Surgical Care Improvement Project Research Articles

Detailed Findings From the CLER National Report of Findings 2018.

Detailed Findings From the CLER National Report of Findings 2018.

Colon and rectal surgery surgical site infection reduction bundle: To improve is to change

BackgroundDespite the introduction of the Surgical Care Improvement Project, surgical site infections remain a source of morbidity. The aim of this study was to determine the value of implementing a colorectal bundle on SSI rates. MethodsBetween 2011 and 2016 a total of 1351 patients underwent colorectal operations. Patients were grouped into pre-implementation (Group A, January 1, 2011–December 31, 2012), implementation (Group B, January 1, 2013–December 31, 2014) and post-implementation (Group C, January 1, 2015–December 31, 2016). Primary endpoints were superficial SSI, deep SSI, wound separation and total SSI. ResultsAfter the bundle was implemented, there was a significant reduction in superficial (6.6%–4%, p < 0.05), deep (3.7%–1.1%, p < 0.05), and total SSI rates (10.9%–4.7%, p < 0.05). Comparing Group A to Group C there was a decrease in total SSI (9.4%–4.7%, p < 0.05). ConclusionImplementation of the bundle resulted in a reduction in overall SSI rates particularly as compliance increased. This study offers evidence that small changes can lead to significant decreases in surgical site infections.

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?

While continuation of β-blockers (BBs) perioperatively has become a national quality improvement measure, the relationship between BB withdrawal and mortality and cardiovascular-related critical quality indicators has not been studied in a contemporary cohort of patients undergoing noncardiac surgery. For this retrospective study, the quality assurance database of a large community-based anesthesiology group practice was used to identify 410,288 surgical cases, 18 years of age or older, who underwent elective or emergent noncardiac surgical procedures between January 1, 2009, and December 31, 2014. Each surgical case that was withdrawn from BBs perioperatively was propensity matched by clinical and surgical characteristics to 4 cases that continued BBs perioperatively. Subsequently, multivariable conditional logistic regression analyses were performed in the matched cohort to determine the extent to which withdrawal of perioperative BBs was independently associated with mortality as the primary outcome and cardiovascular-related critical quality indicators as the secondary outcome (need for vasopressor, electrocardiographic changes requiring treatment, unplanned admission to intensive care unit, postanesthesia care unit stay >2 hours, and a combination of cardiac arrest and myocardial infarction) within 48 hours postoperatively. Of the 66,755 (16%) cases in the cohort admitted on BB therapy, BBs were withdrawn in 3829 (6%) and continued in 62,926 (94%). Propensity score matching resulted in an analysis cohort of 19,145 cases. Withdrawal of perioperative BBs in the multivariable conditional logistic regression analysis was significantly associated with an increased risk for mortality (odds ratio [OR], 3.61; 95% confidence interval [CI], 1.75-7.35; P = .0003), but a significantly decreased risk for need of blood pressure support requiring vasopressor initiation (OR, 0.84; 95% CI, 0.76-0.92; P = .0003) and extended postanesthesia care unit stay (OR, 0.69; 95% CI, 0.54-0.88; P = .004) within 48 hours after noncardiac surgery. Perioperative withdrawal of BBs 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 the postanesthesia care unit.

Risk factors for reinsertion of urinary catheter after early removal in thoracic surgical patients

ObjectivesTo reduce the incidence of urinary tract infection, Surgical Care Improvement Project 9 mandates the removal of urinary catheters within 48 hours postoperatively. In patients with thoracic epidural anesthesia, we sought to determine the rate of catheter reinsertion, the complications of reinsertion, and the factors associated with reinsertion. MethodsWe conducted a prospective observational study of consecutive patients undergoing major pulmonary or esophageal resection with thoracic epidural analgesia over a 2-year period. As per Surgical Care Improvement Project 9, all urinary catheters were removed within 48 hours postoperatively. Excluded were patients with chronic indwelling catheter, patients with urostomy, and patients requiring continued strict urine output monitoring. Multivariable logistic regression analysis was used to identify independent risk factors for urinary catheter reinsertion. ResultsThirteen patients met exclusion criteria. Of the 275 patients evaluated, 60 (21.8%) required reinsertion of urinary catheter. There was no difference in the urinary tract infection rate between patients requiring reinsertion (1/60 [1.7%]) versus patients not requiring reinsertion (1/215 [0.5%], P = .389). Urethral trauma during reinsertion was seen in 1 of 60 patients (1.7%). After reinsertion, discharge with urinary catheter was required in 4 of 60 patients (6.7%). Multivariable logistic regression analysis found esophagectomy, lower body mass index, and benign prostatic hypertrophy to be independent risk factors associated with catheter reinsertion after early removal in the presence of thoracic epidural analgesia. ConclusionsWhen applying Surgical Care Improvement Project 9 to patients undergoing thoracic procedures with thoracic epidural analgesia, consideration to delayed removal of urinary catheter may be warranted in patients with multiple risk factors for reinsertion.

