Surgical Care Improvement Project Research Articles

When Antimicrobial Treatment and Surgical Prophylaxis Collide: A Stewardship Opportunity.

Background: In 2002, the Centers for Medicare and Medicaid Services (CMS) in collaboration with the Centers for Disease Control and Prevention (CDC) established the Surgical Infection Prevention (SIP) project for the purposes of developing and standardizing quality improvement measures known to reduce the rates of post-operative surgical site infections (SSIs). Four years later the Surgical Care Improvement Project (SCIP), an expansion of SIP, was published in governmental Specifications Manual for National Inpatient Quality Measures and provided several additional initiatives applicable to the perioperative period. Central to both projects are the assurance of the timeliness, selection, and duration of peri-operative surgical prophylactic antibiotics. In support of this objective, various medical associations, such as the American Society of Health-System Pharmacists (ASHP) and the Infectious Diseases Society of America (IDSA), have developed the Clinical Practice Guidelines for Antimicrobial Prophylaxis in Surgery. To ensure compliance with quality measures, hospitals are required to report data to the Physicians Quality Reporting System, which is then reviewed by CMS for reimbursement purposes and to measure hospital performance. To maintain optimal standards of care and satisfy all core measures, it is expected that patients undergoing most categories of surgical procedures receive prophylactic antibiotics. We recognized that patients already being administered antimicrobial therapy as treatment for the condition requiring the surgery not uncommonly also were prescribed unwarranted and redundant pre-operative antibiotics. Our study was meant to quantify such antibiotic redundancy, which only risks the development of antimicrobial resistance and adverse events, to bolster our and other hospitals antimicrobial stewardship programs. Methods: A retrospective analysis of computerized hospital records over a one-month period of time (November 2022) was conducted focusing on hospital admissions that involved surgical operative procedures. Only those patients who had received a pre-operative surgical prophylactic antibiotic were included in the analysis. Results: Of the 92 surgeries that fulfilled the inclusion criteria, 38 (41.3%) were performed on patients who were already receiving therapeutic antibiotics for more than 24 hours targeted to treat the infection for which they were undergoing surgery. These included laparoscopic cholecystectomy (24), appendectomy (12), wound debridement (12), and soft tissue incision and drainage procedures (9), comprising nearly 50% of each type of these operations performed during the study time period. Conclusion: These findings demonstrate a clear opportunity to strengthen both our, and presumably other, hospitals antimicrobial stewardship programs. Together with physician education, granting the pharmacy the ability to cancel unnecessary and redundant surgical prophylactic antibiotics would conceivably be of great benefit.

1233. Leveraging Informatics to Evaluate and Sustain Improvements in Peri-Operative Antimicrobial Prophylaxis Achieved Under the Surgical Care Improvement Project (SCIP)

Abstract Background The Surgical Care Improvement Project (SCIP) was a national quality improvement program designed to improve peri-operative outcomes. The SCIP Program included several guideline-based antimicrobial stewardship measures, including discontinuation of antibiotics within 48 hours of skin closure for cardiac surgeries (INF-3). INF-3 was retired at the end of 2015; since this time, no systematic tools have been developed to support ongoing quality assessments. Methods We developed a retrospective, national cohort of cardiac surgeries in the national VA healthcare system during the period from 2010-2015 and merged these data with data from the VA External Peer Review Program, which included manually-assessed SCIP metrics, including INF-3. We electronically re-created the SCIP program by mapping exclusion criteria and developing code to assess the duration of post-operative antimicrobial use (Table 1). Among the manually-adjudicated cohort, we then iteratively refined the electronic tool until pre-specified criterion validity were achieved. After development, INF-3 compliance as assessed manually and by the objective informatics tool were compared. Results During the study period, 11,361 cardiac surgeries representing 26 VA facilities met inclusion criteria. The overall estimated compliance rate was 97.7% in the EPRP-reviewed cases (N=11,361) and 95.9% as-assessed by the informatics tool (N=9,561 cases); facility quality rankings using both methods were similar but not exactly the same (Figure 1). Facility-level compliance trends were similar using both measurement methodologies and the correlation between the two measures was high (r=0.69); however, the informatics tool consistently estimated compliance to be approximately 1.9% lower than manually reviewed cases (Figure 2). As estimated by the manual review program, 16 facilities (61.5%) achieved >97% compliance rates versus 9 facilities (34.6%) as estimated by the informatics tool. Figure 2. Facility-Level Compliance with INF-3 as Measured by Manual Review versus via Objective Electronic Tool Conclusion We developed a comprehensive, objective informatics tool for assessing ongoing compliance with SCIP INF-3. The tool can be applied in future investigations to assess the sustainability of practice changes achieved under the SCIP program and to identify areas for future improvement. Disclosures Westyn Branch-Elliman, MD, MMsc, DLA Piper, LLC/Medtronic: Advisor/Consultant|DLA Piper, LLC/Medtronic: Expert Testimony|Gilead Sciences: Grant/Research Support

