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surgical patients

Improved care for

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Susan M. Daniels, RN, MSN

In December 2004, the Institute for Healthcare Improvement (IHI) launched an ambitious campaign to prevent 100,000 avoidable deaths in hospitals nationwide. When it ended in June 2006, the 100,000 Lives Campaign had exceeded its goal by an estimated 22,000 lives. Building on this accomplishment, the IHI has initiated a new campaign called the 5 Million Lives Campaign, which aims to dramatically reduce incidents of medical harm in American healthcare facilities. To reduce surgical complications, the IHI is urging hospitals to adopt all recommendations from a national quality partnership called the Surgical Care Improvement Project (SCIP). (See Learning about SCIP.) The recommendations focus on these target areas: surgical site infections (SSIs), adverse cardiac events, and postoperative venous thromboembolism (VTE). In addition, the IHI continues to promote its ventilator bundle of interventions to prevent ventilator-associated pneumonia (VAP). Preventing SSIs Surgical site infections account for 14% to 16% of all
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qqq Follow the national patient care recommendations detailed here to help prevent surgical site infections and other postoperative complications. qqq
hospital-acquired infections.1 Under SCIP guidelines, recommendations for preventing SSIs consist of four components: the appropriate use of prophylactic antibiotics, the use of appropriate hair removal methods, glucose control in patients undergoing major cardiac surgery, and normothermia in patients undergoing colon surgery. Appropriate use of prophylactic antibiotics. The quality performance initiatives of both the IHI and the National Hospital Quality Measures program currently focus only on prophylactic antibiotic therapy for a select group of surgical procedures: hip and knee arthroplasty, cardiac surgery including coronary artery bypass graft, hysterectomy, and certain colon and vascular procedures. The National Hospital Quality
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Measures program is a collaboration between the Centers for Medicare & Medicaid Services (CMS) and The Joint Commission (TJC, formerly JCAHO).2 The goal of prophylactic antibiotic therapy administered before surgery is to protect the patient from infection with as little risk as possible. To meet this goal, clinicians must administer antibiotics when theyll do the most good and select the most effective antibiotics to provide maximum coverage. Improving timing and choice of antibiotic to be administered is a crucial first step toward preventing SSIs. Delivering the prophylactic dose just before incision time has produced the best results in preventing SSIs.3 The IHI, SCIP, and CMS/TJC quality performance initiatives have agreed to use 60 minutes prior to incision for measurement purposes. However, vancomycin and fluoroquinolones may be given up to 2 hours before incision because of their longer infusion times. Many hospitals have improved compliance with this standard when one department, such as anesthesia, has accepted ownership and accountability for initiating the antibiotic once the patient arrives in the OR. Other successful strategies have included identifying a specific time to begin the infusion, such as immediately before induction, and incorporating a check for antibiotic administration during the preincision pause. The list of recommended antibiotics is based on surgery type and takes into consideration each medications safety, cost-effectiveness, and spectrum of action, which should cover most of the probable intraoperative contaminants for the procedure. Cephalosporins (first and second generation) are the first choice for most operations, with the addition of another drug for anaerobic coverage during colon surgery. Vancomycin isnt recommended for routine prophylaxis because of the potential for antibiotic resistance, but its acceptable for certain procedures under certain circumstances (for example, if a patient has a beta-lactam allergy). Discontinuing a prophylactic antibiotic when the risks outweigh the benefits is as important as initiating therapy at the right time. Administration of antibiotics for more than a few hours after the incision is closed hasnt been shown to benefit patients, and it may contribute to the development of antibiotic-resistant pathogens.4 For most procedures, prophylactic antibiotics should be discontinued within 24 hours of the surgery end time. For cardiac surgeries, however, this time frame has been extended to 48 hours based on input and evidence supported by groups such as the Society of Thoracic Surgeons.5
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Learning about SCIP

