficiency 1914 –16. The Joint Commission Press, Oakbrook, IL; 1996. 2. Kohn LT, Corrigan JM, Donaldson MS, eds. Committee on Quality of Health Care in America, Institute of Medicine. To Err Is Human. 1999. [cited 2009 February 28]. Available from: http://www.iom.edu/CMS/ 8089/5575/4117.aspx. 3. Campaign to save 5 million lives. Institute for Healthcare Improvement. [cited 2009 February 28]. Available from: http://www.ihi.org/ IHI/Programs/Campaign/. 4. Barnett TE. The not-so-hidden costs of surgical site infections. AORN J 2007;86:249 –58. 5. Zhan C, Miller MR. Excess length of stay, charges and mortality attributable to medical injuries during hospitalization. JAMA 2003; 290:1868 –74. 6. Clancy CM. SCIP: making complications of surgery the exception rather than the rule. AORN 2008;87:621– 4. 7. Fry DE. Surgical site infections and the surgical care improvement project (SCIP): evolution of national quality measures. Surg Infect 2008;9:579 – 84.
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8. Altpeter T, Luckhardt K, Lewis J, et al. Expanded surgical time out: a key to real-time data collection and quality improvement. J Am Coll Surg 2007;204:527–32. 9. Pizza L, Goldfarb NI, Nash DB. Crew resource management and its applications in medicine. [cited 2009 April 22]. Available from: www. ahrq.gov/clinic/ptsafety/chapt44.htm. 10. Beya SC. Surgical care improvement project—an important initiative. AORN J 2006;83:1371–5. 11. Brendle TA. Surgical Care Improvement Project and the perioperative nurse’s role. AORN J 2007;86:94 –101. 12. Bratzler DW, Houch PM, Richards C, et al. Use of antimicrobial prophylaxis for major surgery-baseline results from the national surgical infection prevention project. Arch Surg 2005;140:174 – 82. 13. Dellinger EP, Hausmanns M, Bratzler DW, et al. Hospitals collaborate to decrease surgical site infections. Am J Surg 2005;190:9 –15. 14. Hawn MT, Gray SH, Vick CC, et al. Timely administration of prophylactic antibiotics for major surgical procedures. J Am Coll Surg 2006;203:803–11. 15. Hirsh J, Guyatt G, Albers G, et al. Antithrombotic and thrombolytic therapy. American College of Chest Physicians. Chest 2008;133: 110S–2S. 16. Wick EC, Gibbs L, Indorf LA, et al. Implementation of quality measures to reduce surgical site infection in colorectal patients. Dis Colon Rect 2008;51:1004 –9. 17. Hedrick TI, Turrentine FE, Smith RL, et al. Single-institution experience with the surgical infection prevention project in intra-abdominal surgery. Surg Infect 2007;8:425–35. 18. Trussell J, Gerkin R, Coates B, et al. Impact of a patient care pathway protocol on surgical site infection rates in cardiothoracic surgery patients. Am J Surg 2008;196:883–9. 19. Russell TR. The future of surgical reimbursement: quality care, pay for performance, and outcome measures. Am J Surg 2006;191:301– 4.
Discussion Dr. Russell Postier (Oklahoma City, OK): I have several comments and 2 questions. SCIP as you know is a process improvement program with the inherent benefits and drawbacks of any process improvement measure. The benefits are that it improves patient care as a result of adherence to data-driven best practices. It also is a systems approach to achieving the desired end result such as antibiotic administration in a timely fashion and administration of VTE prophylaxis in a timely fashion. But there are drawbacks to this kind of approach. It has the potential to delay the implementation of new and better therapies as they evolve and it emphasizes and spends a lot of time and energy on arbitrary guidelines such as timing of therapy. For instance, is an antibiotic given 61 minutes before an operation really less effective than one given 60 minutes before an operation? The same is true with deep vein thrombosis (DVT) prophylaxis. The authors provide a nice narrative of their experience and the problems they have encountered and the solutions they have come up with. However, just as in politics, much of SCIP is local. One of my colleagues and I served as a coleader of a Centers for Medicare and Medicaid Services-funded statewide collaborative of hospitals in our state, looking just at the antibiotic prophylaxis component of SCIP. We found that most hospitals need to develop programs that are unique to their local environment. Many
887 of our hospitals will have specific solutions to the problems. It may be different than yours. I really have 2 questions. What is being done to further improve compliance in the area of DVT prophylaxis and -blocker use, which were 2 of your lower scoring areas, and how widely do you distribute your results? Are all surgeons aware of their own data? Are they aware of their services’ data? Again, important work, well presented, and well written. Thank you for allowing me to discuss it. Dr. Potenza: We share many of your concerns about the strict rules and regulations concerning the surgical improvement project. However, there needs to be some degree of standardization of the project so that we all may participate. One can hope that the governing board of SCIP will remain open to consider new and alternative methods to achieve the stated goals as they become apparent. We all have examples of rules that clinically do not make complete sense. For example, in the timing of the preoperative antibiotic being a few minutes late in the administration really does not impact on the clinical outcome. We know from our own literature that whether it is given at 60 minutes or 61 minutes or even 75 minutes, the effect is relatively the same, as long as it is in an appropriate time. We have to live with those rules right now and they have killed us on some of these markers. Yet this has given us some administrative challenges in order to meet the SCIP regulations. For example, our inability to administer our antibiotics within 1 hour of our operative procedures was off by less than 15 minutes in 75% of the cases. We also found out that selected case types were the biggest offenders. These included the big cardiothoracic cases where they are putting in lines, putting in doublelumen endotracheal tubes, but we have changed how we do business trying to achieve that. In