Novel Intra- Operative Wound Irrigation Solution to Manage Infection Prevention in Patients Undergoing Primary Joint Arthroplasty: Retrospective Review of a Case Series of 308 Patients

Introduction Periprosthetic joint infection (PJI) after total hip and total knee arthroplasty is a devastating complication that is known to be associated with costly, resource-intensive interventions that place a significant burden on the US healthcare system. Estimated average hospital costs to treat female patients with PJI after total knee arthroplasty (TKA) or total hip arthroplasty (THA) in 2018 was $27,307, and $32,956 respectively. While the average costs to treat male patients with PJI after TKA or THA was $27,097 and $33,090 respectively. One strategy aimed at preventing PJI after total joint arthroplasty is the use of an intra-operative wound irrigation with an antiseptic solution. This retrospective case review was conducted to assess the incidence of PJI after using a novel wound antiseptic irrigation solution in patients undergoing primary TKA and THA. Methods The CDC defines surgical site infections, (SSI) as infections that occur after the surgery. The infections are further categorized as superficial involving the skin, or deep tissue. These infections are then divided into; superficial incisional SSI, deep incisional SSI, and organ-space SSI. In a study by Kannan et al., SSIs are more commonly seen in patients with more comorbidities. A consecutive series of 308 high-risk patients undergoing primary TKA or THA between January 4, 2021 and August 30, 2021, in whom Prontosan® Wound Irrigation Solution (B. Braun Medical Inc./ Innovice LLC), containing 0.1% Betaine, a surfactant, and 0.1% Polyhexanide (PHMB) was added to the intra-operative procedure, were evaluated for its impact on the incidence of PJI. The CDC’s Surgical Care Improvement Project, (SCIP) guidelines are standard of care and followed with each surgical procedure. The CDC recommends using antimicrobial prophylaxis at a time before skin incision such that the antibiotic concentration reaches the minimum bactericidal concentration at the time of skin incision, Berríos-Torres SI, et al. All data were prospectively submitted to the American Joint Replacement Registry (AJRR) was retrospectively analyzed to measure the incidence of postoperative infection. Results Primary TJA was performed on 308 patients; of these 10 patients were bilateral TKA (205 TKA procedures and 113 THA procedures). The use of Prontosan® Wound Irrigation Solution was associated with zero (0%) incidence of postoperative infection in this population of patients during a 90-day episode of care, nor at any time postoperatively. CMS defines total joint arthroplasty codes as a major surgery, and encounters or procedures within 90 days of the initiating procedure are included in the 90-day episode of care. No patients were lost to follow-up. Conclusion There was no incidence of PJI uncovered in this retrospective analysis. Adding Prontosan® Wound Irrigation Solution to the intra-operative protocol, contributed to the absence of PJI in this population and potentially avoided 1.74 female and 1.34 male TKA as well as .95 female and .75 THA resulting in total hospital-avoided costs of $83,824 and $56,126, respectively totaling $139,950.

Association of adherence to individual components of Society of Thoracic Surgeons cardiac surgery antibiotic guidelines and postoperative infections

ObjectivesThe study objectives were to measure the association among the 4 components of Society of Thoracic Surgeons antibiotic guidelines and postoperative complications in a cohort of patients undergoing valve or coronary artery bypass grafting requiring cardiopulmonary bypass. MethodsIn this retrospective observational study, adult patients undergoing coronary revascularization or valvular surgery who received a Surgical Care Improvement Project–compliant antibiotic from January 1, 2016, to April 1, 2021, at a single, tertiary care hospital were included. The primary exposures were adherence to the 4 individual components of Society of Thoracic Surgeons antibiotic best practice guidelines. The association of each component and a combined metric was tested in its association with the primary outcome of postoperative infection as determined by Society of Thoracic Surgeons data abstractors, controlling for several known confounders. ResultsOf the 2829 included patients, 1084 (38.3%) received care that was nonadherent to at least 1 aspect of Society of Thoracic Surgeons antibiotic guidelines. The incidence of nonadherence to the 4 individual components was 223 (7.9%) for timing of first dose, 639 (22.6%) for antibiotic choice, 164 (5.8%) for weight-based dose adjustment, and 192 (6.8%) for intraoperative redosing. In adjusted analyses, failure to adhere to first dose timing guidelines was directly associated with Society of Thoracic Surgeons–adjudicated postoperative infection (odds ratio, 1.9; 95% confidence interval, 1.1-3.3; P = .02). Failure of weight-adjusted dosing was associated with both postoperative sepsis (odds ratio, 6.9; 95% confidence interval, 2.5-8.5; P < .01) and 30-day mortality (odds ratio, 4.3; 95% confidence interval, 1.7-11.4; P < .01). No other significant associations among the 4 Society of Thoracic Surgeons metrics individually or as a combination were observed with postoperative infection, sepsis, or 30-day mortality. ConclusionsNonadherence to Society of Thoracic Surgeons antibiotic best practices is common. Failure of antibiotic timing and weight-adjusted dosing is associated with odds of postoperative infection, sepsis, and mortality after cardiac surgery.

