The Surgical Care Improvement Project

The Surgical Care Improvement Project

A National Initiative to Improve Outcomes for Patients having Surgery

Dale W. Bratzler, DO, MPH

QIOSC Medical Director

Oklahoma Foundation for Medical Quality, Inc.

Surgical Care Improvement ProjectNational Goal

To reduce preventable surgical morbidity and mortality by 25% by 2010

SCIP Steering Committee

• American College of Surgeons

• American Hospital Association

• American Society of Anesthesiologists

• Association of peri-Operative Registered Nurses

• Agency for Healthcare Research and Quality

• Centers for Medicare & Medicaid Services

• Centers for Disease Control and Prevention

• Department of Veteran’s Affairs

• Institute for Healthcare Improvement

• Joint Commission on Accreditation of Healthcare Organizations

Surgical Care Improvement Project(SCIP)

• Preventable Complication Modules– Surgical infection prevention– Cardiovascular complication prevention– Venous thromboembolism prevention– Respiratory complication prevention

Surgical Infection Prevention

Surgical Site Infections (SSI)

• 2-5% of operated patients will develop SSI – 40 million operations annually in the U.S.– 0.8 - 2 million SSI’s occur annually in the U.S.

• SSI increases LOS in hospital – average 7.5 days

• Excess cost per SSI:– *$2,734-26,019 (1985, US$)– US national costs: $130-845 million/year

*Jarvis, Infect Control HospEpidemiol. 1996;17.

Surgical Care Improvement ProjectPerformance measures - Process

• Surgical infection prevention» Antibiotics

– Administration within one hour before incision– Use of antimicrobial recommended in guideline– Discontinuation within 24 hours of surgery end

» Glucose control in cardiac surgery patients» Proper hair removal» Normothermia in colorectal surgery patients

Efficacy Of Prophylaxis Is Independent Of The Specific Antibiotic

Age of Lesion at Antibiotic Injection (Hours)Age of Lesion at Antibiotic Injection (Hours)

Les

ion

Siz

e, m

m (

24 H

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rs)

Les

ion

Siz

e, m

m (

24 H

ou

rs)

00

55

1010

Penicillin, 40,000 UPenicillin, 40,000 U

Staph + PenicillinStaph + Penicillin

ControlControl

Chloramphenicol, 0.1 mg/KgChloramphenicol, 0.1 mg/Kg

Erythromycin, 0.1 mg/KgErythromycin, 0.1 mg/Kg

Tetracycline, 0.1 mg/KgTetracycline, 0.1 mg/Kg

00 22 44 66-2-2 00 22 44 66-2-2

00

55

1010

00

55

1010

00

55

1010

ControlControl ControlControl

ControlControl

Staph + ErythromycinStaph + Erythromycin

Staph + TetracyclineStaph + TetracyclineStaph + ChloramphenicolStaph + Chloramphenicol

Burke JF. Surgery. 1961;50:161.

0%

5%

10%

15%

20%

12 hr Preop 1 hr Preop Postop Placebo

Stone HH et al. Ann Surg. 1976;184:443-452.

Timing of Antibiotic ProphylaxisGI Operations

0

1

2

3

4

≤-3 -2 -1 0 1 2 3 4 ≥5

Classen, et al. N Engl J Med. 1992;328:281.

Perioperative AntibioticsTiming of Administration

Hours From Incision

14/369

5/6995/1009

2/180

1/81

1/411/47

15/441

Antibiotic Recommendation Sources

• American Society of Health System Pharmacists

• Infectious Diseases Society of America

• The Hospital Infection Control Practices Advisory Committee

• Medical Letter

• Surgical Infection Society

• Sanford Guide to Antimicrobial Therapy

Single vs Multiple Dose Surgical Prophylaxis: Systematic Review

0.01

0.1

1

10

100

McDonald. Aust NZ J Surg 1998;68:388

All

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All

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Impact of Prolonged Antibiotic Prophylaxis

• 2,641 CABG patients– Grp 1 - < 48 hours of antibiotics– Grp 2 - > 48 hours of antibiotics

• SSI Rates– Grp 1 - 8.7% (131/1502)– Grp 2 - 8.8 % (100/1139)

• Antibiotic resistant pathogen - Grp 2– Odds Ratio 1.6 (95% CI: 1.1-2.6)

Harbarth S, et al. Circulation. 2000.

