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Updated Quality Data - Surgical Care Improvement Project

Surgical infections remain a common complication of surgery.  Surgical site infections account for approximately 40% of all hospital associated infections among surgical patients in the USA and 3% of all post operative patients will develop infections.  Using preventative measures, such as appropriate antibiotics before, during and up to 24 hours after surgery, clipping the operative site versus shaving, and keeping the patient warm during the perioperative period have all been shown to reduce the likelihood of infection as a complication.

About the data below:
Below you will find graphs reporting on NMC's performance in the Core Measures relating to our Surgical Care Improvement Project. Above each graph (or sections of graphs), you'll also find helpful definitions and information that can help you understand the data presented. In the upper right-hand corner of each, you will notice a colored block-- this is our "stop-light" system for a quick glance at how we are doing: Green = Meeting Identified Goal of 100% Compliance for Most Current Month; Red = Not Meeting Identified Goal of 100% for Most Current Month; No Color Indicates No Data for the Current Month (it is not unusual for a small hospital to have "no data" on a particular indicator due to the small number of cases seen at the facility).


Surgical Care Improvement Project Appropriate Care Measures:
Data current through February 2014
 

PROPHYLACTIC ANTIBIOTIC RECEIVED WITHIN ONE HOUR PRIOR TO SURGERY

  • * a higher score is better

What this means:
This is a measure that shows the percentage of surgical patients that received prophylactic antibiotics within 1 hour prior to surgical incision.
Why this is important:
Scientific studies show that patients who receive prophylactic antibiotics within 1 hour of surgery incision time can have reduced numbers of post operative infections.

 

 

PROPHYLACTIC ANTIBIOTIC SELECTION FOR SURGICAL PATIENTS

  • * a higher score is better

What this means:
This is a measure that shows the percentage of surgical patients that received the appropriate prophylactic antibiotic for their specific surgical procedure.
Why this important:
The goal of administering prophylactic antibiotics for surgical patients is to use a drug that is safe, cost effective and appropriate for the specific surgical procedure.

 

 

 

PROPHYLACTIC ANTIBIOTICS DISCONTINUED WITHIN 24 HOURS OF SURGERY END TIME

  • * a higher score is better.

What this means:
This is a measure that shows the percentage of surgical patients that had their prophylactic antibiotics discontinued within 24 hours of surgery end time.
Why this is important:
Scientific studies show that the administration of prophylactic antibiotics for more than a few hours after the surgical incision is closed offers no additional benefit to the surgical patient. Prolonged administration can result in resistant strain bacteria.

 

 

 

SURGERY PATIENT WITH APPROPRIATE HAIR REMOVAL
* a higher score is better

What this means:
This is a measure that shows the percentage of surgical patients receiving appropriate surgical site hair removal. No hair removal, hair removal with clippers or creams and lotions are considered appropriate. Shaving is considered inappropriate.
Why this is important:
Scientific studies show that shaving causes multiple skin abrasions that later may become infected.

 

 

 

 

VENOUS THROMBOEMBOLISM PROPHYLAXIS WITHIN 24 HOURS PRIOR TO SURGERY TO 24 HOURS AFTER SURGERY
*a higher score is better

What this means:
This is a measure that shows the percentage of surgical patients that received venous thromboembolism prophylaxis within 24 hours prior to surgery to 24 hours after surgery.
Why this is important:
The recommended optimal start time of VTE prophylaxis for surgical procedures is 24 hours prior to surgery to 24 hours after surgery, in order to reduce the likelihood of blood clots from occurring.

 

 

 

URINARY CATHETER REMOVED POSTOPERATIVE DAY 1 OR DAY 2
*a higher score is better

What this means:
This is a measure that shows the percentage of surgical patients with catheters removed on postoperative day 1(POD 1) or postoperative day 2 (POD 2) with day of surgery being day zero.
Why this is important:
It is well established that the risk of catheter-associated urinary tract infection increases with increasing duration of indwelling urinary catheterization.

 

 

 

SURGERY PATIENTS WITH PERIOPERATIVE TEMPERATURE MANAGEMENT
*a higher score is better

What this means:
This is a measure that shows the percentage of surgical patients that either had active warming performed during surgery or had at least one body temperature equal to or greater than 96.8˚ F/36˚ C within 30 minutes prior to or 15 minutes after Anesthesia End Time.

Why this is important:
Scientific studies show that hypothermia can increase the incidence of infection, can increase the chance of blood product administration, and cause other adverse outcomes resulting in prolonged hospital stays and increased healthcare expenditures.

 

 

 

SURGERY PATIENTS ON BETA-BLOCKER THERAPY PRIOR TO ARRIVAL WHO RECEIVE A BETA-BLOCKER DURING THE PERIOPERATIVE PERIOD
*a higher score is better

What this means:
This is a measure that shows the percentage of surgical patients on beta-blocker therapy who receive a beta-blocker within 24 hours prior to incision through discharge from recovery.
Why this is important:
Scientific studies indicate that continuing beta-blocker therapy during the perioperative period reduces mortality in surgical patients.