Prophylactic Intraoperative Antibiotic Dosing in Head and Neck Surgery: Opportunities for Improvement and Future Study.

To investigate rates of Surgical Care Improvement Project (SCIP) guideline adherence with regard to intraoperative antibiotic prophylaxis in head and neck surgery with free tissue transfer. Retrospective case series. A single academic center. All patients who underwent mucosa-violating head and neck oncologic surgery with free tissue transfer between March 2017 and June 2019 were reviewed. Intraoperative antibiotic data included type, dosage, frequency of administration, and duration. Any deviation from SCIP recommendations was defined as nonadherence. Antibiotic type was categorized as ampicillin-sulbactam, cefazolin/metronidazole, clindamycin, and others. As a secondary exploratory analysis, postoperative infections were analyzed and stratified by adherent vs nonadherent and by antibiotic type. A total of 129 surgical procedures were included. The mean ± SD number of antibiotic doses during surgery was 3.16 ± 1.2. The mean number of missed doses was 1.86 ± 1.65. Adherence rate with first dosing recommendation was 100%, as compared with 41.7% for dose 2, 23.1% for dose 3, 13.7% for dose 4, 5.26% for dose 5, 2.56% for dose 6, and 0% for dose 7 (P < .001). Ampicillin-sulbactam (6.4%) had a significantly lower rate of average redosing adherence when compared with cefazolin/metronidazole (73.2%) and clindamycin (63.3%; P < .001). Significant opportunities exist in SCIP guideline adherence rates for intraoperative antibiotic prophylaxis. Cefazolin/metronidazole had a significantly higher rate of appropriate redosing when compared with ampicillin-sulbactam, which should be considered when choosing a prophylactic antibiotic regimen and performing antibiotic-based outcomes studies. More attention should be given to intraoperative antibiotic prophylaxis in head and neck surgery with free tissue transfer, as this presents an opportunity for quality improvement and future study heretofore not explored.

Surgical Site Infections – Prevention Is Better Than Treatment!

Features| August 2022 Surgical Site Infections – Prevention Is Better Than Treatment! Kumar G. Belani, MBBS, MS, FACA, FAAP, SAMBA-F Kumar G. Belani, MBBS, MS, FACA, FAAP, SAMBA-F Search for other works by this author on: This Site PubMed Google Scholar ASA Monitor August 2022, Vol. 86, 18. https://doi.org/10.1097/01.ASM.0000855652.28534.79 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share MailTo Twitter LinkedIn Cite Icon Cite Get Permissions Search Site Citation Kumar G. Belani; Surgical Site Infections – Prevention Is Better Than Treatment!. ASA Monitor 2022; 86:18 doi: https://doi.org/10.1097/01.ASM.0000855652.28534.79 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search Search Dropdown Menu toolbar search search input Search input auto suggest filter your search All ContentAll PublicationsASA Monitor Search Advanced Search Topics: prevention, surgical wound infection This issue of the ASA Monitor is devoted to the prevention of surgical site infections (SSIs). The Centers for Disease Control and Prevention (CDC) defines SSI as “an infection that occurs after surgery in the part of the body where the surgery took place.” In 2015, the CDC estimated that 110,800 patients suffered from SSIs (asamonitor.pub/3O8UOXi). Such statistics resulted in the Surgical Care Improvement Project (SCIP), which was created to help reduce the rate of SSIs (JAMA Surg 2017;152:784-91). Hospitals are required to report SSIs (asamonitor.pub/3xtGTUM). Treating patients with SSIs is expensive – the average cost for SSIs ranges from $10,443 to $25,546 (JAMA Surg 2017;152:784-91). The role of anesthesiologists in reducing SSIs has increased over the past decade, as summarized in the following articles in this issue of the Monitor. Drs. Ural, Rajan, Metry, and Rafique provide indications, doses, and... You do not currently have access to this content.