Quality, Reliability, Repeatability - What about Excellence?

ABSTRACT Today, I will be giving a general overview of the quality question. I will divide quality into four topics: first essential element—data, second essential element—process, third essential element—culture, and hidden dangers. We were fairly “high on the hog” in the House of Surgery in the late 20th century but then came the Institute of Medicine (IOM) reports. Partly in response to the IOM reports, we have discussed incessantly airplanes and aircrews. However, this is not the only challenge for in addition to this quality problem, we have a cost problem. These intersecting challenges appear insurmountable, but there is hope. We need better data, better process, and an evolution of our culture. The easiest type of data to collect is process measure data. We should all be aware of Surgical Care Improvement Project (SCIP), Physician Reporting Quality System (PRQS), and Merit-Based Incentive Payment System (MIPS). On the performance measures side of the house, the National Surgical Quality Incentive Program and the University Health-System Collaborative are major initiatives. There is an abundance of data, but if we are to improve care, we also need a good process. There is increased attention into process such as checklists, bundles, and standard operating procedures. Data and process is important, but we also need to be strategic. For a process to be effective, it needs to be part of a coherent strategy. And once we have data, process, and strategic thinking, we come to the third essential element, which is culture. Are there some dangers in embracing these new approaches? In a word, yes. We cannot abandon the traditional role of surgeons as leaders. We need to think about training the next generation of surgeons and the risk that this over-systemization of care begets. Surgeons have always led change, so though these new challenges seem profoundly disruptive, I am sure that we will again rise to the task.

Multi-Institution Analysis of Infection Control Practices Identifies the Subset Associated with Best Surgical Site Infection Performance: A Texas Alliance for Surgical Quality Collaborative Project

In an effort to reduce surgical site infection (SSI) rates, a large number of infection control practices (ICPs), including operating room attire policies, have been recommended. However, few have proven benefits and many are costly, time-consuming, and detrimental to provider morale. The goal of this multi-institution study was to determine which ICPs are associated with lower postoperative SSI rates. Twenty American College of Surgeons NSQIP and Texas Alliance for Surgical Quality-affiliated hospitals completed this Quality Improvement Assessment Board-approved study. Surgeon champions at each hospital ranked current surgery, anesthesia, and nursing adherence to 38 separate ICPs in 6 categories (attire, preoperative, intraoperative, preoperative, intraoperative, antibiotics, postoperative, and reporting) on 4-point scales for general surgery cases. These data were compared with the risk-adjusted general surgery SSI odds ratios contained in the July 2016 American College of Surgeons NSQIP hospital-level, risk-adjusted reports. Compliance rates were compared between the 7 best (median SSI odds ratio, 0.64; range, 0.56 to 0.70) and 7 worst (median SSI odds ratio, 1.16; range, 0.94 to 1.65) performers using ANOVA. Nearly all hospitals reported maximal adherence to hair removal with clippers (Surgical Care Improvement Project measure Inf-6) and to best-practice prophylactic antibiotic metrics (Surgical Care Improvement Project measure Inf-1-3). Variable adherence wasidentified across many ICPs and more frequent compliance with 8ICPs correlated withlower SSI odds ratios, including preoperative shower; skin preparation technique; using clean instruments, gowns, and gloves for wound closure and dressing changes; and transparent internal reporting of SSI data. Operating room attire ICPs, including coverage of nonscrubbed provider head and arm hair, did not correlate with SSI rates. This analysis suggests that the subset of ICPs that focus on perioperative patient skin and wound hygiene and transparent display of SSI data, not operating room attire policies, correlated with SSI rates. Implementation of this subset of evidence-based ICPs may improve SSI rates at lower-performing hospitals.