the cases of -blockade and deep-vein thrombosis prophylaxis, we have actually made some good success with the DVT by changing our order sets and really forcing everybody who gets to the operating room to go through a checklist and DVT is one of those processes. The -blocker has been a very challenging process. And that is putting it nicely; a nightmare is probably it a better way to describe it. We believe this is because our patients are coming from different areas of preoperative care and they are getting different ideas from different attending physicians. Just before I came to this meeting I had the opportunity to hear one of these phone encounters. After the OR nurse gave all of the instructions to the patient on where and what time to check in, I overheard the nurse reply to a patient inquiry “I do not know what to do about your medications, I am here just to tell you you are supposed to be here at 5:30 in the morning,” and that was the end of the conversation. So we have lost opportunity to intervene. We now have our preoperative anesthesia clinic be the last and final place that the patients go to before they end up in the operating room. In that clinic, they have the SCIP guidelines as well as other guidelines that we have set up by ourselves. Each patient is given a piece of paper with final preoperative instructions that the patient then goes
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home with, telling them what time, where to report, NPO status, and instructions on any other preoperative issues including medication administration. I hope that works for us. As you can see here on one of those slides, we actually are starting to come up and are in the 80% for ourselves. Dr. Michael Reardon (Houston, TX): I am a cardiac surgeon so I do not deal with anything outside of cardiac and -blockers and antibiotics have been our problem, too. My understanding of the -blocker was everybody coming for coronary bypass on -blockers, not just those that have been on -blockers. Dr. Potenza: The SCIP as it reads now is only if you are on -blockers. The way it looks like they are trying to take it is that you need to be placed on -blockers. Remember there are 10 groups on the SCIP and they are fairly responsive. They put a lot of opposition to saying that everybody who comes for cardiac surgery needs to have the -blockade on. Dr. Reardon: We have queried SCIP and they have told us everybody needs to be on -blockers and they are not putting it forth as you have. The issues that I have of course is that my cardiologists come back with good evidencebased medicine that not everybody needs -blockers, so that makes it hard to challenge, whereas antibiotics are usually
just heart surgeons even older than I am who just say that is the way I do it. How do you handle both those situations? People that come at you with reasonable evidence-based medicine versus those that say that is the way I do it. Dr. Potenza: Evidence-based medicine—what we have tried to do is funnel that energy back into a writing campaign, so we write to various societies so that it gets up to the SCIPS section committees who can create a change in policy. You have seen that the antibiotics have changed and there have been some changes in some of the dogma that they have propagated. I think that we just have to be responsive and just send the material up to them and say this is what we believe. They are not going to take everything. To answer your second question about physicians who are reluctant to change their practice patterns that may not conform to SCIP, we try to individually speak with them, present the data, answer their questions, and try to persuade them to change for the good of all of the surgical patients. We also have our Chairman give them a call and discuss this matter with them in a last effort. Some people, however, remain reluctant to alter their practice patterns and we have not yet found a way to effect change. Fortunately these practitioners are in the minority.
The Southwestern Surgical Congress
Lessons learned from the institution of the Surgical Care Improvement Project at a teaching medical center Bruce Potenza, M.D.*, Michelle Deligencia, R.N., Brenda Estigoy, R.N., Eema Faraday, M.P.H., Andrea Snyder, R.N., Niren Angle, M.D., Alexandra Schwartz, M.D., Leon Chang, M.D., James Hackett, M.D., Anushirvan Minokadeh, M.D., Michael Madani, M.D., Kathryn MacAulay, M.D., Sonia Ramamoorthy, M.D., Lynn Blaner, R.N., Charles James, Pharm.D., Vishal Bansal, M.D., Francesca Torriani, M.D., Raul Coimbra, M.D., Ph.D. Division of Trauma, Critical Care & Burns, University of California, San Diego, 200 W. Arbor Dr., San Diego, CA 921038896, USA KEYWORDS: Surgical care infection project; Surgical site infection; Patient safety; Performance improvement quality measures
Abstract BACKGROUND: The Surgical Care Improvement Project (SCIP) was designed to reduce perioperative complications. We describe our institutional experience in 6 major areas: surgical site infection, venous thromboembolism prevention, use of perioperative -blockade, serum glucose level greater than 200 mg/dL, normothermia, and the use of electric razors for hair removal. METHODS: This was a retrospective review of surgical cases. Evidence-based training and standardization of system and process were undertaken. Compliance with SCIP guidelines was determined. RESULTS: Overall SCIP compliance improved from 80% to 94% over a 2-year period. Standardized antibiotic dosing times improved compliance to more than 90%. Appropriate preoperative antibiotic choice improved to 100%. Cessation of antibiotics postoperatively within 24 hours remains a difficult task. Venous thromboembolism prophylaxis has been difficult to achieve because of postoperative bleeding concerns. Administration of -blockers has remained one of the most difficult problems to correct because of the multiplicity of avenues by which a patient may arrive to the operating suite. CONCLUSIONS: Achievement of the SCIP goals is a formidable, but achievable, process requiring individual, cultural, systems, and institutional changes to achieve success. © 2009 Published by Elsevier Inc.