ID:16253 NACC Infection Control Recommendations and NANS Members Practice Patterns

Surgical site infections (SSI) are the second most common healthcare-related infections with high annual cost (10 billion US$). However, SSI rates have not significantly declined despite more than a decade of infection control recommendations by both Centers for Disease Control & Prevention (CDC) and Surgical Care Improvement Project (SCIP). Particularly, SSI rates after spinal cord stimulator (SCS) implantation range from 1 to 10%, with large studies reporting rates of 3.4 to 4.6%. In 2017, Neuromodulation appropriateness consensus committee (NACC) under auspices of International Neuromodulation Society, published evidence-based recommendations for infection prevention and management during SCS implantation. We conducted a survey of North American Neuromodulation Society (NANS) members to evaluate their knowledge and adherence to these guidelines and if knowledge and adherence varied by members’ practice setting.

Surgical Site Infection in Thoracic Surgery Is Not Associated With Perioperative Hypothermia.

Introduction: The Surgical Care Improvement Project (SCIP) added the SCIP-Inf-10 measure to mandate that all surgical patients have perioperative temperature management to reduce surgical site infection. While the basis of this measure originated in colorectal surgery, we hypothesized that this would also apply to thoracic surgery patients.Methods: This was a retrospective single-center pilot study reviewing two years of thoracic surgery cases for the incidence and duration of hypothermia during the operation and surgical site infection occurring within 30 days. Hypothermia was defined as a core temperature of < 36° C. Results: A total of 317 patients were included in the study. Sixty-two percent of patients were identified as hypothermic. The average intraoperative temperature was 35.4°C ± 0.8°C in the hypothermic group and 36.4°C ± 0.3°C in the normothermic group. There were four surgical site infections in the study with three cases from the <36°C group (p = 1). There was no difference in average post-anesthesia care unit length of stay between the groups. The average hospital length of stay was 5.5 ± 5.2 days for the hypothermic group and 8.6 ± 12.8 days for the normothermic group (p=0.0024).Conclusion: Perioperative hypothermia was common in thoracic surgery and did not have a negative impact on surgical site infection.

Assessing the sustainability of compliance with surgical site infection prophylaxis after discontinuation of mandatory active reporting: study protocol

BackgroundSurgical site infections are common. Risk can be reduced substantially with appropriate preoperative antimicrobial administration. In 2005, the VA implemented the Surgical Care Improvement Project (SCIP) in the setting of high rates of non-compliance with antimicrobial prophylaxis guidelines. SCIP included public reporting of evidenced-based antimicrobial guideline compliance metrics in high-risk surgeries. SCIP was highly successful and led to high rates of adoption of preoperative antimicrobials and early discontinuation of postoperative antimicrobials (>95%). The program was retired in 2015, as the manual measurement and reporting process was costly with limited expected additional benefit. To our knowledge, no studies have assessed whether the gains achieved by SCIP were sustained since active support for the program was discontinued. Furthermore, there has been no investigation of the spread of antimicrobial prophylaxis guideline adoption beyond the limited set of procedures that were included in the program.MethodsUsing a mixed methods sequential exploratory approach, this study will (1) quantitatively measure compliance with SCIP metrics over time and across all procedures in the five major surgical specialties targeted by SCIP and (2) collect qualitative data from stakeholders to identify strategies that were effective for sustaining compliance. Diffusion of Innovation Theory will guide assessment of whether improvements achieved spread to procedures not included under the umbrella of the program. Electronic algorithms to measure SCIP antimicrobial use will be adapted from previously developed methodology. These highly novel data mining algorithms leverage the rich VA electronic health record and capture structured and text data and represent a substantial technological advancement over resource-intensive manual chart review or incomplete electronic surveillance based on pharmacy data. An interrupted time series analysis will be used to assess whether SCIP compliance was sustained following program discontinuation. Generalized linear models will be used to assess whether compliance with appropriate prophylaxis increased in all SCIP targeted and non-targeted procedures by specialty over the duration the program’s active reporting. The Dynamic Sustainability Framework will guide the qualitative methods to assess intervention, provider, facility, specialty, and contextual factors associated with sustainability over time. Barriers and facilitators to sustainability will be mapped to implementation strategies and the study will yield an implementation playbook to guide future sustainment efforts.RelevanceSustainability of practice change has been described as one of the most important, but least studied areas of clinical medicine. Learning how practices spread is also a critically important area of investigation. This study will use novel informatics strategies to evaluate factors associated with sustainability following removal of active policy surveillance and advance our understanding about these important, yet understudied, areas.