Quality improvement initiative: Preventative Surgical Site Infection Protocol in Vascular Surgery

In an attempt to lower patient morbidity, we developed and implemented the Preventative Surgical Site Infection Protocol in Vascular Surgery. Surgical site infections lead to prolonged hospital stays, adjunctive procedure, and additive costs. We employed targeted interventions to address the common risk factors that predispose patients to post-operative complications. Methods Retrospective review was performed between 2012 and 2016 for all surgical site infections after revascularization procedures of the lower extremity. A quality improvement protocol was initiated in January 2015. Primary outcome was the assessment of surgical site infection rate reduction in the pre-protocol vs. post-protocol era. Secondary outcomes evaluated patient demographics, closure method, perioperative antibiotic coverage, and management outcomes. Results Implementation of the protocol decreased the surgical site infection rate from 6.4% to 1.6% p = 0.0137). Patient demographics and comorbidities were assessed and failed to demonstrate a statistically significant difference among the infection and no-infection groups. Wound closure with monocryl suture vs. staple proved to be associated with decreased surgical site infection rate ( p < 0.005). Conclusions Preventative measures, in the form of a standardized protocol, to decrease surgical site infections in the vascular surgery population are effective and necessary. Our data suggest that there may be benefit in the incorporation of MRSA and Gram-negative coverage as part of the Surgical Care Improvement Project perioperative guidelines.

Reduction of Surgical Site Infections After Cesarean

To decrease cesarean surgical site infection (SSI) rates to less than the National Healthcare Safety Network (NHSN) mean. By decreasing SSI rates, secondary goals included improving the patient experience, decreasing readmissions, and promoting bonding between the mother and newborn. A review of the literature from the following was completed: the Collaborative Healthcare Associated Infection Network, the Surgical Care Improvement Project, and the Mayo Collaborative. A regional birthing unit at which approximately 800 cesareans are performed per year. All women who had cesarean births. Thermoregulation, antibiotics administration (pre-op and timing), skin prep (pre-op and intra-op), operating room attire, operating room traffic, hair removal, closing trays, standardized incision care, standardized dressings, environmental cleaning processes, and improved team communication through briefing and debriefing. By implementing SSI bundles and evidence-based nursing practices, we saw a greater than 50% reduction in SSIs, which placed the facility rate at less than the NHSN mean. The bedside nurse is able to directly affect outcomes related to SSI by the providing evidence-based care and implementing standardized care practices.

Morbidity and Mortality in Elective Total Hip Arthroplasty Following Surgical Care Improvement Project Guidelines

BackgroundFollowing evidence questioning the safety and efficacy of perioperative beta-blocker therapy in noncardiac surgery, the Surgical Care Improvement Project (SCIP) guidelines were retired in 2015. However, perioperative myocardial infarctions and cardiac complications remain leading causes of mortality following noncardiac surgery. The impact of the SCIP guidelines on reducing cardiac complications in patients undergoing elective total hip arthroplasty (THA) has not been evaluated. MethodsThe Nationwide Inpatient Sample was queried for 345,875 elective THA performed from 2003 to 2011. Patient demographics and morbidity as well as the incidence of nonfatal and fatal cardiac complications and overall mortality associated with cardiac complications were determined before and following SCIP implementation. ResultsFollowing the institution of the SCIP guidelines, the overall mortality following cardiac complications decreased by 41%. Although the incidence of nonfatal cardiac events after THA did increase 5% (primarily secondary to an increased incidence of nonfatal hypotension), the incidence of postoperative inpatient mortality, stroke, fatal hypotension, fatal myocardial infarction, and nonfatal and fatal cardiac arrest significantly decreased. ConclusionFollowing the implementation of SCIP guidelines, there was a 41% reduction in mortality and a significant decrease in fatal cardiac complications, postoperative hypotension, myocardial infarction, and cardiac arrest. Despite SCIP guidelines being retired in 2015, evidence supports continuation of perioperative beta-blockade in primary elective total adult hip and knee arthroplasty.