As part of its commitment to improving surgical care nationally, the IHI has joined forces with a coalition of healthcare organizations called the Surgical Care Improvement Project (SCIP). The goal of SCIP is to reduce the incidence of surgical complications by 25% by the year 2010. To reduce the morbidity and mortality associated with inpatient surgery, SCIP has developed a list of evidence-based interventions that have proven effective in reducing certain complications, such as infection, blood clots, and pneumonia. Many have been incorporated into the National Hospital Quality Measures (Core Measures) initiative launched by the CMS and TJC. Performance data collected by these two organizations are currently being used for public reporting on consumer healthcare quality Web sites such as http://www.qualitycheck.org. Organizations joining the SCIP partnership include the Centers for Disease Control and Prevention, the American College of Surgeons, the American Hospital Association, and the Association of periOperative Registered Nurses. For more information on SCIP , visit http://www. medqic.org/scip.

Compliance with the discontinuation of antibiotics has been challenging for many hospitals. Inconsistent practices related to marking the end time of surgery, poor communication at handoffs, individual practitioner preferences, and lack of awareness have all contributed to the continuation of antibiotics beyond the recommended time. Standardizing the process with the use of preprinted order sets and protocols can help facilities improve their performance on this goal by increasing consistency among various healthcare providers. The most successful improvement efforts will be focused on designing systems that dont rely on humans remembering to do the right thing at the right time. Appropriate surgical site hair removal before surgery. The recommended principles of hair removal are applicable to virtually all types of surgery. The IHI recommends no hair removal, or surgical site hair removal with clippers or a depilatory.6 When preoperative hair removal is warranted, removing hair with electric clippers is preferable because depilatories can cause local adverse reactions. Under SCIP guidelines, hair removal should occur immediately before surgery, not the night before.1,7 Shaving hair with a razor isnt recommended
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Improved care for surgical patients

because shaving creates abrasions and microscopic skin nicks. These, combined with the introduction of bacteria from the hair follicles, increase the infection risk. According to the Centers for Disease Control and Prevention, Preoperative shaving of the surgical site the night before an operation is associated with a significantly higher SSI risk than either the use of depilatory agents or no hair removal.7 Some effective changes in the OR environment that can improve compliance with this measure include the removal of razors from the supply area, having clippers readily available, and rethinking the need for routine hair removal. Outside the OR, nurses and healthcare providers who prepare and educate patients before surgery can share information about preferred hair removal practices. Maintaining glycemic control. Hyperglycemia, which can cause significant damage to most body organs and systems, has been associated with many postoperative complications. For example, because hyperglycemia impairs immune system function, it inhibits the bodys ability to fight infection. Immediate postoperative glucose control has been correlated with a reduction in surgical infection. One study demonstrated that the incidence of deep wound infections in diabetic patients undergoing cardiac surgery was reduced by controlling mean blood glucose levels below 200 mg/dL in the immediate postoperative period. In another study, hyperglycemia in the immediate postoperative phase was shown to increase the risk of infection in both diabetic and nondiabetic patients; the higher the serum glucose, the higher the potential for infection in both patient groups.2 Glucose control is defined within this quality initiative as the maintenance of blood glucose levels under 200 mg/dL in the 48-hour postoperative period, and includes only patients undergoing major cardiac surgery. Diabetes management across the continuum of care in both inpatient and outpatient settings is currently receiving a lot of attention within the healthcare community. Additional quality improvement initiatives related to diabetes are currently under consideration. Establishing consistent and reliable processes and tools such as medication reconciliation, order sets and protocols, and patient education can not only standardize testing and treatment options for hospitalized patients today, but also position hospitals to improve their care for all patients at risk for hyperglycemia in the future. Maintaining normal body temperature. Hypothermia has been associated with various compli-

