Transcript Surgical Care Improvement Project (SCIP)

Surgical Care Improvement
Project (SCIP)
CURRENT SCIP MEASURES
• SCIP-1
Pre-op Antibiotic given within 1 hr. before incision
• SCIP-2
Must receive SCIP recommended prophylactic antibiotic
• SCIP-3
Discontinue antibiotic within 24 hrs. of anesthesia end time
(cardiac op exception)
• SCIP-4
Controlled 6 am postoperative serum glucose (cardiac only)
• SCIP-6
Appropriate hair removal
• SCIP-CARD-2 Perioperative beta-blocker therapy for pre B blocker Rx
• SCIP-VTE-2
VTE prophylaxis within 24 hrs. prior to or after anesthesia end time
• SCIP-9
Remove urinary catheter by postop day 2
• SCIP-10
Temperature >96.8 F- 15 min. after anesthesia end time
SCIP-1-2-3 Antibiotics
Appropriate, Pre-incision Timing, D/C Time
Antibiotics
1. Given on time: 1 hour before incision, 2 hrs – Vancomycin & Levaquin
2. Appropriate selection of antibiotic-see guidelines sheet
3. Discontinued within 24 hour after anesthesia end time
(exception: 48 hours for cardiovascular surgery)
Provider must document reason to extend if applicable, i.e.: infection, suspected infection
Why:
Antibiotic must be present at time of fibrin formation (at surgical incision) for effectiveness.
Cephalosporins have broad spectrum of activity against both gram-positive and gramneg bacteria and wide range of therapeutic to toxic dosage.
Cephalosporin's are inexpensive and easy to administer, and allergic reactions are rare.
After an incision is closed, antibiotics have no appreciable effect of preventing
infections.
Preferred Antibiotic Prophylaxis
PREFERRED ANTIBIOTIC PROPHYLAXIS
(complete infusion prior to incision when possible)
Adult Surgery
Procedure
No history of Penicillin OR
Cephalosporin Allergies = rash
Yes, history of Penicillin OR Cephalosporin
Allergies
Cardiac
Cefazolin (Ancef®)
Vancomycin**
Clindamycin
Vascular
Cefazolin (Ancef®)
Vancomycin**
Clindamycin
Hip/Knee
Arthroplasty
Cefazolin (Ancef®)
Vancomycin**
Clindamycin
Colon
Cefotetan
Ertapenem (Invanz®) x 1 dose only
Cefoxitin (Mefoxin®)
Ampicillin/Sulbactam (Unasyn®)
Cefazolin + Metronidazole (Flagyl®)
Levofloxacin (Levaquin®) + Metronidazole (Flagyl®)
Gentamicin + Metronidazole (Flagyl®)
Clindamycin + Gentamicin
Clindamycin + Aztreonam
Clindamycin + Levofloxacin (Levaquin®)
Hysterectomy
Cefazolin (Ancef®)
Cefotetan
Ampicillin/Sulbactam (Unasyn®)
Cefoxitin (Mefoxin®)
Clindamycin + Gentamicin
Levofloxacin(Levaquin®) + Metronidazole (Flagyl®)
Clindamycin + Aztreonam
Clindamycin + Levofloxacin (Levaquin®)
Gentamicin + Metronidazole (Flagyl®)
If Using Vanco
**If Vancomycin is marked on the physician order and patient does NOT
have any allergies, one of the following needs to be documented :
•
•
•
•
•
MRSA, Colonization or infection
Patient with an acute inpatient hospitalization within the last year
Patient residing in a nursing home within the last year
Patient with chronic wound care or dialysis
Patient with continuous inpatient stay more than 24 hours prior to the
principal procedure
• Patient transferred from another inpatient hospitalization after a 3 day
stay
• Patient undergoing valve surgery
Re-dosing
**Levofloxacin, gentamicin, ertapenem, and metronidazole do NOT need to be re-
dosed at any time intraoperatively
2 hours
3 hours
4 hours
6 hours
12 hours
Cefoxitin
Cefotaxime
Cefazolin
Cefotetan
Vancomycin
Aztreonam
Clindamycin
Ampicillin/