Strategies for Improving Surgical Quality

Surgical morbidity and mortality are major public health concerns. The outcomes of surgery have been shown to differ among providers; this variability in the outcomes of surgical procedures has long suggested opportunities to improve the quality of surgical care. Payers, health care policy makers, and surgeons’ professional organizations have implemented a range of strategies to effect large-scale quality improvement efforts targeted toward patients undergoing surgery. This review examines outcomes measurement and feedback, regional collaborative quality improvement, selective referral, pay for performance strategies, and new strategies for surgical quality improvement. Figures show example of provider desktop user interface for a regional quality collaborative; mortality after (30-day) bariatric surgery: Michigan hospitals versus non-Michigan hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) based on data from the 2007 to 2009 Michigan Bariatric Surgery Collaborative and national ACS-NSQIP registries; and percentage of mortality decline for esophagectomy, pancreatectomy, cystectomy, and lung resection attributable to increases in market concentration, based on 2001 to 2008 national Medicare data. Tables list characteristics of different strategies for improving surgical quality; components of the Institute for Healthcare improvement ventilator and central catheter insertion bundle checklists; evidence regarding the relationship between compliance with Surgical Care Improvement Project (SCIP) measures and clinical outcomes; SCIP measures retired as of January 15, 2015; and SCIP measures remaining. This review contains 3 highly rendered figures, 5 tables and 74 references.

Quality Improvement Initiatives in Colorectal Surgery: Value of Physician Feedback

The impact of process improvement through surgeon feedback on outcomes is unclear. We sought to evaluate the effect of biannual surgeon-specific feedback on outcomes and adherence to departmental and Surgical Care Improvement Project process measures on colorectal surgery outcomes. This was a retrospective analysis of prospectively collected 100% capture surgical quality improvement data. This study was conducted at the department of colorectal surgery at a tertiary care teaching hospital from January 2008 through December 2013. Each surgeon was provided with biannual feedback on process adherence and surgeon-specific outcomes of urinary tract infection, deep vein thrombosis, surgical site infection, anastomotic leak, 30-day readmission, reoperation, and mortality. We recorded adherence to Surgical Care Improvement Project process measures and departmentally implemented measures (ie, anastomotic leak testing) as well as surgeon-specific outcomes. We abstracted 7975 operations. There was no difference in demographics, laparoscopy, or blood loss. Adherence to catheter removal increased from 73% to 100% (p < 0.0001), whereas urinary tract infection decreased 52% (p < 0.01). Adherence to thromboprophylaxis administration remained unchanged as did the deep vein thrombosis rate (p = not significant). Adherence to preoperative antibiotic administration increased from 72% to 100% (p < 0.0001), whereas surgical site infection did not change (7.6%-6.6%; p = 0.3). There were 2589 operative encounters with anastomoses. For right-sided anastomoses, the proportion of handsewn anastomoses declined from 19% to 1.5% (p < 0.001). For left-sided anastomoses, without diversion, anastomotic leak testing adherence increased from 88% to 95% (p < 0.01). Overall leak rate decreased from 5.2% to 2.9% (p < 0.05). Concurrent process changes make isolation of the impact from individual process improvement changes challenging. Nearly complete adherence to process measures for deep vein thrombosis and surgical site infection did not lead to measureable outcomes improvement. Process measure adherence was associated with decreased rate of anastomotic leak and urinary tract infection. Biannual surgeon-specific feedback of outcomes was associated with improved process measure adherence and improvement in surgical quality.

Discordance between surgical care improvement project adherence and postoperative outcomes: implications for new Joint Commission standards