Patient safety and risk reduction have been important issues for physicians and surgeons over the years. In the early 1900s, a pioneering surgeon from Massachusetts GenPresented at the Southwest Surgical Congress, March 22-25, 2009, San Diego, CA. * Corresponding author. Tel.: ⫹1-619-543-6001; fax: ⫹1-619-543-6003. E-mail address: [email protected] Manuscript received March 25, 2009; revised manuscript August 17, 2009
0002-9610/$ - see front matter © 2009 Published by Elsevier Inc. doi:10.1016/j.amjsurg.2009.08.015
eral Hospital by the name of Earnest Codman introduced the concept of a dedicated morbidity and mortality conference to discuss surgical complications.1 This method of discussion and peer evaluation now is standard in all surgical teaching programs. In 1999, the Institute of Medicine’s report “To Err Is Human” estimated there may be 44,000 to 88,000 potentially preventable deaths in hospitalized patients.2 It acknowledged individual errors of omission and commission, but stressed there is a greater need to explore
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system and process errors that lead to medical and surgical complications. Since this report, numerous patient safety initiatives have been implemented from various private, state, and federal agencies.3 The Centers for Medicare and Medicaid Services are placing an ever-increasing emphasis on reducing medical and surgical complications both for patient safety and to reduce the economic cost of these misadventures. In the United States, surgical complications result in approximately 750,000 cases of surgical site infections annually.4 This translates into 2.4 million excess hospital admission days at an estimated cost of $9.3 billion dollars.5 Each surgical site infection to a surgical inpatient yields, on average, an additional $4,768 in cost.6 To address the issue of surgical infection and safety, a collaborative effort under the direction of the Centers for Medicare and Medicaid Services and the Centers for Disease Control and Prevention was initiated called the Surgical Care Improvement Project (SCIP). SCIP has 9 major areas of concentration that include surgical antibiotic prophylaxis (3 process measures), deep-vein thrombosis prophylaxis (2 process measures), perioperative -blockade, postoperative glucose control, patient temperature control, and surgical site hair removal policies7 (Table 1). The recommendations and process measures that have emerged from this project are a combination of evidence-based and expert opinion. Comparison result data for this project have been available to enrolled hospitals. Recently, many state agencies have been mandating public reporting of the individual hospital results to the SCIP measures. As a result, there is an increased emphasis at each local hospital and medical center to comply and achieve reasonable levels of compliance. This report describes one institution’s experience with the SCIP. It is intended to give the reader a how-to approach Table 1
to what can be a very challenging project. Oftentimes, ideas that seem so simple or based in solid reasoning may have unexpected results. Yet success often is measured by perseverance and a willingness to change.
Methods SCIP was designed to decrease surgical complications and surgical site infections, enhance patient safety, and to bring our institution into compliance with the guidelines that were mandated by state and federal agencies. The specific aim of this study was to determine compliance with the SCIP process measures. Secondary aims were to define barriers and bridges to achieve compliance. This project was a retrospective chart review of surgical patients who underwent selected surgical procedures at the University of California San Diego Medical Center during July 2006 through September 2008. The University of California San Diego Medical Center is a 325-bed teaching institution. The selected surgical procedures were delineated by SCIP to form the core group of surgical patients for the project. These surgical categories included colorectal, vascular, cardiovascular (coronary artery bypass surgery and noncardiac), orthopedic (knee and hip arthroplasty), gynecology (hysterectomy), and patients undergoing other selected major surgical procedures. The SCIP team members consisted of representative members of each of the specialties, as well as nursing and pharmacy. There was a lead performance improvement nurse and data analyst who were key members for technical and logistical organization, data abstraction, and analysis.
Surgical Care Improvement Project Quality Measures
SCIP infection—antibiotics given preoperatively Prophylactic antibiotic received within 1 hour before surgical incision SCIP infection—appropriate antibiotic choice Prophylactic antibiotic selection for surgical patients SCIP infection—antibiotic discontinuation Prophylactic antibiotics discontinued within 24 hours after surgery end time (48 hours for cardiac patients) SCIP infection—shaving Surgery patients with appropriate hair removal SCIP infection—normothermia Colorectal surgery patients with immediate postoperative normothermia (ⱖ96.8°F) within the first 15 minutes after leaving the operating room SCIP cardiac Surgery patients on a -blocker before arrival who received a -blocker during the perioperative period, defined as 24 hours before surgical incision through discharge from the postanesthesia care unit SCIP cardiac Cardiac surgery patients with controlled 6 am postoperative serum glucose level ⱕ 200 mg/dL VTE prophylaxis Surgery patients with recommended VTE prophylaxis ordered anytime from hospital arrival to 48 hours after surgery end time VTE prophylaxis Surgery patients who received appropriate VTE prophylaxis within 24 hours before surgical incision time to 24 hours after surgery end time Adapted from the Specifications Manual for National Hospital Inpatient Quality Measures for the Surgical Care Improvement Project Discharges October 1, 2008, through March 31, 2009.