2.7 1.24.3

20.3

56

2.8 1.4 0.9 0.9

9.6

0

10

20

30

40

50

60

> 24

0

240-

181

180-

121

120-

6160

-00-

60

61-1

20

121-

180

181-

240

> 24

0

Minutes Before or After Incision

Per

cen

t

Inc

isio

n

Antibiotic Timing Related to Incision

Bratzler DW, Houck PM, et al. Arch Surg. 2005;140:174-182.

26.2

10

22.6

6.2 6.32.2 2.7

9.3

14.5

40.7

50.7

73.3

79.5

85.888

90.7

0

20

40

60

80

100

12 o

r les

s

>12-

24

>24-

36

>36-

48

>48-

60

>60-

72

>72-

84

>84-

96>

96

Hours After Surgery End Time

Pe

rce

nt

0

20

40

60

80

100

Cu

mu

lati

ve

Pe

rce

nt

Discontinuation of Antibiotics

Patients were excluded from the denominator of this performance measure if there was any documentation of an infection during surgery or in the first 48 hours after surgery.


Surgical Infection PreventionPerformance Stratified by Surgery1

Surgery (N)

Antibiotic within 1 hour2

% (95% CI)Cardiac (3,287) 58.5 (56.8-60.2)

Vascular (1,116) 47.0 (44.0-49.9)

Hip/knee (2,694) 59.7 (58.3-61.2)

Colon (732) 46.0 (43.5-48.4)

Hysterectomy (432) 54.8 (51.4-58.3)

All Surgeries (11,220) 55.7 (54.8-56.6)

1 All results are weighted to reflect adjustment based on the state-specific sampling scheme.

2 Reflects data for only 11 220 cases that had an explicitly documented incision time.

These results include patients who received vancomycin between one and two hours before the incision (N=213).

Cases were excluded from this performance measure if there was insufficient data to determine the time interval between prophylactic antimicrobial dose and surgical incision (N=22,902). In addition, patients undergoing colon surgery who received oral antimicrobials only for prophylaxis were excluded from the denominator (N=11).



Surgery (N)

Correct Antibiotic

% (95% CI)Cardiac (7,843) 95.1 (94.7-95.6)

Vascular (3,140) 91.5 (90.5-92.5)

Hip/knee (14,996) 97.2 (96.7-97.5)

Colon (4,855) 75.8 (74.6-77.0)

Hysterectomy (2,395) 90.2 (89.0-91.3

All Surgeries (33,229) 92.6 (92.3-92.8)1 All results are weighted to reflect adjustment based on the state-specific sampling scheme.

Antimicrobials were considered “prophylactic” if they were given before surgery, given intraoperatively, or given within 24 hours after the end of surgery.

Cases were excluded from this performance measure if no antimicrobials were administered, if no antimicrobials administered were considered “prophylactic,” or if there was insufficient data to make the determination on timing (N=336). In addition, because there are no published guidelines for antimicrobial selection for beta-lactam allergic patients undergoing colon surgery or hysterectomy, cases with a documented beta-lactam allergy that did not pass the performance measure for these two operations were excluded from the denominator (N=568).



Surgery (N)

Antibiotic Stopped within 24 hours

% (95% CI)

Median Time to Discontinuation

(Hours)

Cardiac (7,635) 34.4 (33.4-35.5) 40.9

Vascular (2,913) 45.2 (43.4-47.0) 42.7

Hip/knee (14,575) 36.7 (35.9-37.4) 39.0

Colon (4,911) 40.8 (39.5-42.2) 57.0

Hysterectomy (2,569) 77.9 (76.3-79.5) 21.4

All Surgeries (32,603) 40.7 (40.2-41.2) 40.4

1 All results are weighted to reflect adjustment based on the state-specific sampling scheme.

Antimicrobials were considered “prophylactic” if they were given before surgery, given intraoperatively, or given within 24 hours after the end of surgery.

Cases were excluded from this performance measure if no antimicrobials were administered, if no antimicrobials administered were considered “prophylactic,” or if there was insufficient data to make the determination of timing (N=344). Any patient with documentation in the medical record of an infection during surgery or within 48 hours after the end of surgery was excluded from the denominator (N=634). In addition, patients who underwent more than one surgical procedure of interest during the hospitalization were excluded from the denominator (N=552).


Glucose Control among Cardiothoracic Surgery Patients

30

4.2

12.19.2

44.5

diabetics

previously undxdiabeticsHyperglycemia

Abn A1c

Normal

Latham R, et al. Infect Control Hosp Epidemiol. 2001.

Perioperative Glucose Control• 1,000 cardiothoracic surgery patients• Diabetics and non-diabetics with hyperglycemia

Patients with a blood sugar > 300 mg/dL during or within 48 hours of surgery had more than 3X the likelihood of a wound infection!