BackgroundInfectious (INF) and venous thromboembolism (VTE) complication rates are targeted by surgical care improvement project (SCIP) INF and SCIP VTE measures. We analyzed how adherence to SCIP INF and SCIP VTE affects targeted postoperative outcomes (wound complication [WC], deep vein thrombosis, and pulmonary embolism [PE]) using all-payer data. Materials and methodsA retrospective review (2007-2011) was conducted using Healthcare Cost and Utilization Project State Inpatient Database Florida and Medicare's Hospital Compare. The association between SCIP adherence rates and outcomes across 355 included surgical procedures was measured using multilevel mixed-effects linear regression models. ResultsOne hundred sixty acute care hospitals and 779,922 patients were included. Over 5 y, SCIP INF-1, -2, and -3 adherence improved by 12.5%, 8.0%, and 20.9%, respectively, whereas postoperative WC rate decreased by 14.8%. When controlling for time, SCIP INF-1 adherence was associated with improvement of postoperative WC rates (β = −0.0044, P = 0.005), whereas SCIP INF-2 adherence was associated with increased WCs (β = 0.0031, P = 0.018). SCIP VTE-1, -2 adherence improved by 14.6% and 20.2%, respectively, whereas postoperative deep vein thrombosis rate increased by 7.1% and postoperative PE rate increased by 3.7%. SCIP VTE-1 and -2 adherence were both associated with increased postoperative PE when controlling for time (SCIP VTE-1: β = 0.0019, P < 0.001; SCIP VTE-2: β = 0.0015, P < 0.001). Readmission analysis found SCIP INF-1 adherence to be associated with improved 30-d WC rates when controlling for patient and hospital characteristics (β = −0.0021, P = 0.032), whereas SCIP INF-3 adherence was associated with increased 30-d WC rates when controlling for time (β = 0.0007, P = 0.04). ConclusionsOnly SCIP INF-1 adherence was associated with improved outcomes. The Joint Commission has retired SCIP INF-2, -3, and SCIP VTE-2 and made SCIP INF-1 and VTE-1 reporting optional. Our study supports continued reporting of SCIP INF-1.

White Paper on MACRA: Past, Present and Future

IntroductionThe U.S. health care system is undergoing significant change as demands to improve medical quality and reduce health care costs expand. U.S. health care spending accounted for 16.9% of gross domestic product in 2013, the highest amount compared to other developed countries. On April 16, 2015 the U.S. Congress passed a historical piece of bipartisan legislation, the Medicare Access and CHIP (Children’s Health Insurance Program) Reauthorization Act (MACRA). We describe the events leading up to the passage of MACRA, review the various components of MACRA and describe how MACRA will likely impact physician practices. We also suggest how best to prepare for compliance with the Centers for Medicare & Medicaid Services (CMS) MACRA final rule with comment period, which was released on October 14, 2016. MethodsA literature review of the quality measures defined by CMS before the passage of MACRA was performed as well as a review of the current MACRA final rule (Quality Payment Program) and related CMS commentary. An expert panel of health care consultants provided guidance concerning compliance with the final rule. Furthermore, case studies are described as examples to assist the urological community in meeting the expectations of MACRA. ResultsThe Surgical Care Improvement Project process measures (current quality) for urological surgery are reviewed and their impact on surgical site infections is described. Details of MACRA and its Quality Payment Program framework, the Merit-based Incentive Payment System and Alternative Payment Models, are also described. A detailed understanding of and preparation for the implementation of MACRA will help physicians comply with the regulations which offer future opportunities for better reimbursement. Opportunities to comply with MACRA through Advanced Alternative Payment Models may mitigate the complexity of reporting under the alternate Merit-based Incentive Payment System. The development of bundled payment procedures in urology, similar to the Comprehensive Care for Joint Replacement program in orthopedics, may eventually qualify for Advanced Alternative Payment Model status. ConclusionsPhysicians should be proactive, and lead the effort to improve medical quality and control health care related costs, the primary goals of MACRA. Academic and community urologists should collaborate and define optimal quality measures that are meaningful and relevant to the practice of urology, which is currently being done by the AUA (American Urological Association) Quality Registry program. The specialty of urology would benefit from a concerted effort to develop bundled payment models for a variety of urological procedures and seek CMS recognition as qualifying for Advanced Alternative Payment Models.

Incidence and risk factors for surgical site infection post-hysterectomy in a tertiary care center.