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The core members of the team met monthly to review specialty-specific data and the entire team met on a quarterly basis. Charts were reviewed to determine compliance with 9 SCIP guidelines delineated in Table 1. Data abstracted included all the mandated SCIP elements and general demographic and therapeutic information. Analysis of data included determination of compliance rates for each process measurements. Comparison of compliance rates at the beginning of the study (2006 vs 2008) was performed for each of the SCIP process measures. Trends were analyzed for compliance to SCIP by determining the chi-square statistic for trends. Significance was set at a P value of .05 or less.
Results There were 8,989 patients who met criteria for entry into this project. A total of 1,359 patients (15%) met sampling criteria outlined by the SCIP protocol. The surgical case breakdown included 305 cardiothoracic cases, 329 colorectal, 359 hip arthroplasty, 266 knee arthroplasty, 344 hysterectomy, 103 vascular surgery, and 358 major surgical cases (Table 2). All 9 SCIP process measures were evaluated. The mean compliance rates across all 9 SCIP measures improved from the baseline rate of 80% (2006) to 94% (2008), a 14% improvement (P ⫽ .01). There were 3 process measures showing a 90% or better compliance rate during the beginning of the study. These included the following: (1) hair removal with a shaver (100%), (2) glucose control of 200 mg/dL or less (100%), and (3) normothermia of colorectal patients in the postanesthesia recovery unit (91%). At the conclusion of the data collection there were 8 of 9 process measures that achieved a 90% or higher compliance rate. The only measure that failed to meet this goal was the administration of perioperative -blockade in selected patients (77%) (Table 3). Most process measures showed gradual improvement in compliance over the study period. The 3 SCIP process measures that showed the most improvement included the
Table 2
Table 3
Rates of compliance 2006
Overall compliance with all SCIP measures Preoperative antibiotic administered within 1 h of incision Appropriate choice of antibiotic Cessation of prophylactic antibiotic therapy in ⬍24 or ⬍48 h for cardiac surgery Glucose control ⱕ200 mg/dL Appropriate hair removal with clippers, not a razor Normothermia in PACU (only colorectal patients) -blockade administered Venous thromboprophylaxis ordered Venous thromboprophylaxis administered
80%
2008
P value
94% .01
81% 98% .02 89% 100% .01
58% 100%
91% .01 91% .19
100% 100% NA 91% 47% 82%
94% .73 77% .01 97% .02
69%
96% .01
following: (1) cessation of antibiotic therapy within 24 hours of surgery (33% improvement: P ⫽ .01), (2) administration of -blockade to selected patients (30% improvement: P ⫽ .01), and (3) administration of venous thromboprophylaxis (27% improvement: P ⫽ .01). There was a decrease in compliance (of 9%) of adequate glucose control of less than 200 mg/dL, which was not significant (P ⫽ .19). Temporal variation of compliance was shown in multiple SCIP guidelines. For example, the process measure for cessation of antibiotic therapy in less than 24 hours showed a compliance rate that ranged from 58% at the beginning of the study (late 2006) to 87% (early 2007), decreasing to 76% (mid-2007), and then improving at the end of the study to 91% (2008). Compliance with perioperative -blockade remained variable throughout the study period. It was low for the entire first half of the project period (range, 35%– 56%), with improvement for the last quarter of 2008 of 77%. -blockade remains the lowest compliance indicator to date.
Patient sampling by surgical procedure
CABG Other cardiac surgery Colorectal Hip arthroplasty Knee arthroplasty Hysterectomy Vascular surgery Major surgery Total
Patients sampled
Eligible patients
Sampled/eligible,%
Percentage of all patients sampled
142 114 155 156 154 156 97 385 1,359
207 128 329 359 266 344 103 7,253 8,989
69 89 47 43 58 45 94 5.3 15
10.4 8.4 11.4 11.5 11.3 11.5 7.2 28.3 100
CABG ⫽ coronary artery bypass graft.
