1. Surgical Care Improvement Project (SCIP)

2. CURRENT SCIP MEASURES
SCIP Pre-op Antibiotic given within 1 hr. before incision
SCIP Must receive SCIP recommended prophylactic antibiotic
SCIP Discontinue antibiotic within 24 hrs. of anesthesia end time
(cardiac op exception)
SCIP Controlled 6 am postoperative serum glucose (cardiac only)
SCIP Appropriate hair removal
SCIP-CARD-2 Perioperative beta-blocker therapy for pre B blocker Rx
SCIP-VTE VTE prophylaxis within 24 hrs. prior to or after anesthesia end time
SCIP Remove urinary catheter by postop day 2
SCIP Temperature >96.8 F- 15 min. after anesthesia end time

3. 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.

4. 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®)

5. 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

6. 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

7. 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

8. 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.

9. 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

10. 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!

11. 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

12. 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

13. 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

14. 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

15. 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

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

17. Guidelines page

18. We Can’t Afford Even One Miss!!
We CAN achieve our goal of 100% compliance if
we ALL work together to make it happen!