Preoperative antibiotic prophylaxis and surgical technological advances have greatly reduced, but not totally eliminated surgical site infection (SSI) posthysterectomy. We aimed to identify risk factors for SSI posthysterectomy among women with a high prevalence of gynecologic malignancies, in a tertiary care setting where compliance with the Joint Commission's Surgical Care Improvement Project core measures is excellent. The study was a matched case-control, 2 controls per case, matched on date of surgery. Study time was January 2, 2012-December 31, 2015. Procedures included abdominal and vaginal hysterectomies (open, laparoscopic, and robotic). SSI (superficial incisional or deep/organ/space) was defined as within 30 days postoperatively, per Centers for Disease Control and Prevention criteria. Statistical analysis included bivariate analysis and conditional logistic regression controlling for demographic and clinical variables, both patient-related and surgery-related, including detailed prophylactic antibiotic exposure. Of the total 1,531 hysterectomies performed, we identified 52 SSIs (3%), with 60% being deep incisional or organ/space infections. All case patients received appropriate preoperative antibiotics (timing, choice, and weight-based dosing). Bivariate analysis showed that higher median weight, higher median Charlson comorbidity index, immune suppressed state, American Society of Anesthesiologists score ≥ 3, prior surgery within 60 days, clindamycin/gentamicin prophylaxis, surgery involving the omentum or gastrointestinal tract, longer surgery duration, ≥4 surgeons present in the operating room, higher median blood loss, ≥7 catheters or invasive devices in the operating room, and higher median length of hospital stay increased SSI risk (P < .05 for all). Cefazolin preoperative prophylaxis, robot-assisted surgery, and laparoscopic surgery were protective (P < .05 for all). Duration of surgery was the only independent risk factor for SSI identified on multivariate analysis (odds ratio, 3.45; 95% confidence interval, 1.21-9.76; P = .02). In our population of women with multimorbidity and hysterectomies largely due to underlying gynecologic malignancies, duration of surgery, presumed a marker of surgical complexity, is a significant SSI risk factor. The choice of preoperative antibiotic did not alter SSI risk in our study.

Intraoperative Hypothermia and Surgical Site Infections in Patients with Class I/Clean Wounds: A Case-Control Study

Numerous surgical quality metrics focus on prevention of unintentional perioperative hypothermia due, in part, to the association between hypothermia and surgical site infections (SSI). However, few studies have comprehensively evaluated the relationship between these metrics and SSI. In this study, we evaluated individual components of 1 set of hypothermia metrics to determine their association with SSI. Patients with clean (class I) wounds who developed an SSI within 30 days after surgery, from January 2003 to December 2012, in 1 of 5 surgical specialties, were matched to specialty-specific controls without SSI. Stratified logistic regression models were used to assess the associations between (1) compliance with the Surgical Care Improvement Project (SCIP) Performance Measure, Surgery Patients with Perioperative Temperature Management (SCIP-Inf-10), overall and its components (maintenance of minimum body temperature and use of an active warming device) and SSI and (2) intraoperative hypothermia. In both univariate and adjusted analyses using adjusted odds ratios (OR), SCIP-Inf-10 compliance was not associated with SSI (composite compliance OR 0.89, 95% CI 0.63 to 1.24; temperature compliance OR 0.92, 95% CI 0.78 to 1.09; forced-air warming device compliance OR 0.95, 95% CI 0.76 to 1.19). Higher intraoperative nadir temperature (OR 1.19, 95% CI 1.05 to 1.35) was associated with SSI. Percent of time exposed to a temperature < 36°C (OR 0.98, 95% CI 0.96 to 1.01), and cumulative hypothermic exposure (°C*h <36°C) (OR 0.98, 95% CI 0.90 to 1.05) were not associated with SSI. Intraoperative hypothermia was not significantly associated with SSI. These results suggest that development of compliance metrics may not be an effective strategy for SSI reduction in class I surgical wounds.

Measuring Patient Safety: The Medicare Patient Safety Monitoring System (Past, Present, and Future).