sulbactam
*Re-dosing
recommendations come from 2012 Infectious Disease Society of America (IDSA)
Recommendations
SCIP-4 Blood Glucose < 200
• Blood Glucose
(CV has it in their guidelines)
Cardiac surgery patients – controlled 6AM postoperative serum glucose
(less than 200 mg/dl postop day 1 and 2)
Why?
Risk of infections higher if blood glucose levels elevated
SCIP-6 Hair Removal
• Hair Removal
Clippers in OR only-no other option
Why?
Shaving with a razor causes skin abrasions which may lead to
infections.
SCIP-9 Foley D/C
• Urinary Catheter
Discontinued by postop day 2
Or physician, PA, APN documented reason to continue beyond day
2-i.e.: pts. with urologic, gyne, perineal op, I&O
Why?
Risk of urinary tract infection (UTI) with > use of urinary catheter
SCIP-Cardiac-2
Beta Blocker
• Beta Blocker
– Continue if patient on home beta blocker therapy
– Beta blocker may be given 24 hrs. prior to op or day of
procedure (up to 12 midnight) heart rate must be ≥ 50 and
systolic blood pressure ≥ 100
If held according to parameters, physician, PA, APN reason must be
documented
– Then Beta blocker continued postop days 1 & 2
(Physician, PA, APN documented reason if held postop)
Why?
Perioperative myocardial ischemia has been identified as the #1 risk
factor for mortality after non-cardiac surgery. This is attributed to the
exaggerated sympathetic response leading to persistently elevated
heart rate.
Has the potential to significantly reduce cardiac deaths for up to 2 years
postoperatively!
SCIP-VTE-2 Timing Of VTE Prophylaxis
VTE (Venous Thromboembolism) Prophylaxis
 Mechanical and/or pharmacological prophylaxis is ordered according
to VTE risk assessment tool and type of surgery
 Prophylaxis is given 24 hrs. prior to surgery or within 24 hours after
anesthesia end time
 (guidelines on back of checklist)
Provider documentation required if contraindicated : i.e. open wound,
bleeding risk.
Why?
Reduces the risk of development of pulmonary embolism and DVT
VTE Prophylaxis
RECOMMENDED VTE PROPHYLAXIS
Pharmacological VTE Prophylaxis is required for surgeries below unless contraindication is
documented. Applicable for surgeries of 60 minutes or greater
General and Colorectal
Surgery
 Heparin
 Enoxaparin/Lovenox
If contraindication to above is documented, then:
 Graduated compression stockings
 Sequential compression devices
Elective Hip
Replacement
 Enoxaparin/Lovenox •Fondaparinux/Arixtra
 Warfarin/Coumadin
•Rivaroxaban/Xarelto
If contraindication to above is documented, then:
 Venous foot pumps
 Sequential compression devices
Hip Fractures
 Heparin
•Fondaparinux/Arixtra
 Enoxaparin/Lovenox
 Warfarin/Coumadin
If contraindication to above is documented, then:
 Graduated compression stockings
 Venous foot pumps
 Sequential compression devices
VTE Prophylaxis
RECOMMENDED VTE PROPHYLAXIS
Pharmacological or Mechanical VTE Prophylaxis is required for surgeries below. Applicable for
surgeries of 60 minutes or greater. Patients should be evaluated for risk factors for VTE.
Elective Total Knee
Replacement
Urologic Surgery
Gynecological Surgery
Intracranial Neurosurgery
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Enoxaparin/Lovenox
Warfarin/Coumadin
Rivaroxaban/Xarelto
Fondaparinux/Arixtra
Venous foot pumps
Sequential compression devices
Heparin
Enoxaparin/Lovenox
Sequential compression devices
Graduated compression stocking
