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 AntibioticsAppropriate, 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 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 ProphylaxisPREFERRED 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 CefotetanErtapenem (Invanz®) x 1 dose onlyCefoxitin (Mefoxin®)Ampicillin/Sulbactam (Unasyn®)Cefazolin + Metronidazole (Flagyl®)

Levofloxacin (Levaquin®) + Metronidazole (Flagyl®)Gentamicin + Metronidazole (Flagyl®)Clindamycin + GentamicinClindamycin + AztreonamClindamycin + Levofloxacin (Levaquin®)

Hysterectomy

Cefazolin (Ancef®)Cefotetan Ampicillin/Sulbactam (Unasyn®)Cefoxitin (Mefoxin®)

Clindamycin + Gentamicin Levofloxacin(Levaquin®) + Metronidazole (Flagyl®)Clindamycin + AztreonamClindamycin + 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

2 hours 3 hours 4 hours 6 hours 12 hours

Cefoxitin Cefotaxime Cefazolin Cefotetan Vancomycin

Ampicillin/

sulbactam

Aztreonam Clindamycin

**Levofloxacin, gentamicin, ertapenem, and metronidazole do NOT need to be re-dosed at any time intraoperatively

*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 ProphylaxisVTE (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 ProphylaxisRECOMMENDED 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/LovenoxIf contraindication to above is documented, then: Graduated compression stockings Sequential compression devices

Elective Hip Replacement

Enoxaparin/Lovenox •Fondaparinux/Arixtra Warfarin/Coumadin •Rivaroxaban/XareltoIf contraindication to above is documented, then: Venous foot pumps Sequential compression devices

Hip Fractures Heparin •Fondaparinux/Arixtra Enoxaparin/Lovenox Warfarin/CoumadinIf 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

Enoxaparin/Lovenox Warfarin/Coumadin Rivaroxaban/Xarelto Fondaparinux/Arixtra Venous foot pumps Sequential compression devices

Urologic Surgery Heparin Enoxaparin/Lovenox Sequential compression devices Graduated compression stocking

Gynecological Surgery Heparin Enoxaparin/Lovenox Sequential compression devices

Intracranial Neurosurgery 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 Team2011-present

SCIP Performance

Team Leader

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

Patient Sticker

SCIP CHECKLIST FOR SURGICAL PATIENT > 18 years of age (Excluding Outpatients)

Surgical Care Improvement Project

Clerks: Please return weekly via in-house mail with your unit return address on front

to: Linda Cooper, APN, North Bldg., Room 2695

PRE-OP/NURSING UNIT

Before Anesthesia Induction Date of Surgery___________

Patient on a Beta Blocker prior to

admission

□Yes □ N/A*

Last Beta Blocker dose documented

Date/Time: ______________

Antibiotic appropriate for procedure

□ Yes □ No

□N/A (See Chart on Back)

□ VTE Risk Assessment

completed

SCD/TED Hose applied (circle one)

□ Yes □ N/A* _____/_________/________

Signatures *Not Applicable

INTRA-OP

Before Skin Incision

Antibiotic given within 1 hour prior to incision

(2 hrs for Vancomycin and Levaquin)

□ Yes □ No □ N/A*

Antibiotic Time: _____________________

Intra-Op Re-dose Time or N/A*:

_____________________

FORCED AIR WARMER Documented

□ Yes □ No

Mechanical VTE Prophylaxis applied

□ Yes □ No

□ Foley Cath – Ask provider if Foley catheter can be removed or

□ no Foley _________/_____________

Signatures

*NOT A PERMANENT PART OF THE MEDICAL RECORD*

PACU/ICU

Before Patient Leaves PACU

Temp documented above 96.8F (36C) within 15 minutes

anesthesia end time.

□ Yes □ No

VTE Prophylaxis Orders in place: (See Chart on Back)

□ Mechanical

□ Pharmacological Intervention

□ Contraindicated, Provider Documentation

Anesthesia End Time:

__________________

_____/_________/________ Signatures

NURSING UNIT

After Patient Leaves PACU

Beta Blocker or N/A* Post Op Day 1: □ Yes □ No POD 2: □ Yes □ No

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

Foley Catheter d/c’d Post-Op day 1 or 2 or N/A*

Removed POD 1: □ Yes □ No Removed POD 2: □ Yes □ No

Provider must document reason to continue Foley if not discontinued

by POD 2

_______/___________/_______ Signatures

Rev 1/10/13

Day Zero = Date of Surgery

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

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 Enoxaparin/Lovenox Sequential compression devices Graduated compression stocking

Gynecological Surgery

Heparin Enoxaparin/Lovenox Sequential compression devices

Intracranial Neurosurgery

Heparin Enoxaparin/Lovenox Sequential compression devices

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®)

INTRAOP RE-DOSING Guidelines for Prophylactic Antibiotics*

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 **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

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/cilistatin, or doripenem

*General Surgery includes esophageal, lung, abdominal/peritoneal & rectal surgeries. NOTE: If SCIP guidelines are not followed, the surgeon must document

**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

Post-op Antibiotic: Discontinue within 24 hours (exception: Cardiac surgery); If continue document suspected infection

We Can’t Afford Even One Miss!!

We CAN achieve our goal of 100% compliance if we ALL work together to make it happen!