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Comments Identification of barriers and bridges to compliance with SCIP guidelines There were a number of barriers to overcome and bridges to be built before we were able to improve our compliance rates. For illustration they have been divided into 3 main areas: people, process, and systems issues. Our first task was to educate our staff about the project. The first task to initiate SCIP was to inform our surgical attending, house staff, and nursing staff of the project-specific goals and objectives. Equally important was to build a case for the need to attempt a quality project of this magnitude that would standardize our approach to some of the basic issues of surgical practice. This required an informational roll-out of the project at many different venues. Each time it was necessary to defend the conceptual rubric that supported the use of standardized surgical practices to decrease surgical complications. Evidence-based discussions were conducted throughout the surgical specialties, anesthesia, and nursing to build a foundation for this project. Examples of our institution-specific quality benchmark successes and challenges were presented to staff. These local examples proved to be one of the best learning tools. A group practice model appeared to be the best method to achieve compliance with the SCIP process measures. Initially, this was difficult to promote because our staff showed a strong sense of individuality with their surgical practice. Many surgeons practiced good evidence-based medicine, but the actual practice patterns were different from those prescribed by SCIP. These surgeons needed to be reassured that the practice change would be as efficacious as their present practice and convinced that a group practice model was necessary for the organization to move forward. The 2 most contentious areas to secure agreement concerned the use of prophylactic antibiotics and venous thromboembolic prophylaxis. Over time, through the educational venues such as morbidity and mortality conferences, there was a gradual agreement by key surgical personnel that led the effort of change. Some staff needed extra attention to improve compliance. Some noncompliance issues were caused by omission whereas some were caused by a resistance to change, but oftentimes it centered on a misunderstanding of the process measure. Individual discussions with these surgeons, peer pressure, as well as Department of Surgery and Anesthesiology Chair encouragement seemed ultimately to win out. Process problems consisted of issues related to how to best perform specific tasks. Once there is institutional and staff buy-in for the project we needed a mechanism to achieve the SCIP goals. This involved setting up a process by which all the SCIP measures were addressed with each patient. An initial effort to develop surgical specialty order sets led to multiple parallel ordering systems that always seemed to find a way around one of the SCIP guidelines.
Developing more central order sets that funnel all subspecialty groups into common pathways with specific subspecialty recommendations for prophylactic antibiotics and venous thromboembolism orders were the most challenging to develop. Glucose control proved to be difficult because of the inherent problems of weaning from an insulin drip to daily glycemic control measures. New insulin protocols were developed, piloted, modified, and then implemented into our general practice. Many documentation forms for the SCIP measures needed modification or clarification so the SCIP abstraction of data analysis would be simplified. Additional modifications were added to forms to serve as prompts for the staff to perform certain duties during the perioperative period. Simple additions to the anesthetic record to accentuate the administration of the preoperative antibiotic and document the timing and the route of administration improved our compliance. System problems were identified during the entire study period. In fact, we are certain that we have not yet identified all the potential system problems or developed the best solutions for the problems encountered to date. Unfortunately, ideas that seemed good in the planning stage actually resulted in a worsening of some of the performance measures. The most egregious example was when we decided that all preoperative antibiotics were to be administered in the preoperative holding area. This resulted in our lowest compliance with a preoperative antibiotic dose administration less than 60 minutes before incision because of an inability to predict when the patient would move to the operating room to start the case. Another area that resulted in preoperative antibiotic administration given outside the 60-minute window was shown in operating rooms where there was a long anesthesiology preparation time. Patients who needed central lines, arterial lines, special positioning, or bronchoscopy fell into this group. The antibiotics were not administered within the 60-minute window, but fell into the 61- to 75-minute window in 50% of the noncompliant cases. This was remedied by setting a standard policy of when to administer the preoperative antibiotics in these types of cases. Unless indicated for any other procedure the antibiotics were given as the last step before the surgery began. System issues for the pharmacy to deliver adequate supplies of approved drugs and for anesthesia to stock them on their carts needed to be worked out. Making sure that rotating ancillary support personnel kept up with all of our policies and practices was very challenging. Eventually, the new policies became the norm for everyone and the compliance began to improve.
Institutional roll-out of SCIP and other patient safety projects The introduction of the SCIP came at a time when similar patient safety and practice guideline projects were coming online at the medical center. A perioperative
B. Potenza et al. Table 4
Lessons learned from SCIP
Surgical briefing and time out
Sign in all team members Surgeon, anesthesia, and operating nurse verify Correct patient Correct site Correct procedure Allergies Patient position Brief discussion of plan of surgery Anticipated needs or special equipment available in the operating room Anticipated need for blood products (none needed, screened, cross-matched) Antibiotics needed and administered VTE prophylaxis Any concerns or clarifications from any team members Modification of this briefing and time-out can be made to fit local needs.
safety initiative entitled “Crew resource management” was a mandatory requirement for all surgeons and operating room personnel.8 This project centered on a “team responsibility” for patient safety, recognized individual clinical judgment fallibility, and promoted peer monitoring. Fundamental to the project was an operating room team approach philosophy.9 This collective mind set was designed limit potential errors, recognize errors as they occur, and mitigate the consequences of these errors before major harm was done. One of the key constructs of the project was to have a preoperative briefing and a final surgical time-out (Table 4). During these collective moments of group thinking we were able review and enforce SCIP process measures before the start of the case. The circulating nurse was empowered to initiate the preoperative checklist and to delay the start of the surgery if all requisite checks were not complete.10,11 In each surgical case a series of questions were raised. They included verification of the patient, procedure, surgical site, patient allergies, special equipment requests, availability of blood products, venous thromboembolism (VTE) prophylaxis, and preoperative antibiotics. By using the crew resource management process there was an increase in the institutional awareness of the SCIP project as well as an infrastructure to promote SCIP performance measures.