Adherence to Guidelines for the Administration of Intraoperative Antibiotics in a Nationwide US Sample

Despite widespread adherence to Surgical Care Improvement Project antibiotic measures, prevention of surgical site infections (SSIs) remains a clinical challenge. Several components of perioperative antibiotic prophylaxis guidelines are incompletely monitored and reported within the Surgical Care Improvement Project program. To describe adherence to each component of perioperative antibiotic prophylaxis guidelines in regard to procedure-specific antibiotic choice, weight-adjusted dosing, and timing of first and subsequent administrations in a nationwide, multicenter cohort of patients undergoing noncardiac surgery. This cohort study included adult patients undergoing general, urological, orthopedic, and gynecological surgical procedures involving skin incision between January 1, 2014, and December 31, 2018, across 31 academic and community hospitals identified within the Multicenter Perioperative Outcomes Group registry. Data were analyzed between April 2 and April 21, 2021. The primary end point was overall adherence to Infectious Diseases Society of America guidelines, including (1) appropriateness of antibiotic choice, (2) weight-based dose adjustment, (3) timing of administration with respect to surgical incision, and (4) timing of redosing when indicated. Data were analyzed using mixed-effects regression to investigate patient, clinician, and institutional factors associated with guideline adherence. In the final cohort of 414 851 encounters across 31 institutions, 51.8% of patients were women, the mean (SD) age was 57.5 (15.7) years, 1.2% of patients were of Hispanic ethnicity, and 10.2% were Black. In this cohort, 148 804 encounters (35.9%) did not adhere to guidelines: 19.7% for antibiotic choice, 17.1% for weight-adjusted dosing, 0.6% for timing of first dose, and 26.8% for redosing. In adjusted analyses, overall nonadherence was associated with emergency surgery (odds ratio [OR], 1.35; 95% CI, 1.29-1.41; P < .001), surgery requiring blood transfusions (OR, 1.30; 95% CI, 1.25-1.36; P < .001), off-hours procedures (OR, 1.08; 95% CI, 1.04-1.13; P < .001), and procedures staffed by a certified registered nurse anesthetist (OR, 1.14; 95% CI, 1.11-1.17; P < .001). Overall adherence to guidelines for antibiotic administration improved over the study period from 53.1% (95% CI, 52.7%-53.5%) in 2014 to 70.2% (95% CI, 69.8%-70.6%) in 2018 (P < .001). In this cohort study, although adherence to perioperative antibiotic administration guidelines improved over the study period, more than one-third of surgical encounters remained discordant with Infectious Diseases Society of America recommendations. Future quality improvement efforts targeting gaps in practice in relation to guidelines may lead to improved adherence and possibly decreased SSIs.

Improved Postoperative Outcomes By Utilizing A Comprehensive Perioperative Surgical Site Infection (SSI) Reduction Bundle

Background: Surgical site infections (SSIs) can be attributed to increased patient morbidity and mortality, prolonged hospital stays, and overall increased healthcare costs. The Surgical Care Improvement Project (SCIP) was implemented in 2002 but has made limited impact on SSI rates across our facilities, which has led to the creation of a bundled approach of current evidence-based strategies. Methods: In January 2019, a comprehensive SSI prevention bundle of strategies was implemented across a multihospital health system. The bundle was comprised of 8 interventions focusing on the preoperative, intraoperative, and postoperative continuum of care, and refining documentation in the electronic medical record. From January to September 2019 (preointervention period), data were collected from 7,163 adult inpatient and observation elective patients undergoing colon surgery (COLO), abdominal hysterectomy (HYST), hip arthroplasty (HPRO), knee arthroplasty (KPRO), and cardiac bypass graft (CBGB/CBGC). The preintervention period for SSI standardized infection ratios (SIRs) and retrospective review of process measures was set as January–December 2018 (postintervetnion period). Each process measure had outlined targets along with primary outcome measures of overall SSI SIRs and SIRs for each of the 5 reported procedure categories. SSIs were validated to meet CDC and NHSN surveillance case definitions. Secondary outcomes evaluated included length of stay (LOS), readmission rates, and mortality. Results: Overall SIR for all 5 monitored surgical categories decreased by 5% to 1.131 from January to September 2019, compared to SIR of 1.190 in 2018. Hip and knee arthroplasties demonstrated 40% and 38% reductions after the intervention, respectively. Completion of 7 or 8 interventions of the SSI bundle were correlated with lower readmission rates (P = .0488). When any portion of the bundle was used, this was correlated with shorter LOS (P &lt; .0001). Adherence to standardized antimicrobial prophylaxis was associated with decreased mortality (P = .017), for all 5 surgical categories. Conclusions: With the implementation of a focused SSI reduction bundle, our institution has realized reductions in surgical readmissions, length of stay, and mortality. Additionally, SSI rates in certain procedure categories have shown marked improvement. The initial success of this bundle has garnered development of additional procedure focused supplemental strategies for the future year.Funding: NoneDisclosures: Aarikha D’Souza, Banner Health