Heparin
Enoxaparin/Lovenox
Sequential compression devices
Heparin
Enoxaparin/Lovenox
Sequential compression devices
SCIP-10 Normothermia
• Temperature Management
At least ≥ 96.8°F/36°C within 15 minutes of anesthesia end time or warmer
used in OR
Exception: Provider documentation of intentional hypothermia
Why?
3 times greater incidence of surgical site infections with hypothermia
Delayed wound closure which results in prolonged hospitalization
SCIP Performance Team
2011-present
Surgery
managers
Surgery
Director
Pre, Post ,
and PACU
Managers
Pharm D's
SCIP
Perioperative
APN’s
Performance
Quality
experts
Team
Educators
Leader
Nursing unit
managers
6 Sigma
Resources
Heart Hospital
coordinator
SCIP CHECKLIST FOR SURGICAL PATIENT
> 18 years of age (Excluding Outpatients)
Patient Sticker
Surgical Care Improvement Project
PRE-OP/NURSING UNIT
Clerks: Please return weekly
via in-house mail with your
unit return address on front
to: Linda Cooper, APN, North
Bldg., Room 2695
INTRA-OP
PACU/ICU
NURSING UNIT
Before Anesthesia Induction
Before Skin Incision
Before Patient Leaves PACU
After Patient Leaves PACU
Date of Surgery___________
Antibiotic given within 1 hour
prior to incision
Temp documented above 96.8F
(36C) within 15 minutes
anesthesia end time.
(2 hrs for Vancomycin and
Levaquin)
Patient on a Beta Blocker prior to
admission
□Yes □
□
N/A*
Last Beta Blocker dose
documented
Date/Time: ______________
Yes
□
Intra-Op Re-dose Time or N/A*:
_____________________
FORCED AIR WARMER
Documented
No
□
□N/A (See Chart on Back)
□
No □ N/A*
Antibiotic Time:
_____________________
Antibiotic appropriate for
procedure
□
□
Yes
Yes
□
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Yes
□
No
VTE Prophylaxis Orders in place:
(See Chart on Back)
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□
Mechanical
Pharmacological Intervention
Contraindicated, Provider
Documentation
No
□
Yes
□
SCD/TED Hose applied
(circle one)
□
Yes
□
□
Provider MUST Document reason
for holding Beta Blocker each 24
hrs
Antibiotic Post-Op First Dose
Time:
___________________
Antibiotic d/c less than 24 hrs
after anesthesia end time
Yes
□
No
Removed POD 1: □ Yes □ No
Removed POD 2: □ Yes □ No
Anesthesia End Time:
__________________
Provider must document reason to
continue Foley if not discontinued
by POD 2
_____/_________/________
Signatures
_______/___________/_______
Signatures
no Foley
N/A*
_____/_________/________
Signatures
*Not Applicable
Foley Cath – Ask provider if
Foley catheter can be removed or
□ No
□ No
Foley Catheter d/c’d
Post-Op day 1 or 2 or N/A*
No
□
Beta Blocker or N/A*
Post Op Day 1: □ Yes
POD 2: □ Yes
□
Mechanical VTE Prophylaxis
applied
VTE Risk Assessment
completed
Day Zero = Date of Surgery
_________/_____________
Signatures
*NOT A PERMANENT PART OF
THE MEDICAL RECORD*
Rev 1/10/13
RECOMMENDED VTE PROPHYLAXIS
RECOMMENDED VTE PROPHYLAXIS
Pharmacological VTE Prophylaxis is required for surgeries
below unless contraindication is documented. Applicable for
surgeries of 60 minutes or greater
Pharmacological or Mechanical VTE Prophylaxis is required
for surgeries below. Applicable for surgeries of 60 minutes or
greater. Patients should be evaluated for risk factors for
VTE.
General and
Colorectal Surgery
Elective Hip
Replacement
Hip Fractures
 Heparin
 Enoxaparin/Lovenox
If contraindication to above is documented, then:

