Surgical Care Improvement Project

Published On 07/11/2011

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The Surgical Care Improvement Project (SCIP) focuses on how well Methodist Le Bonheur Healthcare follows recommended surgical practices. Following these recommended process measures for evidence based care should lead to improved outcomes in our surgical patients.

SCIP includes patients that have specific surgeries. These surgeries are: Coronary Artery Bypass Graft (CABG), Other Cardiac Surgery, Hip Replacement, Knee Replacement, Colon Surgery, Hysterectomy, and Vascular Surgery.
  

Quality Report Findings for July 2013 - June 2014
Within Top 10%        Above National Average        Below National Average
Hospital Quality MeasuresMethodist HealthcareUniversitySouthNorthGermantownOlive BranchTop 10% NationallyStatewide AverageNationwide Average
SCIP Appropriate Care Score 97.8% 97.8% 97.4% 95.4% 98.4%
100.0%
* No data available No data available
Prophylactic Antibiotics Received Within 1 Hour Prior to Surgical Incision
99.1%

98.2%

100.0%

98.5%

99.1%

100.0%
100.0% 97.0% 96.0%
Prophylactic Antibiotic Selection for Surgical Patients
99.4%

99.2%

98.2%

99.3%

99.7%

100.0%
100.0% 98.0% 98.0%
Prophylactic Antibiotics Discontinued Within 24/48 Hours After Surgery End Time 98.8% 99.3% 96.6% 98.1% 99.0%
100.0%
100.0% 97.0% 97.0%
Cardiac Surgery Patients with Controlled 6 A.M. Postoperative Blood Glucose
97.0%

94.7%

100.0%

96.7%

100.0%

100.0%
100.0% 100.0% 100.0%
Surgery Patients with Appropriate Hair Removal
100.0%

100.0%

100.0%

100.0%

100.0%

100.0%
100.0% 100.0% 100.0%
Perioperative Beta Blockers
98.5%

97.8%

96.4%

97.2%

99.6%

100.0%
100.0% 95.0% 95.0%
Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered N/A N/A N/A N/A N/A N/A 100.0% 98.0% 98.0%
Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis Within 24 Hrs Prior to Surgery to 24 Hrs After Surgery
99.9%

99.9%

100.0%

99.2%

100.0%

100.0%
100.0% 98.0% 98.0%

Methodist Fayette Hospital had no patients to report or too few patients to report for this indicator.  

What These Indicators Mean & Why They're Important to You

Prophylactic Antibiotics Received Within 1 Hour Prior to Surgical Incision - Patients having surgery should receive an antibiotic within one hour of the beginning of their surgical procedure.  Studies show that this helps reduce the chance of a patient developing a surgical site infection.

Prophylactic Antibiotic Selection for Surgical Patients - Patients having surgery should receive the right antibiotic based on the type of surgery and their medical history.  Studies show that choosing the right antibiotic helps to reduce the chance of a patient developing a surgical site infection.

Prophylactic Antibiotics Discontinued Within 24/48 Hours After Surgery End Time - Patients having surgery should have their antibiotics stopped within 24 hours after the surgery ended.  For patients having cardiac surgery, antibiotics should be stopped within 48 hours.  The use of antibiotics should provide benefit to the patient with as little risk as possible.  There is no additional benefit to giving antibiotics to the patient for more than a few hours after the surgery is finished.  Prolonged use of antibiotics can lead to other types of infection and resistant organisms.

Cardiac Surgery Patients With Controlled 6 A.M. Postoperative Blood Glucose - Patients having cardiac surgery should have their blood sugar monitored and under control following their surgery. Studies have shown that uncontrolled (high) blood sugar levels in cardiac surgery patients have been linked to increased risk for infection, other adverse outcomes (kidney failure, lung failure, blood transfusions), and in rare cases, death.  Effective control of the patient’s blood sugar leads to faster healing and improved outcomes.

Surgery Patients With Appropriate Hair Removal - Patients having surgery should have appropriate hair removal.  No hair removal, hair removal with clippers, or depilatory is considered appropriate. Shaving the site is considered inappropriate.  Studies have shown that shaving causes multiple skin abrasions (cuts and tears in the skin), that later may become infected.

Perioperative Beta Blockers Administered - Patients having surgery who were taking a beta-blocker prior to their surgery should receive a beta-blocker before, during, or shortly after their surgery. Beta blockers help relieve stress on the heart by reducing the heart rate and reducing the force needed to make the heart pump. Studies have shown that stopping beta-blocker therapy during the patient’s surgical experience can lead to an increased risk for death, especially during the first year post-surgery.

Surgery Patients With Recommended Venous Thromboembolism (VTE) Prophylaxis Ordered - Patients having surgery should have measures to prevent blood clots from forming after surgery ordered by their surgeon. These measures can include medications and/or compression stockings. Studies show that these measures can help prevent complications and death resulting from blood clots.

Surgery Patients Who Received The Appropriate Venous Thromboembolism (VTE) Prophylaxis Within 24 Hours Prior to Surgery to 24 Hours After Surgery -  Patients having surgery should receive medications and/or compression stockings to prevent blood clots from forming  prior to or after surgery. Studies show that these measures can help prevent complications and death resulting from blood clots. 

How We Measure

We have a team of associates that review patient information for our hospitals. Our team attends abstraction clinics so they will be up to date on the most current abstraction rules. Our abstracted information is entered into a computerized system that checks the information for completeness and accuracy. Each missed opportunity is reviewed by our Clinical Decision Support department and all corrections are made before the data is submitted to the Centers for Medicare and Medicaid (CMS) or The Joint Commission.

Working to Ensure the Best Patient Care

We regularly communicate with the caregivers you see throughout the hospital about the best practices and evidence-based care that we are measuring behind the scenes. We review the care of our patients during their hospital stay, and we conduct reviews to identify opportunities for improvement. We use this information to develop processes that provide our patients with safe, reliable, consistent, high-quality care.