Surgical Care Improvement Project Research Articles

Adherence to Surgical Care Improvement Project Measures and the Association With Postoperative Infections

Adherence to Surgical Care Improvement Project Measures and the Association With Postoperative Infections

Adherence To Surgical Care Improvement Project Measures: The Whole Is Greater Than The Parts

Much effort has been put into the Surgical Care Improvement Project (SCIP) in an effort to reduce surgical complications with a significant emphasis on reducing the rate of surgical site infections. The causes and the prevention of surgical site infections are complex and multifactorial. By the nature of its size and scope, SCIP is naturally somewhat oversimplified and incomplete. Nevertheless, all the measures are supported by strong prospective evidence. Stulberg et al. examine the association between adherence to SCIP infection measures and the occurrence of surgical site infections in a large administrative database and conclude that while the individual measures for the most part do not appear to be associated with a lower surgical site infection risk, the performance of all relevant measures does.

Association of Surgical Care Improvement Project Infection-Related Process Measure Compliance with Risk-Adjusted Outcomes: Implications for Quality Measurement

Facility-level process measure adherence is being publicly reported. However, the association between measure adherence and surgical outcomes is not well-established. Our objective was to determine the degree to which Surgical Care Improvement Project (SCIP) process measures are associated with American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) risk-adjusted outcomes. This cross-sectional study included hospitals participating in the ACS NSQIP and SCIP (n = 200). ACS NSQIP outcomes (30-day overall morbidity, serious morbidity, surgical site infections [SSI], and mortality) and adherence to SCIP SSI-related process measures (from the Hospital Compare database) were collected from January 1, 2008, through December 31, 2008. Hospital-level correlation coefficients between compliance with 4 process measures (ie, antibiotic administration within 1 hour before incision [SCIP-1]; appropriate antibiotic prophylaxis [SCIP-2]; antibiotic discontinuation within 24 hours after surgery [SCIP-3]; and appropriate hair removal [SCIP 6]) and 4 risk-adjusted outcomes were calculated. Regression analyses estimated the contribution of process measure adherence to risk-adjusted outcomes. Of 211 ACS NSQIP hospitals, 95% had data reported by Hospital Compare. Depending on the measure, hospital-level compliance ranged from 60% to 100%. Of the 16 correlations, 15 demonstrated nonsignificant associations with risk-adjusted outcomes. The exception was the relationship between SCIP-2 and SSI (p = 0.004). SCIP-1 demonstrated an intriguing but nonsignificant relationship with SSI (p = 0.08) and overall morbidity (p = 0.08). Although adherence to SCIP-2 was a significant predictor of risk-adjusted SSI (p < 0.0001) and overall morbidity (p < 0.0001), inclusion of compliance for SCIP-1 and SCIP-2 caused only slight improvement in model quality. Better adherence to infection-related process measures over the observed range was not significantly associated with better outcomes with one exception. Different measures of quality might be needed for surgical infection.

Anesthesia Literature Review

Anesthesia Literature Review

Surgical Care Improvement Project Adherence and Postoperative Infections

Surgical Care Improvement Project Adherence and Postoperative Infections

Surgical Care Improvement Project Adherence and Postoperative Infections

Surgical Care Improvement Project Adherence and Postoperative Infections

Surgical Care Improvement Project Adherence and Postoperative Infections—Reply

Surgical Care Improvement Project Adherence and Postoperative Infections—Reply

Surgical Care Improvement Project Adherence and Postoperative Infections

Surgical Care Improvement Project Adherence and Postoperative Infections

Surgical Care Improvement Project Adherence and Postoperative Infections

Surgical Care Improvement Project Adherence and Postoperative Infections

All-or-none compliance is the best determinant of quality of care

The Surgical Care Improvement Project (SCIP) aims to reduce complications by ensuring adherence to a number of procedural criteria. The findings of a recent study imply that adherence to individual SCIP infection-prevention measures may not be an effective measure of quality. Rather, 'all-or-none' compliance with multiple SCIP recommendations is required if hospitals are to achieve quality-improvement outcomes.