Changing practice patterns The SCIP committee began a series of informational and educational events to introduce the faculty and resident surgical house staff to the project. The educational programs were important in changing this perspective and enlisting key clinical staff members to the project. Grand rounds, small didactic meetings, faculty meetings, and informal discussions were used to present the evidence for a standardized approach to surgical infection prophylaxis. Surgical literature was reviewed at these conferences describing
885 the surgical principles for the timing of prophylaxis and the choice and duration of prophylaxis in the various specialty target areas.12,13 In an effort to assist the clinician, standardized preoperative order sets were developed. All the surgical service order sets now go through a centralized antibiotic and venous thromboembolic prophylaxis ordering program to help direct the clinician to the appropriate management choices. Surgical house staff and faculty were given laminated cards with the SCIP guidelines including antibiotic choices. All operating rooms have prophylactic antibiotic listings by surgical specialty for quick reference. Key partners in this phase of the SCIP program were our anesthesiologists. They were directly responsible for administering the prophylactic antibiotics, therefore, during the surgical briefing and again at the surgical time-out they asked if antibiotics were indicated. They were empowered to question the choice of antibiotics if they did not meet the guidelines. They have been the driving force for antibiotic administration within the 60 minutes before incision as well as the choice of antibiotics. They were vigilant about antibiotic redosing during long cases. The anesthetic worksheet also was revised to improve SCIP documentation. The simple expansion of the antibiotic section and listing modes of drug administration improved documentation.
Specific SCIP Process Measure Challenges Obtaining surgical staff support for prophylactic antibiotic use was one of the most difficult tasks in the early portion of the study. Additional issues developed when newer antibiotics were described in the literature to be effective for prophylaxis in some of the surgical specialties. SCIP lags in the adoption of some of these antibiotics and practices. It was necessary to remind our staff not to use the drugs until there was approval from the SCIP experts. If we were not reviewing our data monthly we might not have caught some of these practice changes that were not SCIP compliant. When non-SCIP antibiotics were requested by a surgeon, the anesthesiologist or the circulating nurse were empowered to ask why these drugs were being used in lieu of SCIP-approved antibiotics.14 In this manner there was a chance to correct the mistake and administer the correct drug. Glucose control was addressed using insulin protocols and new methods to convert patients from an insulin drip to daily intermittent dosing. In the outpatient clinic we attempted to identify potential patients with hyperglycemia by screening for an increased hemoglobin A-1C level in highrisk patients. The patients were stratified to appropriate glucose control measures based on this information. VTE was a challenging problem Individual surgeons showed wide variation in their interpretation of the VTE prophylaxis guidelines. To counter
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this, VTE prophylaxis recommendations from the American College of Chest Physicians were e-mailed to all staff were discussed at surgical grand rounds and morbidity and mortality conferences when applicable.15 Our compliance improved from 82% to 97% by the end of the study. The use of a -blocker within 24 hours of the start of the procedure to the time of discharge from the postanesthesia recovery unit has continued to be the most difficult guideline to achieve. We identified multiple areas where this process measure was not followed. These included the following: (1) improper preoperative instructions from surgical staff or medical consultants, (2) misunderstanding of what medications the patient may take the night before or the morning of surgery, (3) forgetfulness on the part of the surgical staff to administer the -blocker if there is no contraindication to do so, and (4) not documenting why the drug was not administered when there was a clinical reason not to administer the drug. We now have designated the anesthesia preoperative clearance visit as the time when all patient medications were reviewed and final patient instructions were given in both verbal and written form. The surgical removal of hair without the use of a razor was a simple guideline to meet. All razors were removed from the operating room and replaced with electric shavers. This was a relatively easy process measure to meet. For some surgeries that require a very close shave, such as neurosurgery, more expensive and better electric shavers are provided. If a surgeon needed a razor they need to ask for it and document in the chart why they are using it. Achieving near-100% compliance should be the norm. Achieving normothermia in colorectal patients has been a minor problem. In those cases that were noncompliant, the mean value below the minimum temperature of 96.8°F that we found our cases to be was 0.5°F. To combat this we now encourage total abdominal preparation and then covering the patient quickly with sterile towels and drapes, using warm lavage fluid, use of the warming blanket, and warming up the operating rooms. The latter idea of warming operating rooms still is met with resistance.
Limitations This study was an accurate representation of the compliance to SCIP guidelines at a university teaching institution. Our faculty is predominantly a closed panel. All faculty attend weekly surgical conferences where SCIP information is disseminated. We do not have an inpatient electronic medical record system that would afford a seamless data entry, order, and retrieval system. All of our data abstraction is performed by hand, which makes concurrent data collection challenging. We are 1 to 1.5 quarters behind in data analysis and in physician notification of SCIP compliance problems.