Latham R, et al. Infect Control Hosp Epidemiol. 2001.

Furnary et al. Ann Thorac Surg 1999:67:352

Pre-operative shaving

• Shaving the surgical site with a razor induces small skin lacerations– potential sites for infection– disturbs hair follicles which are often colonized

with S. aureus– Risk greatest when done the night before– Patient education

» be sure patients know that they should not do you a favor and shave before they come to the hospital!

Temperature Control

• 200 colorectal surgery patients– control - routine intraoperative thermal care

(mean temp 34.7°C)– treatment - active warming (mean temp on

arrival to recovery 36.6°C)

• Results– control - 19% SSI (18/96)– treatment - 6% SSI (6/104), P=0.009

Kurz A, et al. N Engl J Med. 1996.

Also: Melling AC, et al. Lancet. 2001. (preop warming)

Cardiovascular Complication Prevention

Prevention of Cardiac EventsIntroduction

• As many as 7-8 million Americans that undergo major noncardiac surgery have multiple cardiac risk factors or established coronary artery disease– More than 1 million cardiac events annually

• Myocardial ischemia either clinically occult or overt confers a 9-fold increase in risk of unstable angina, nonfatal myocardial infarction, and cardiac death

Schmidt M, et al. Arch Intern Med. 2002;162:63-69.

Mangano DT, et al. N Engl J Med. 1996;335:1713-1720.

Selzman CH, et al. Arch Surg. 2001;136:286-290.


• Perioperative cardiac events» Perioperative beta blockers in patients with

known coronary artery disease undergoing non-cardiac vascular surgery

» Perioperative beta blockers in patients who are on beta blockers before surgery

Perioperative is defined as preoperatively on the day of surgery or intraoperatively prior to extubation.


Neurohormonal stress– Increased heart rate– Increased myocardial

contractility– Increased myocardial

oxygen demand

Selzman CH, et al. Arch Surg. 2001;136:286-290.


• Perioperatively administered beta blockers have the potential to:– Decrease myocardial oxygen demand

» Reduced heart rate» Reduced wall tension» Reduced contractility

– Decrease myocardial ischemia and adverse cardiac events

Prevention of Cardiac EventsA Sample of Some of the Studies

Study, yStudy Type N Surgery Drug Findings

Smulyan, 1982

CC 13Gen.

AbdominalPropranolol No perioperative cardiac events

Hammon, 1984

PR 50 CABG PropranololDecreased myocardial oxygen demand, infarction, and arrhythmias

Pasternack, 1989

CC 48Peripheral vascular

MetroprololDecreases silent myocardial ischemia

Yeager, 1995 CC 53General vascular

Unknown 50% decreased MI

Mangano, 1996

PR 99 Noncardiac AtenololDecreased cardiac events from 21% to 10% at two years

Poldermans, 1999

PR 59Major

vascularBisoprolol

Decreased cardiac events from 34% to 3.4% at 30-days

Urban, 2000 PR 60 Total knee Esmolol Decreased myocardial ischemia

Prevention of Cardiac EventsMangano DT, et al. N Engl J Med. 1996;335:1713-1720.

• Randomized, placebo controlled trial of perioperative atenolol on overall survival and cardiovascular mortality in patients with or at risk of cardiovascular disease.– 200 patients (99 atenolol)– Atenolol or placebo before anesthesia

induction, immediately after surgery, and for seven days postoperatively

» Heart rate maintained > 55 bpm, BP maintained > 100 mm Hg

Mangano DT, et al. N Engl J Med. 1996;335:1713-20.

Postoperative Survival

• 6-month survival 100% vs 92% (P<0.001)

• 2-yr survival 90% vs 79% (P=0.019)

How often is postoperative myocardial infarction potentially preventable?

• 72 Patients identified with postoperative MI using 2º dx– Charts reviewed by trained nurse abstractors– Diagnosis of MI required both laboratory physician confirmation

• Demographic characteristics– Mean age 70– 53% Female– Race

81% White, 7% Black, 1% Latino, 10% unknown– Surgery Type

» 35% Vascular, 28% General, 17% Ortho, 10% Ob-Gyn, 11% other

• 25% in-hospital mortality rate

Lindenauer PK, et al. Arch Intern Med. 2004;164:762-766.