Normothermia to Prevent Surgical Site Infections After Gastrointestinal Surgery

To analyze the association between perioperative normothermia (temperature ≥36°C) and surgical site infections (SSIs) after gastrointestinal (GI) surgery. Although active warming during colorectal surgery reduces SSIs, there is limited evidence that perioperative normothermia is associated with lower rates of SSI. Nonetheless, hospitals participating in the Surgical Care Improvement Project must report normothermia rates during major surgery. We conducted a nested, matched, case-control study; cases consisted of GI surgery patients enrolled in our National Surgical Quality Improvement Program database between March 2006 and March 2009 who developed SSIs. Patient/surgery risk factors for SSI were obtained from the National Surgical Quality Improvement Program database. Perioperative temperature/antibiotic/glucose data were obtained from medical records. Cases/controls were compared using univariate/random effects/logistic regression models. Independent risk factors for SSIs were identified using multivariate/random effects/logistic regression models. A total of 146 cases and 323 matched controls were identified; 82% of patients underwent noncolorectal surgery. Cases were more likely to have final intraoperative normothermia compared with controls (87.6% vs. 77.8%, P = 0.015); rates of immediate postoperative normothermia were similar (70.6% vs. 65.3%, respectively, P = 0.19). Emergent surgery/higher wound class were associated with higher rates of intraoperative normothermia. Independent risk factors for SSI were diabetes, surgical complexity, small bowel surgery, and nonlaparoscopic surgery. There was no independent association between perioperative normothermia and SSI (adjusted odds ratio, 1.05; 95% confidence interval, 0.48-2.33; P = 0.90). Pay-for-reporting measures focusing on perioperative normothermia may be of limited value in preventing SSI after GI surgery. Studies to define the benefit of active warming after noncolorectal GI surgery are warranted.

Improving and Sustaining Core Measure Performance Through Effective Accountability of Clinical Microsystems in an Academic Medical Center

Evidence-based performance measures, known as core measures, have been established by The Joint Commission to improve the quality of care for patient populations, such as those with acute myocardial infarction (AMI), heart failure, and community-acquired pneumonia (CAP), as well as to improve the quality of surgical care--the Surgical Care Improvement Project (SCIP) measures. Hospital administrators have traditionally held academic and community physicians and hospital clinicians accountable for integrating the core measures into daily practice. Such efforts have often led to suboptimal results because of the belief that the "organization" (macrosystem) is the appropriate level at which to work to improve quality. Stanford Hospital and Clinics (Stanford, California) has instead held leaders of clinical microsystems--the clinical units where care is provided--accountable to improve performance on the core measures. The strategic approaches taken for this initiative include engagement of the hospital's board of directors; clear assignment of accountability among interdisciplinary care teams to drive the change; implementation of a unit-based medical director program; transparency of core measure performance at the microsystem, mesosystem, and macrosystem levels; and concurrent monitoring with rapid feedback of results. In 2007, the first year of this initiative, the 24-metric composite compliance score for all four core measures increased from 64% to 82%. The composite score was sustained at a minimum of 90% during 2009 and Quarter 1 of 2010. Holding clinical microsystems accountable for improving unit performance proved beneficial to macrosystem performance of the Joint Commission core measures.

Plastic Surgeon Compliance with National Safety Initiatives: Clinical Outcomes and “Never Events”

Venous thromboembolism and surgical-site infection have been identified as preventable complications that are addressed by the National Quality Forum and the Surgical Care Improvement Project. The authors examined compliance of faculty with venous thromboembolism and surgical-site infection prophylaxis and incidence of adverse outcomes in patients at risk. The authors performed retrospective chart reviews on 243 patients who underwent abdominoplasty or panniculectomy from 2000 to 2007 and documented demographics and adverse outcomes. Analysis was completed using Pearson's chi-square and Fisher's exact test for categorical variables. Significance was set at p < 0.05. Obesity was defined as body mass index more than 30 and morbid obesity was defined as body mass index more than 40. Of 243 patients, 144 (59 percent) were obese. Seventeen patients (7 percent) suffered complications. All 243 patients received at least one form of venous thromboembolism prophylaxis. One patient had a deep venous thrombosis, and two had pulmonary embolism. These three patients were morbidly obese. Seventy-four percent of patients received appropriate antibiotics. Thirteen patients (5.3 percent) developed significant postoperative infection requiring hospitalization, 12 (92 percent) of whom received appropriate antibiotics. Eleven of these 13 patients (85 percent) were obese, and seven (54 percent) were morbidly obese. Obesity proved to be the only significant risk factor (p > 0.05). Despite very good compliance with safe practice initiatives, significant adverse outcomes occurred. Obesity was the only pervasive risk factor. This study highlights the potential need for compliance with quality measures and demonstrates that adverse outcomes may result despite adherence to best surgical practices.