CAUTIs in Patients With Thoracic Epidurals

Background: The Surgical Care Improvement Project 9 (SCIP 9) mandates the removal of urinary catheters within 48 hours following surgery to reduce the risk of catheter-associated urinary tract infections (CAUTIs). Although patients with thoracic epidurals are not exempt from SCIP 9, these patients may be inherently different from other surgical patients. Early removal of Foley catheters may cause urinary retention and recatheterization, which in turn can lead to CAUTI or urethral trauma. Our hospital’s current policy is to allow Foley catheters to remain in place until the thoracic epidural is removed. The goal of our study was to identify and compare the rate of CAUTI in patients with thoracic epidural catheters to the rate of CAUTI in patients without thoracic epidural catheters Methods: We performed a retrospective cohort study of patients with and without thoracic epidurals who had Foley catheters during hospitalization from July 1, 2017, to May 31, 2019. We used descriptive statistics to compare CAUTI rates based on unit between the 2 groups of patients. Results: We identified 1,834 unique patients with thoracic epidurals and urinary catheters during the study period. We found 4 CAUTIs of 9,896 catheter days (0.4 CAUTIs per 1,000 catheter days) in patients with epidural catheters and 43 CAUTIs of 36,809 catheter days (1.17 CAUTI per 1,000 catheter days) in patients without thoracic epidurals for a rate ratio of 0.346 (95% CI, 0.1242– 0.9639; P &lt; .03). We conducted a sensitivity analysis on a subset of patients admitted under the cardiothoracic service and compared the patients with Foley catheters with and without thoracic epidurals. In this subset, we found 1 CAUTI in 5,890 catheter days (0.17 CAUTI per 1,000 catheter days) in patients with thoracic epidurals and 4 CAUTIs in 9,429 catheter days (0.42 CAUTIs per 1,000 catheter days) in patients without thoracic epidurals), for a rate of 0.4002 (95% CI, 0.0447–3.5808; P &lt; .39). In this subgroup, 7.0% of patients with thoracic epidurals required a second Foley catheter compared to 16.9% of patients without thoracic epidurals who required a second Foley catheter (P &lt; .01). Conclusions: Although patients with thoracic epidurals maintain Foley catheters beyond 48 hours, the CAUTI rate in these patients is lower than in patients without thoracic epidurals. Therefore, removing Foley catheters within 48 hours of surgery in patients with thoracic epidurals may not reduce the risk of CAUTI and, in fact, could be harmful. Further evaluation of confounding variables is warranted.Funding: NoneDisclosures: None

New-onset intra-operative hyperthermia in a large surgical patient population: A retrospective observational study.

Intra-operative hypothermia has been extensively investigated. However, the incidence of intra-operative hyperthermia has not been investigated in detail. The main objective of this study was to assess the incidence and risk factors of new-onset intra-operative hyperthermia in a large surgical patient population. Retrospective database review. Tertiary-care teaching hospital. Patients undergoing surgery with general anaesthesia between 1 January 2002 and 31 December 2017 were included. The primary outcome measurement was new-onset intra-operative hyperthermia (>37.5 °C). A logistic regression model was fitted to identify risk factors for intra-operative hyperthermia. A total of 103 648 patients were included in the final analyses. The incidence of new-onset hyperthermia in the overall patient cohort was 6.45%, reaching 20 to 30% after prolonged (>8 h) surgery, and was up to 26.5% in paediatric patients. The use of forced air active patient warming, larger amounts of fluid administration, longer surgery, younger age and smaller body size were all independently associated with intra-operative hyperthermia. The adoption of the Surgical Care Improvement Project (SCIP) temperature measures was associated with an increased incidence of intra-operative hyperthermia. Mild intra-operative hyperthermia is not uncommon particularly in longer procedures and small children.

Implementing a multidisciplinary care bundle to reduce colon surgical site infections.

PurposeThe aim of this study was to investigate how rates of surgical site infections (SSI) were changed over 2 years after applying colon SSI bundle in patients who underwent colon surgery.MethodsThe multidisciplinary working group developed a care bundle consisting of 8 components, including several recommendations of Surgical Care Improvement Project and monitoring of medical/surgical hand washing. We implemented the care bundle for each patient who underwent colon surgery from April 2013 to December 2014.ResultsOverall bundle compliance was 87.9% before implementation, 88.2% in 2013, and 90.5% in 2014. In particular, compliance of the following 3 components was substantial improved during the project period; discontinuation of prophylactic antimicrobial agent within 24 hours of surgery (from 88.3% to 100%), surgical hand washing (from 50.0% to 78.9%), and medical hand washing (from 74.7% to 82.8%). The rate of SSI was 8.0% (12/150) during 3 months before implementation, 3.3% (16/480) from April to December in 2013, and 2.3% (14/607) in 2014.ConclusionAfter implementation of multidisciplinary care bundle, the compliance of each component was increased and rates of SSIs were significantly decreased compared to those before the quality improvement project.

