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 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 gram- neg 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 (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 Hip/Knee Arthroplasty 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   Levofloxacin(Levaquin®) + 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 2 hours 3 hours 4 hours 6 hours 12 hours Cefoxitin **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 Ampicillin/ sulbactam   Aztreonam Clindamycin *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 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 Venous foot pumps Hip Fractures Heparin •Fondaparinux/Arixtra Warfarin/Coumadin

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 Enoxaparin/Lovenox Warfarin/Coumadin Rivaroxaban/Xarelto Fondaparinux/Arixtra Venous foot pumps Sequential compression devices Urologic Surgery Heparin Graduated compression stocking Gynecological Surgery Intracranial Neurosurgery

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 Leader Team SCIP Surgery managers Surgery Director Pre, Post , and PACU Managers Quality experts 6 Sigma Resources Heart Hospital coordinator Nursing unit managers Perioperative APN’s Educators Pharm D's

Nursing tool to aid physicians House wide roll out 12/10/12

Guidelines page

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