72 Patients with PMI

70 at high risk

58 ideal candidates

12 with BB contraindications

2 not high risk

30/58 Rx with BB(5 optimal Rx)

28/58 Not Rx with BB

22 Previously treated8 initiated in hospital

26 previously untreated 2 discontinued

• 48 % of postoperative myocardial infarction potentially preventable• Only 9% of patients received optimal beta blocker therapy

Perioperative Beta Blocker Use in Patients with Postoperative MI

Lindenauer PK, et al. Arch Intern Med. 2004;164:762-766.

Perioperative Beta blockersACC/AHA Guideline

– Class I recommendation» Beta blockers required in the recent past to

control symptoms of angina, symptomatic arrhythmias, or hypertension

» Patients at high cardiac risk owing to the finding of ischemia on preoperative testing who are undergoing vascular surgery

– Class IIa» Patients with known coronary artery disease or

major risk factors for coronary disease

Eagle KA, et al. ACC/AHA. http://www.acc.org/clinical/guidelines.perio/dirIndex.htm.

Venous Thromboembolism Prevention

Prevention of Venous ThromboembolismIntroduction

• VTE Remains a major health problem in the US– 200,000 new cases annually– In addition to the risk of sudden death

» 30% of survivors develop recurrent VTE within 10 years

» 28% of survivors develop venous stasis syndrome within 20 years

– The incidence of VTE is more than 100 times greater for patients who have been hospitalized than among community dwelling

– Incidence increases with ageGoldhaber SZ. N Engl J Med. 1998;339:93-104.

Silverstein MD, et al. Arch Intern Med. 1998;158:585-593.

Heit JA, et al. Thromb Haemost. 2001;86:452-463.

Heit JA. Clin Geriatr Med. 2001;17:71-92.

Heit JA, et al. Mayo Clin Proc. 2001;76:1102-1110.

Prevention of Venous Thromboembolism

• Despite the well known risk of VTE and the publication of evidence-based guidelines for prevention, previous medical record audits have demonstrated underuse of prophylaxis

Anderson FA Jr, et al. Ann Intern Med. 1991;115:591-595.Anderson FA Jr, et al. J Thromb Thrombolysis. 1998; 5 (1 Suppl):7S-11S.Bratzler DW, et al. Arch Intern Med. 1998;158:1909-1912.Stratton MA, et al. Arch Intern Med. 2000;160:334-340.


• Prevention of venous thromboembolism

» Proportion who receive recommended VTE prophylaxis

» Proportion who receive appropriate form of VTE prophylaxis (based on ACCP Consensus Recommendations)

Published Audits of VTE ProphylaxisGeneral Surgery

• Anderson, et al.– 1986 audit of 16 Massachusetts

hospitals» Approximately 1/3 received prophylaxis

• Anderson, et al.– 1994 audit, statewide in Massachusetts

» 84% of colectomy patients received prophylaxis

» regional variation 57-93%

Anderson FA Jr, et al. Physician practices in the prevention of venous thromboembolism. Ann Intern Med. 1991;115:591-595.Anderson FA Jr, et al. Practices in the prevention of venous thromboembolism. J Thromb Thrombolysis. 1998; 5 (1 Suppl):7S-11S.


0

40

80

120

160

200

240

280

Moderate High Very High

Ca

se

s

Received Prophylaxis No Prophylaxis

30/86 (35%) 33/83 (40%)

97/250 (39%)

Use of any form of prophylaxis based on level of risk for venous thromboembolism among 419 Medicare patients from 20 hospitals undergoing major abdominothoracic surgery. Measures were implemented for patients at moderate risk (35%; 95% CI, 25-46%), at high risk (40%; 95% CI, 29-51%), and at very high risk (39%; 95% CI, 33-45%). Overall utilization rate for prophylaxis was 38% (95% CI, 33-43%).

Bratzler DW, et al. Arch Intern Med. 1998;158:1909-1912.


• Stratton, et al– Audit in 10 teaching or community

university-affiliated hospitals (size ranged from 350-747 beds)

» 495 major abdominal surgery patients» 372 (75.2%) received prophylaxis

• 249/495 (50.3%) received grade A therapy

Stratton MA, et al. Prevention of venous thromboembolism: adherence to the 1995 American College of Chest Physicians Consensus Guidelines for surgical patients. Arch Intern Med. 2000;160:334-340.