Using evidence to direct quality improvement efforts: Defining the highest impact complications after complex cytoreductive surgery for ovarian cancer

ObjectiveWe sought to identify postoperative complications with the greatest impact on patient-centric outcomes to serve as high yield QI targets in ovarian cancer (OC) surgery. MethodsWomen undergoing complex CRS (defined as cytoreductive surgery with colon resection) for OC between January 1, 2012 and 12/31/2016 were identified from the National Surgical Quality Improvement Program (NSQIP) database. We determined the population attributable fraction (PAF) to quantify the contribution of each major complication towards adverse outcomes. PAF represents the burden of adverse outcomes that could be eliminated if the corresponding complication was prevented. Organ space surgical site infection (SSI) was used as a surrogate for anastomotic leak (AL). ResultsA total of 1434 women met inclusion criteria. Any adverse clinical outcome (composite of death, reoperation, or end organ dysfunction) occurred in 9.1% of women, and AL was the largest contributor to adverse clinical outcomes [PAF = 33.4% (95%CI: 22.3%–45.6%)]. The rates of increased resource utilization were as follows; prolonged hospitalization in 23.7%, non-home discharge in 10.7% and unplanned readmission in 14.8% of women. AL was the largest contributor to prolonged hospitalizations [PAF = 75.7% (95%CI: 51.4%–90.0%)] and readmissions [PAF = 17.1% (95%CI: 11.5%–22.6%)]; while transfusion was the largest contributor to non-home discharge [PAF = 22.8% (95%CI: 0.7%–42.4%)]. By comparison, the impact of other complications, including those targeted by the Surgical Care Improvement Project (SCIP), such as incisional SSI, venous thromboembolism, myocardial infarction, and urinary infection, was small. ConclusionsAnastomotic leak is the largest contributor to adverse clinical outcomes and increased resource utilization after complex cytoreductive surgery. Quality improvement efforts to reduce AL and its impact should be of highest priority in OC surgery.

Automatic Methods to Extract Prescription Status Quality Measures from Unstructured Health Records.

Hospital systems frequently implement quality measures to quantify healthcare processes and patient outcomes. One such measure that has previously been used is the Surgical Care Improvement Project (SCIP) quality measure of perioperative beta blocker continuation, SCIP-Card-2. The SCIP-Card-2 measure requires resource-intensive medical chart abstraction, limiting its application to a small sample of eligible patients. This paper describes a natural language processing (NLP) system for automatic extraction of SCIP-Card-2 quality measures in clinical text notes.

Surgical Care Improvement Project Recommendations Versus Extended Course of Antibiotics in Tissue Expander Breast Reconstruction

Surgical Care Improvement Project Recommendations Versus Extended Course of Antibiotics in Tissue Expander Breast Reconstruction

Impact of Surgical Care Improvement Project Compliance on Surgical Site Infection in a Trauma Population

Impact of Surgical Care Improvement Project Compliance on Surgical Site Infection in a Trauma Population

Does Patient Safety Pay? Evaluating the Association Between Surgical Care Improvement Project Performance and Hospital Profitability.

Financial issues are top concerns for hospital executives. Evolving reimbursement structures focused on value provide an incentive to fully understand how patient safety performance and financial outcomes are connected. To that end, this study examines the relationships between Surgical Care Improvement Project (SCIP) measurements and hospital financial performance.Using multinomial logistic regression, we determined the association between hospital patient safety performances via analysis of eight prophylaxis data elements drawn from the archived Hospital Compare data. The measures are SCIP-Inf-1 (prophylactic antibiotic prophylaxis received within 1 hr prior to surgical incision), SCIP-Inf-2 (prophylactic antibiotic selection for surgical patients), SCIP-Inf-3 (prophylactic antibiotics discontinued within 24 hr after surgery end time), SCIP-Inf-4 (cardiac surgery patients with controlled 6 A.M. postoperative serum glucose management), SCIP-Inf-9 (urinary catheter removal postsurgery), SCIP-Inf-Card-2 (beta-blocker during the perioperative period), and SCIP-Inf-VTE-2 (venous thromboembolism prophylaxis). Data from the American Hospital Association provided two dimensions of organizational profitability: operating margin and net patient revenue. Our results indicate that improved hospital safety performance is associated with a relative risk of higher operating margin and net patient revenue, with some variation noted among the measures of patient safety. Our findings suggest that targeted improvement in patient safety performance, as evaluated in the Hospital Compare data, is associated with improved financial performance at the hospital level. Increased attention to safe care delivery may allow hospitals to generate additional patent care earnings, improve margins, and create capital to advance hospital financial position.