A situational overview of surgical quality and safety in 2010

Background Surgical safety and quality initiatives have now moved to the front of the agenda for contemporary surgery. Methods Sixty-two surgical specialists began to study quality and cost control in 1998, and those efforts grew into a Centers for Medicare and Medicaid Services–funded pilot study of the Surgical Care Improvement Project in 2004. Subsequent symposia and studies evolved. Results A greater awareness of the issues and methods for meaningful improvement of surgical safety in nearly 25,000 specialty surgeries have been described in numerous peer-reviewed publications. Conclusions Surgeon-initiated efforts have led to marked improvements in multiple specialties and in many small and large hospitals and academic training centers.

Surgical Care Improvement

THE SURGICAL CARE IMPROVEMENT PROJECT (SCIP) was established in 2006 with the goal of reducing surgical complications by 25% in 2010. Of the 9 performance measures, 6 are related to surgical site infection prevention. Efforts to reduce surgical site infection are important because this complication results in significant morbidity and additional resource use. To this end, the SCIP was designed to improve adherence for prophylactic antibiotic administration, as well as processes related to glucose control, hair removal from the surgical site, and intraoperative normothermia, in patients undergoing elective surgical procedures. It has achieved this goal to the extent that hospitals have successfully implemented these processes. However, what evidence exists demonstrating that improved adherence has achieved the goal of reducing surgical complications? Complications from surgical procedures are costly and cause substantial patient morbidity. Patients need transparent information guiding them to the best hospitals for their surgical procedure and third-party payers need a mechanism to influence and make accountable the care of patients undergoing expensive procedures. The time, resources, and importance placed on SCIP process measures lead to the conclusion that adherence to these measures can discriminate practices associated with optimal surgical outcomes. The SCIP measures were added to the Hospital Compare Web site (http://www.hospitalcompare .hhs.gov) with the goal of guiding patients about where to receive surgical care, based on the underlying assumption that higher performance on these measures equals better surgical outcomes. Furthermore, the Centers for Medicare & Medicaid Services has proposed use of the SCIP measures for value-based purchasing and payment to hospitals. The report by Stulberg et al in this issue of JAMA is the largest study to date that fails to demonstrate an association between adherence to SCIP process measures and the occurrence of postoperative infections. The authors found no significant association between individual process measures or the all-or-none composite core measurement composed of all 3 measures for prophylactic antibiotic administration and postoperative infection. They report a modest association between adherence to a composite measure that included at least 2 of the 6 SCIP measures applied to an expanded SCIP population and postoperative infection. Despite substantial improvements in SCIP adherence over the 2-year study period, postoperative infection rates actually increased. The SCIP includes 3 core infection-prevention measures: SCIP-1, antibiotic administration within 60 minutes prior to incision; SCIP-2, appropriate selection of antibiotic coverage; and SCIP-3, timely discontinuation of antibiotics. The SCIP-2 measure ensures that adequate antimicrobial coverage is administered with a focus on limiting too broad of coverage. Similarly, for the SCIP-3 measure, data support that prolonged coverage has no incremental improvement in surgical site infection rates and is potentially harmful due to the development of resistant organisms. Of these 3 measures, there has been evidence to support that the SCIP-1 measure reduces the incidence of surgical site infection, although that evidence involves whether the prophylactic antibiotic is administered at all, and not the timing of antibiotic administration. Other studies have shown that even though administration of antibiotics in the operating room resulted in better SCIP-1 adherence, there was no association with lower surgical site infection in patientor hospital-level analyses. Delivery of preoperative prophylactic antibiotics improves surgical site infection rates in the appropriate clinical setting and all patients in the study by Stulberg et al received prophylactic antibiotics. However, the SCIP-1 measures a dichotomous variable based on a continuous event (the time between antibiotic administration and surgical incision). This measure presumes that any antibiotic administered within 60 minutes prior to incision is effective, but that antibiotics administered outside that interval are not. To date, no prospective trials have validated the 60-minute window as a measure to discriminate meaningful differences in patient outcomes. Between 2002 and 2009, at least 8 reports that evaluated the association between SCIP-1 adherence and surgical site infection

Adherence to Surgical Care Improvement Project Measures and the Association With Postoperative Infections