Graduated compression stockings

Sequential compression devices
 Enoxaparin/Lovenox
•Fondaparinux/Arixtra
 Warfarin/Coumadin
•Rivaroxaban/Xarelto
If contraindication to above is documented, then:

Venous foot pumps

Sequential compression devices
 Heparin
•Fondaparinux/Arixtra
 Enoxaparin/Lovenox
 Warfarin/Coumadin
If contraindication to above is documented, then:

Graduated compression stockings

Venous foot pumps

Sequential compression devices
Elective Total Knee
Replacement
Urologic Surgery
Gynecological
Surgery
Intracranial
Neurosurgery
















Enoxaparin/Lovenox
Warfarin/Coumadin
Rivaroxaban/Xarelto
Fondaparinux/Arixtra
Venous foot pumps
Sequential compression devices
Heparin
Enoxaparin/Lovenox
Sequential compression devices
Graduated compression stocking
Heparin
Enoxaparin/Lovenox
Sequential compression devices
Heparin
Enoxaparin/Lovenox
Sequential compression devices
PREFERRED ANTIBIOTIC PROPHYLAXIS (complete infusion prior to incision when possible)
Adult Surgery Procedure
Cardiac
No history of Penicillin OR
Cephalosporin Allergies = rash
Cefazolin (Ancef®)
Vascular
Cefazolin (Ancef®)
Hip/Knee Arthroplasty
Cefazolin (Ancef®)
Colon
Cefotetan
Ertapenem (Invanz®) x 1 dose only
Cefoxitin (Mefoxin®)
Ampicillin/Sulbactam (Unasyn®)
Cefazolin + Metronidazole (Flagyl®)
Cefazolin (Ancef®)
Cefotetan
Ampicillin/Sulbactam (Unasyn®)
Cefoxitin (Mefoxin®)
Hysterectomy
Yes, history of Penicillin OR Cephalosporin
Allergies
Vancomycin**
Clindamycin
Vancomycin**
Clindamycin
Vancomycin**
Clindamycin
Levofloxacin (Levaquin®) + Metronidazole (Flagyl®)
Gentamicin + Metronidazole (Flagyl®)
Clindamycin + Gentamicin
Clindamycin + Aztreonam
Clindamycin + Levofloxacin (Levaquin®)
Clindamycin + Gentamicin
Levofloxacin(Levaquin®) + Metronidazole (Flagyl®)
Clindamycin + Aztreonam
Clindamycin + Levofloxacin (Levaquin®)
Gentamicin + Metronidazole (Flagyl®)
**If Vancomycin is marked on the physician order sheet and patient does NOT have any
allergies, one of the following needs to be documented on the order sheet:
 MRSA, Colonization or infection
 Patient with an acute inpatient hospitalization within the last year
 Patient residing in a nursing home within the last year
 Patient with chronic wound care or dialysis
 Patient with continuous inpatient stay more than 24 hours prior to the principal procedure
 Patient transferred from another inpatient hospitalization after a 3 day stay
Patient undergoing valve surgery
Use
Alternative
Prophylaxis
for patients
with
cephalosporin
allergy or
major
penicillin
allergy (e.g.
Shortness of
breath,
anaphylaxis,
swelling,
angioedema)
or major
allergy to
ertapenem)
meropenem,
imipenem/cili
statin, or
doripenem
*General Surgery includes
esophageal, lung,
abdominal/peritoneal &
rectal surgeries. NOTE: If
SCIP guidelines are not
followed, the surgeon
must document
Post-op Antibiotic: Discontinue within 24 hours (exception: Cardiac surgery); If continue document suspected infection
INTRAOP RE-DOSING Guidelines for Prophylactic Antibiotics*
2 hours
3 hours
4 hours
6 hours
12 hours
Cefoxitin
Cefotaxime
Cefazolin
Cefotetan
Vancomycin
Aztreonam
Clindamycin
Ampicillin/sulbactam
*Re-dosing recommendations come from 2012 Infectious Disease Society of America (IDSA) Recommendations
**Levofloxacin, gentamicin, ertapenem, and metronidazole do NOT need to be re-dosed at any time intraoperatively
1/23/2013 OSF SFMC-SCIP P4P Team, K Self/L Cooper
We Can’t Afford Even One Miss!!
We CAN achieve our goal of 100% compliance if
we ALL work together to make it happen!