VTE Prophylaxis in General SurgeryNational SIP Project - Results

State/territory

High-risk Very-high-risk

Cases

(N)

Any Prophylaxis

%

Recommended Prophylaxis*

%

Cases

(N)

Recommended Prophylaxis†

%

All 6896 86.7 80.6 3533 31.4

Lowest performance

Puerto Rico

Mississippi

Texas

169

137

113

59.8

75.9

77.0

54.4

65.0

69.9

87

79

54

16.1

25.3

25.9

Highest performance

District of Columbia

Connecticut

Michigan

125

160

122

96.8

94.4

94.3

94.4

91.3

88.5

66

73

63

53.0

47.9

41.3

* Prophylaxis was considered appropriate if the patient received IPC, LDUH, or LMWH with or without other modalities (American College of Chest Physicians’ grade 1A recommendation). † This column is limited to the subset of patients who had a principal diagnosis of malignancy. Prophylaxis was considered appropriate if the patient received a combination of LDUH or LMWH with IPC or ES with or without other interventions (American College of Chest Physicians’ grade 1C recommendation), or warfarin with or without other interventions (American College of Chest Physicians’ grade 2C recommendation).

Bratzler DW, et al. (in review).

Geerts WH, et al. CHEST. 2004;126:338S-400S.

ACCP Guidelines for VTE Prevention

Respiratory Complication Prevention

Prevention of Ventilator-associated Pneumonia

• Hospital-acquired pneumonia (HAP) occurs 48 hours or more after admission– Ventilator-associated pneumonia (VAP)

arises more than 48 hours after endotracheal intubation

» 6-20 fold increased incidence of HAP in patients on the ventilator (9-27% of all intubated patients)

» Approximately half of all VAP cases occur within the first four days of intubation

Niederman MS, Craven DE, et al. Am J Respir Crit Care Med. 2005;171:388-416.

Complications of Ventilator-associated Pneumonia

• “Attributable mortality” estimated to be between 33 and 50%– Mortality greater for medical illness, bacteremia with

Pseudomonas aeruginosa or Acinetobacter species, and with ineffective antibiotic treatment

– Patients often at risk for multi-drug resistant pathogens– Increased risk of stress ulceration and bleeding within

48 hours of mechanical ventilation

• Dramatic increase in costs of care– Increases hospital stay 7-9 days on average– Excess costs of $40,000

Niederman MS, Craven DE, et al. Am J Respir Crit Care Med. 2005;171:388-416.


• Prevention of ventilator-associated pneumonia

» Proportion of patients on ventilator with head of bed elevated 30 degrees

» Proportion of ventilator patients put on a rapid weaning protocol (daily sedation vacations and assessments of readiness to extubate)

» Proportion of ventilator patients who receive peptic ulcer disease prophylaxis

Outcomes Measures

• Useful for internal quality improvement efforts only

• Useful for public reporting

• Useful for pay-for-performance

SCIP Outcomes Measures

• Measures useful for QI only– SSI rates during index hospitalization– In-hospital cardiac event rates– Rates of DVT/PE diagnosed during index hospitalization– Rate of postoperative pneumonia cases that are

diagnosed during index hospitalization

• Measures that may be useful for public reporting– Risk-adjusted 30-day readmission rate (Medicare only)– Risk-adjusted 30-day mortality rate (Medicare only)

Surgical Care Improvement Project: Why?

Medicare could prevent* up to:

13,027 perioperative deaths

271,055 surgical complications

* Major surgical cases

Potential to Reduce Perioperative Complications in SCIP

3.35

2.28

0.72 0.58

2.49

0.490.29

0

0.5

1

1.5

2

2.5

3

3.5

4

SSI Pneumonia AMI VTE

Pe

rce

nt

Current Complication Rate Potential Complication Rate

25.7% relative reduction

31.9% relative reduction 50.0% relative

reduction

Based on the goal of achieving near-complete guideline compliance to prevent each of these complications as compared to current national rates

of guideline compliance for each complication.

Preliminary Results – CMS Three State Pilot

91.5

60.8

70.9

84.1

59.5

70.865.6

0

20

40

60

80

100

Per

cent

Surgical Care ImprovementPreliminary Results – CMS Pilot

Surgical Infection Module

47.2

75.8

46.1

0

20

40

60

80

100

Per

cent


Cardiac Complications Module

76.9

0

20

40

60

80

100

Any perioperative VTE prophylaxis

Per

cen

t


VTE Prevention Module

91.7

7075

0

20

40

60

80

100

Per

cent


Respiratory Complications Module

Summary

• There remain substantial opportunities to improve outcomes from surgery

• There is a national commitment to performance measurement and improvement of surgical outcomes

• Through a broad national partnership hospitals across the nation will be encouraged to participate in activities to reduce the complications of surgery in the US

Project overview available at: www.medqic.org/scip

Documents

The Surgical Care Improvement Project