The Surgical Care Improvement Project (SCIP) aims to reduce surgical infectious complication rates through measurement and reporting of 6 infection-prevention process-of-care measures. However, an association between SCIP performance and clinical outcomes has not been demonstrated. To examine the relationship between SCIP infection-prevention process-of-care measures and postoperative infection rates. A retrospective cohort study, using Premier Inc's Perspective Database for discharges between July 1, 2006 and March 31, 2008, of 405 720 patients (69% white and 11% black; 46% Medicare patients; and 68% elective surgical cases) from 398 hospitals in the United States for whom SCIP performance was recorded and submitted for public report on the Hospital Compare Web site. Three original infection-prevention measures (S-INF-Core) and all 6 infection-prevention measures (S-INF) were aggregated into 2 separate all-or-none composite scores. Hierarchical logistical models were used to assess process-of-care relationships at the patient level while accounting for hospital characteristics. The ability of reported adherence to SCIP infection-prevention process-of-care measures (using the 2 composite scores of S-INF and S-INF-Core) to predict postoperative infections. There were 3996 documented postoperative infections. The S-INF composite process-of-care measure predicted a decrease in postoperative infection rates from 14.2 to 6.8 per 1000 discharges (adjusted odds ratio, 0.85; 95% confidence interval, 0.76-0.95). The S-INF-Core composite process-of-care measure predicted a decrease in postoperative infection rates from 11.5 to 5.3 per 1000 discharges (adjusted odds ratio, 0.86; 95% confidence interval, 0.74-1.01), which was not a statistically significantly lower probability of infection. None of the individual SCIP measures were significantly associated with a lower probability of infection. Among hospitals in the Premier Inc Perspective Database reporting SCIP performance, adherence measured through a global all-or-none composite infection-prevention score was associated with a lower probability of developing a postoperative infection. However, adherence reported on individual SCIP measures, which is the only form in which performance is publicly reported, was not associated with a significantly lower probability of infection.

"Bundling” SCIP for the Perioperative Staff

The Surgical Care Improvement Project (SCIP) is a national quality partnership of organizations focused on improving surgical care by reducing surgical complications by 25 percent by the year 2010. To achieve this reduction numerous performance measures were identified and monitored including antibiotics, normothermia, glycemic control, appropriate hair removal, venous thromboembolism (VTE), and beta blocker therapy. The SCIP team is a multi-disciplinary team compromised of staff from OR, CV, CCU, PST, PACU, Pharmacy, Med-Surg, QI, and IC.

Improving SCIP Compliance Through Flight Check

The Surgical Care Improvement Project (SCIP) has become an integral part of Surgical Services across the Nation. At Inova Fair Oaks Hospital, our initial compliance with SCIP recommendations for almost all measures was around 70% for over a year. Our objective was to provide ‘perfect care’ to our patients on a consistent basis. A multi-disciplinary team was assembled in 2008 to improve our compliance with these measures and gain a sustained improvement. We developed a ‘Flight Check’ to go along with our ‘Boarding Pass’ to make sure every surgical patient gets perfect care.

Improving Venous Thromboembolism Performance: A Comprehensive Guide for Physicians and Hospitalists

Venous thromboembolism (VTE) is a major potentially preventable cause of hospital deaths and is associated with a substantial clinical and economic burden in the United States. Despite the availability of effective thromboprophylactic agents and evidence-based management guidelines, VTE prophylaxis is commonly underused and inappropriately prescribed in real-world practice. Several US organizations have developed quality-improvement initiatives to close the gap between guideline recommendations and clinical practice, and thus reduce VTE-associated morbidity and mortality. The Surgical Care Improvement Project and the National Quality Forum, in collaboration with The Joint Commission, have developed performance measures to allow assessment of the quality and appropriateness of VTE prevention practices. A number of potential barriers to optimal VTE performance exist, including underestimation of the risks posed by VTE, overestimation of the risk of bleeding complications, and a lack of familiarity with clinical guidelines. Hospitals are urged to develop an institution-wide policy to improve VTE prevention and employ several quality-improvement initiatives to overcome barriers and optimize prescribing practices. In particular, multiple integrated, active strategies are required to raise awareness of the need for appropriate VTE prophylaxis. Hospital-wide education, risk-assessment tools, electronic alerts, computerized decision-support systems, together with audit and feedback mechanisms, are valuable tools that can be used to promote the use of performance measures to drive improvement of VTE prophylaxis and clinical outcomes.

Hypothermia: Two Tales of One Temperature

THIS ISSUE features two articles addressing broadly differing discussions of hypothermia. Unplanned perioperative hypothermia (UPH) is a common complication that perianesthesia nurses battle everyday. Defined as a core temperature of less than 36°C, UPH is common in patients undergoing general and/or regional anesthesia, and is associated with adverse outcomes ranging from patient discomfort to increased morbidity and mortality.1 The maintenance of perioperative normothermia remains a core quality measure in the Surgical Care Improvement Project (SCIP)2 and is a core quality/performance improvement measure in most hospital settings.