In Response

In Response We appreciate comments by Poelaert1 regarding our article titled “Is Compliance With Surgical Care Improvement Project Cardiac (SCIP-Card-2) Measures for Perioperative β-Blockers Associated With Reduced Incidence of Mortality and Cardiovascular-Related Critical Quality Indicators After Noncardiac Surgery?”2 Poelaert1 suggests that our findings show that “initiating beta-blockers in the preoperative setting of noncardiac surgery may increase the risk of cardiac failure.” Importantly, a limitation of our study was the inability to explore the potential effects of initiating β-blockers in the preoperative setting, and whether their initiation was associated with a higher risk for cardiac failure or all-cause mortality. To be precise, our retrospective finding was that, compared to continuation, “perioperative withdrawal of β-blockers was associated with increased risk for mortality within 48 hours after noncardiac surgery and with decreased risk for need of vasopressor during the early postoperative period and a shorter stay in postanesthesia care unit.” Indeed, we had no specific data regarding how many individuals among the 343,533 cases without β-blocker therapy before admission then received β-blocker therapy during the perioperative period. Hence, we restricted our Surgical Care Improvement Project Cardiac-2 definition of preoperative/perioperative β-blocker therapy, as well as analysis and conclusions, to the patient population receiving β-blocker therapy before admission. Poelaert1 also asserts that our study did not explore reasons for discontinuation of β-blocker therapy and, thus, is limited in terms of its findings and generalizability. In particular, he highlights the importance of considering type of β-blocker therapy when it comes to studying their effects on outcome after noncardiac surgery. In support of this statement, Poelaert1 claims that, due to their intrinsic sympathomimetic activity (ISA), continuation of some earlier generation β-blockers such as metoprolol can be potentially beneficial in the perioperative setting, while preoperative discontinuation of third-generation β-blockers such as labetalol and carvedilol, which lack ISA and have α1-antagonistic effect, may reduce risk of adverse events and mortality. Indeed, we agree that when it comes to variation in β-blocker therapy and studying potential effects on perioperative outcomes, these differentiating pharmacokinetic (cytochrome P450 2D6-dependent metabolism) and pharmacodynamic (relative β1 receptor selectivity, β1/β2 receptor affinity, and ISA) properties should be taken into consideration.3 Unfortunately, given that β-blocker therapy was a binary variable in our data source, we could not ascertain the various β-blocker therapies, and whether this factor was associated with their discontinuation in the postoperative period. Nevertheless, in our study, >85% of cases had a history of hypertension, and >30% had a history of coronary artery disease. It is highly likely that the majority of these individuals received metoprolol therapy given the past and current recommendations of guidelines for β-blocker therapy4 and the cost-effective prescribing of β-blocker therapy in the United States.5 Therefore, we believe that it is reasonable to consider the observed relationship between β-blocker withdrawal and mortality and cardiovascular-related critical quality indicators in our study as potentially related to withdrawal of metoprolol therapy. Of note, metoprolol does not have ISA, but, as previously acknowledged, its pharmacokinetic and pharmacodynamic properties may significantly influence its efficacy and safety relative to perioperative cardiovascular morbidity and mortality.3 Finally, Poelaert1 highlights the lack of information on type of surgery in our study. As clarification, we detailed extensively on the type of surgery relative to factors relevant to the study focus, including classifying risk of surgery type according to Revised Cardiac Risk Index suggested by Lee et al6 and modified by Kristensen et al.7 As described in the study, we used this composite risk index in our statistical modeling, both to account for surgical and patient characteristics while avoiding overfitting due to the limited number of perioperative events and to enable assessment of interaction between demographic and clinical risk factors (including type of surgery) and patterns of β-blocker use relative to all-cause mortality and cardiovascular complications. We thank Poelaert1 for his interesting comments, and while beyond the scope of our study, we agree that further research is warranted to explore how differences among types of β-blocker therapy, the de novo initiation of perioperative β-blocker therapy, and withdrawal or continuation of other cardiovascular medications are associated with mortality and cardiovascular-related risk indicators in noncardiac surgery patient cohorts. Miklos D. Kertai, MD, PhDDivision of Cardiothoracic AnesthesiologyDepartment of AnesthesiologyVanderbilt University Medical CenterNashville, Tennessee[email protected] Mary Cooter, MScDivision of Cardiothoracic Anesthesiology and Critical Care MedicineDepartment of AnesthesiologyDuke University Medical CenterDurham, North Carolina Richard J. Pollard, MDDepartment of Anesthesia Critical Care and Pain ManagementBeth Israel Deaconess Medical CenterHarvard Medical SchoolBoston, Massachusetts Mark Stafford-Smith, MD, FRCPCDivision of Cardiothoracic Anesthesiology and Critical Care MedicineDepartment of AnesthesiologyDuke University Medical CenterDurham, North Carolina