Conclusions The SCIP is one of the largest surgical patient safety and surgical site infection initiatives in the county. The stated goal is to reduce preventable surgical morbidity and mortality by 25% by 2010. We have shown at our universitybased teaching hospitals that it is possible to implement a project such as SCIP and achieve good results. SCIP necessitates some fundamental changes in the way surgeons practice and institutions function in the care of surgical patients. Most importantly, SCIP requires all of us to practice in a standardized evidence-based fashion in an effort to improve patient care.16 Surgical quality and performance improvement projects already have shown a reduction in surgical site infections in colorectal and cardiothoracic patients by following evidence-based practices.17–19 The savings in surgical morbidity and mortality should be well worth this intense effort. The Centers for Medicare and Medicaid Services estimates a reduction in surgical mortality of 13,000 lives and more than 270,000 complications if these measures are followed. These are underestimates of potential lives saved because the estimates are based on patients enrolled by Medicare and do not consider other surgical patients. The imperative is on the surgical profession to show an ability to take on these projects in the interest of good, safe patient care. By giving up a small amount of autonomy of individual practice, there are huge benefits to be accrued for the greater good. We now live in an era during which local and regional differences in patient care and outcomes will begin to diminish as we embrace common evidence-based surgical practice. If we do not take up the public health, best practice approach, we may find a more punitive payment methodology forced on us to use patient safety measures such as SCIP.19 It is time to move forward and embrace those practices that unite us and serve to provide for the optimal care of the surgical patient.
References 1. Codman EA. A study in hospital efficiency 1914 –16. The Joint Commission Press, Oakbrook, IL; 1996. 2. Kohn LT, Corrigan JM, Donaldson MS, eds. Committee on Quality of Health Care in America, Institute of Medicine. To Err Is Human. 1999. [cited 2009 February 28]. Available from: http://www.iom.edu/CMS/ 8089/5575/4117.aspx. 3. Campaign to save 5 million lives. Institute for Healthcare Improvement. [cited 2009 February 28]. Available from: http://www.ihi.org/ IHI/Programs/Campaign/. 4. Barnett TE. The not-so-hidden costs of surgical site infections. AORN J 2007;86:249 –58. 5. Zhan C, Miller MR. Excess length of stay, charges and mortality attributable to medical injuries during hospitalization. JAMA 2003; 290:1868 –74. 6. Clancy CM. SCIP: making complications of surgery the exception rather than the rule. AORN 2008;87:621– 4. 7. Fry DE. Surgical site infections and the surgical care improvement project (SCIP): evolution of national quality measures. Surg Infect 2008;9:579 – 84.
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8. Altpeter T, Luckhardt K, Lewis J, et al. Expanded surgical time out: a key to real-time data collection and quality improvement. J Am Coll Surg 2007;204:527–32. 9. Pizza L, Goldfarb NI, Nash DB. Crew resource management and its applications in medicine. [cited 2009 April 22]. Available from: www. ahrq.gov/clinic/ptsafety/chapt44.htm. 10. Beya SC. Surgical care improvement project—an important initiative. AORN J 2006;83:1371–5. 11. Brendle TA. Surgical Care Improvement Project and the perioperative nurse’s role. AORN J 2007;86:94 –101. 12. Bratzler DW, Houch PM, Richards C, et al. Use of antimicrobial prophylaxis for major surgery-baseline results from the national surgical infection prevention project. Arch Surg 2005;140:174 – 82. 13. Dellinger EP, Hausmanns M, Bratzler DW, et al. Hospitals collaborate to decrease surgical site infections. Am J Surg 2005;190:9 –15. 14. Hawn MT, Gray SH, Vick CC, et al. Timely administration of prophylactic antibiotics for major surgical procedures. J Am Coll Surg 2006;203:803–11. 15. Hirsh J, Guyatt G, Albers G, et al. Antithrombotic and thrombolytic therapy. American College of Chest Physicians. Chest 2008;133: 110S–2S. 16. Wick EC, Gibbs L, Indorf LA, et al. Implementation of quality measures to reduce surgical site infection in colorectal patients. Dis Colon Rect 2008;51:1004 –9. 17. Hedrick TI, Turrentine FE, Smith RL, et al. Single-institution experience with the surgical infection prevention project in intra-abdominal surgery. Surg Infect 2007;8:425–35. 18. Trussell J, Gerkin R, Coates B, et al. Impact of a patient care pathway protocol on surgical site infection rates in cardiothoracic surgery patients. Am J Surg 2008;196:883–9. 19. Russell TR. The future of surgical reimbursement: quality care, pay for performance, and outcome measures. Am J Surg 2006;191:301– 4.