The explicit declaration in the landmark 1999 Institute of Medicine report "To Err Is Human" that, in the United States, 44,000 to 98,000 patients die each year as a consequence of "medical errors" gave widespread validation to the magnitude of the patient safety problem and catalyzed a number of U.S. federal government programs to measure and improve the safety of the national healthcare system. After more than 10 years, one of those federal programs, the Medicare Patient Safety Monitoring System (MPSMS), has reached a level of maturity and stability that has made it useful for the consistent measurement of the safety of inpatient care. The MPSMS is a chart review-based national patient safety surveillance system that provides rates of 21 specific hospital inpatient adverse event measures, which have been divided into 4 clinical domains (general, hospital-acquired infections, postprocedure adverse events, and adverse drug events) for analysis. The 2014 MPSMS national sample was drawn from 1109 hospitals and includes approximately 20,000 medical records of patients admitted to the hospital (all payors) for at least 1 of the 4 conditions of congestive heart failure, acute myocardial infarction, pneumonia, and major surgical procedures as defined by the Centers for Medicare and Medicaid Services Surgical Care Improvement Project. The MPSMS is now going through a major transformation to capture additional types of adverse events and is being redeveloped as the Quality and Safety Review System (QSRS). As an example of this transformation, QSRS will electronically import electronic data, which are standardized according to the Centers for Medicare and Medicaid Services billing definitions and will be updated and evolve over time to incorporate expanded standardized data available from electronic health records. This article reviews the development of MPSMS, the strengths and limitations of MPSMS, and expected future directions in patient safety measurement, focusing on those issues that are informing the development and implementation of QSRS.

Advanced Electronic Health Record Adoption Improves Hospital Compliance with Surgical Care Improvement Project Core Measures

Advanced Electronic Health Record Adoption Improves Hospital Compliance with Surgical Care Improvement Project Core Measures

Examining IV Insulin Practice Guidelines in the Cardiac Surgery Patient: Nurses Evaluating Quality Outcomes.

Recent changes in the Surgical Care Improvement Project guideline require blood glucose values be less than 180 mg/dL 18 to 24 hours after anesthesia end time after cardiac surgery. Our study compares the first group of patients transitioned off IV insulin on postoperative day 1, 24 hours after anesthesia end time, whereas the second group was transitioned off IV insulin on the second day, 48 hours after anesthesia end time. Results show no statistical difference in outcomes between groups.

Preventing perioperative hypothermia

PREVENTING unplanned or unintentional perioperative hypothermia has been a quality measure of The Joint Commission and the Centers for Medicare and Medicaid Services since 2009, when the Surgical Care Improvement Project (SCIP) went into effect.1 Research shows that hypothermia can lead to a host of

The Impact of Surgical Care Improvement Project Measures on In-Hospital Outcomes following Elective Vascular Procedures

As part of the Surgical Care Improvement Project (SCIP), a national quality partnership of organizations including the Centers for Medicare and Medicaid Services and the Centers for Disease Control and Prevention implemented several perioperative guidelines regarding antibiotic, venous thromboembolism (VTE), and beta-blocker prophylaxis for surgical patients. We evaluated the effect of SCIP on in-hospital surgical site infections (SSI), graft infections, VTE, myocardial infarctions (MIs), cardiac complications, mortality, and length of stay following elective major vascular surgery. Using International Classification of Diseases, Ninth Revision (ICD-9) diagnostic and procedure codes, we identified elective open abdominal aneurysm repair (OAR), endovascular aneurysm repair (EVAR), carotid endarterectomy (CEA), major lower extremity amputation, and lower extremity bypass (LEB) procedures in the National Inpatient Sample from 2000 to 2012. Logistic regression and generalized linear models controlling for covariates were used to compare postoperative in-hospital outcomes before and after SCIP implementation (pre-SCIP era 2000-2005 versus post-SCIP era 2009-2012). In the post-SCIP era, the rate of in-hospital SSI following OAR increased from 1.0% to 1.6% (P<0.05). Nonetheless, there were improvements in in-hospital SSI (in EVAR and CEA), graft infections (in OAR, EVAR, and LEB for tissue loss), VTE (in CEA), MI (in EVAR and LEB for tissue loss), cardiac complication (in all procedures except OAR), mortality (in EVAR, CEA, major lower extremity amputation, and LEB for tissue loss), and length of stay (in all procedures except OAR) (all P<0.05). However after adjusting for covariates, SCIP was only associated with reducing SSI in CEA and major lower extremity amputation, graft infections in OAR and LEB for tissue loss, VTE in LEB for claudication or rest pain, mortality in OAR, and length of stay in all procedures except EVAR and CEA. Implementation of SCIP measures was associated with slight improvements in a few in-hospital outcomes following vascular procedures. Additional measures that are more specific to the clinical and technical challenges of treating vascular disease may be more effective for improving the management of vascular patents.