Discussion Dr. Russell Postier (Oklahoma City, OK): I have several comments and 2 questions. SCIP as you know is a process improvement program with the inherent benefits and drawbacks of any process improvement measure. The benefits are that it improves patient care as a result of adherence to data-driven best practices. It also is a systems approach to achieving the desired end result such as antibiotic administration in a timely fashion and administration of VTE prophylaxis in a timely fashion. But there are drawbacks to this kind of approach. It has the potential to delay the implementation of new and better therapies as they evolve and it emphasizes and spends a lot of time and energy on arbitrary guidelines such as timing of therapy. For instance, is an antibiotic given 61 minutes before an operation really less effective than one given 60 minutes before an operation? The same is true with deep vein thrombosis (DVT) prophylaxis. The authors provide a nice narrative of their experience and the problems they have encountered and the solutions they have come up with. However, just as in politics, much of SCIP is local. One of my colleagues and I served as a coleader of a Centers for Medicare and Medicaid Services-funded statewide collaborative of hospitals in our state, looking just at the antibiotic prophylaxis component of SCIP. We found that most hospitals need to develop programs that are unique to their local environment. Many
887 of our hospitals will have specific solutions to the problems. It may be different than yours. I really have 2 questions. What is being done to further improve compliance in the area of DVT prophylaxis and -blocker use, which were 2 of your lower scoring areas, and how widely do you distribute your results? Are all surgeons aware of their own data? Are they aware of their services’ data? Again, important work, well presented, and well written. Thank you for allowing me to discuss it. Dr. Potenza: We share many of your concerns about the strict rules and regulations concerning the surgical improvement project. However, there needs to be some degree of standardization of the project so that we all may participate. One can hope that the governing board of SCIP will remain open to consider new and alternative methods to achieve the stated goals as they become apparent. We all have examples of rules that clinically do not make complete sense. For example, in the timing of the preoperative antibiotic being a few minutes late in the administration really does not impact on the clinical outcome. We know from our own literature that whether it is given at 60 minutes or 61 minutes or even 75 minutes, the effect is relatively the same, as long as it is in an appropriate time. We have to live with those rules right now and they have killed us on some of these markers. Yet this has given us some administrative challenges in order to meet the SCIP regulations. For example, our inability to administer our antibiotics within 1 hour of our operative procedures was off by less than 15 minutes in 75% of the cases. We also found out that selected case types were the biggest offenders. These included the big cardiothoracic cases where they are putting in lines, putting in doublelumen endotracheal tubes, but we have changed how we do business trying to achieve that. In the cases of -blockade and deep-vein thrombosis prophylaxis, we have actually made some good success with the DVT by changing our order sets and really forcing everybody who gets to the operating room to go through a checklist and DVT is one of those processes. The -blocker has been a very challenging process. And that is putting it nicely; a nightmare is probably it a better way to describe it. We believe this is because our patients are coming from different areas of preoperative care and they are getting different ideas from different attending physicians. Just before I came to this meeting I had the opportunity to hear one of these phone encounters. After the OR nurse gave all of the instructions to the patient on where and what time to check in, I overheard the nurse reply to a patient inquiry “I do not know what to do about your medications, I am here just to tell you you are supposed to be here at 5:30 in the morning,” and that was the end of the conversation. So we have lost opportunity to intervene. We now have our preoperative anesthesia clinic be the last and final place that the patients go to before they end up in the operating room. In that clinic, they have the SCIP guidelines as well as other guidelines that we have set up by ourselves. Each patient is given a piece of paper with final preoperative instructions that the patient then goes
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The American Journal of Surgery, Vol 198, No 6, December 2009
home with, telling them what time, where to report, NPO status, and instructions on any other preoperative issues including medication administration. I hope that works for us. As you can see here on one of those slides, we actually are starting to come up and are in the 80% for ourselves. Dr. Michael Reardon (Houston, TX): I am a cardiac surgeon so I do not deal with anything outside of cardiac and -blockers and antibiotics have been our problem, too. My understanding of the -blocker was everybody coming for coronary bypass on -blockers, not just those that have been on -blockers. Dr. Potenza: The SCIP as it reads now is only if you are on -blockers. The way it looks like they are trying to take it is that you need to be placed on -blockers. Remember there are 10 groups on the SCIP and they are fairly responsive. They put a lot of opposition to saying that everybody who comes for cardiac surgery needs to have the -blockade on. Dr. Reardon: We have queried SCIP and they have told us everybody needs to be on -blockers and they are not putting it forth as you have. The issues that I have of course is that my cardiologists come back with good evidencebased medicine that not everybody needs -blockers, so that makes it hard to challenge, whereas antibiotics are usually
just heart surgeons even older than I am who just say that is the way I do it. How do you handle both those situations? People that come at you with reasonable evidence-based medicine versus those that say that is the way I do it. Dr. Potenza: Evidence-based medicine—what we have tried to do is funnel that energy back into a writing campaign, so we write to various societies so that it gets up to the SCIPS section committees who can create a change in policy. You have seen that the antibiotics have changed and there have been some changes in some of the dogma that they have propagated. I think that we just have to be responsive and just send the material up to them and say this is what we believe. They are not going to take everything. To answer your second question about physicians who are reluctant to change their practice patterns that may not conform to SCIP, we try to individually speak with them, present the data, answer their questions, and try to persuade them to change for the good of all of the surgical patients. We also have our Chairman give them a call and discuss this matter with them in a last effort. Some people, however, remain reluctant to alter their practice patterns and we have not yet found a way to effect change. Fortunately these practitioners are in the minority.