cations following surgery, including impaired wound healing, cardiac events, and infection. Maintaining the patients normal body temperature (normothermia) or actively warming him in the OR can improve his chances of avoiding SSI. Immediate postoperative normothermia is defined in this quality initiative as a body temperature of 96.8 F to 100.4 F (36 C to 38 C) within the first hour after leaving the OR and currently includes only colorectal surgery patients. For various reasons, including the comfort of staff who must work under bright lights wearing protective garb for long periods, ORs are commonly kept quite cool. Altering this practice may be a challenge within many hospital cultures and will require education and recommendations by hospital practice groups with the endorsement and support of executive leadership. Consistent and reliable implementation of the four SSI prevention measures discussed above has been credited with reducing the postsurgical site infection rate by 27% in one demonstration project sponsored by the CMS.4 Results like these can have an enormous impact on the outcomes of surgical patients in terms of pain and suffering, extended hospital stays, and increased costs associated with SSIs. Avoiding adverse cardiac events The second category of SCIP recommendations focuses on preventing adverse cardiac events. This SCIP initiative calls for continuing beta-blocker therapy for all patients taking a beta-blocker before admission for surgery. Although consensus hasnt been reached about the benefits of this therapy for all surgical patients, SCIP participants agree that surgical patients who are already receiving beta-blockers should continue this therapy throughout hospitalization. Transition of care points are vulnerable times for medication errors of omission for all hospitalized patients and especially for surgical patients. For example, continuation of beta-blocker therapy may be missed during the postoperative period because the surgeon is unlikely to be the patients primary care provider. In addition, medication orders for surgical procedures may not include all of the patients previously ordered medications; this may result in unintentional withdrawal of beta-blockers and lead to adverse cardiac events. Medication reconciliation at all transition points is essential to ensure the continuity of beta-blocker therapy. Teach patients to inform all caregivers about the medications theyre taking before undergoing any medical procedure and to ask questions about changes
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in their drug regimen during treatment. Preventing VTE The third category of SCIP recommendations calls for prophylactic pharmacologic and mechanical therapies to prevent VTE. The term VTE encompasses both deep vein thrombosis (DVT) and pulmonary embolism. In recommendations for VTE prophylaxis for surgical patients, the American College of Chest Physicians (ACCP) notes that without prophylaxis, the incidence of objectively confirmed, hospital-acquired DVT is approximately 10% to 40% among medical or general surgical patients and 40% to 60% following major orthopedic surgery.8 The ACCP recommendations, which form the basis for the SCIP guidelines, include these measures: use of intermittent pneumatic compression devices and graduated compression stockings administration of low-dose unfractionated heparin, low-molecular-weight heparin, factor Xa inhibitor (fondaparinux), or warfarin. Under ACCP recommendations, aspirin-only therapy has no role in DVT prophylaxis, even though some practitioners continue to prescribe it for this indication. Also, the ACCP hasnt included an order for early ambulation in its recommendations because this measure isnt considered sufficient for VTE prevention. Too often, patients limit their ambulation to trips to the bathroom and short walks up and down the halls; this level of activity isnt enough to prevent VTE. The SCIP guidelines recommend assessing each patients risk of VTE and administering appropriate perioperative prophylaxis. Although the efficacy, effectiveness, and cost-effectiveness of pharmacologic and mechanical prophylactic therapies are well accepted, these measures continue to be underutilized.1 Because VTE continues to be a significant risk for all surgical and medical hospitalized patients, additional quality measures are in development at the national level for VTE diagnosis, treatment, and prevention. Preventing VAP Although SCIP is currently reviewing the inclusion of a respiratory component, the 5 Million Lives Campaign recommends using the ventilator bundle to prevent VAP in postoperative patients requiring mechanical ventilation, particularly those ventilated for more than 24 hours. During the 100,000 Lives Campaign, hospitals that consistently implemented the IHIs ventilator bundle of recommendations realized significant reductions
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in the incidence and rate of VAP; in fact, several hospitals experienced periods of 1 year or longer without any cases of VAP. The ventilator bundle is a collection of interventions intended to protect patients who are intubated and mechanically ventilated from developing certain serious complications. These interventions are believed to be more effective when all are delivered as a group, or bundle, rather than individually. The ventilator bundle contains the following four interventions: Elevate the head of the bed between 30 and 45 degrees at all times except when care is being provided or when contraindicated (for example, because of hemodynamic instability or spinal cord injury). Provide every patient with a daily sedation vacation. This means lightening sedation medications to assess his responsiveness and to evaluate his readiness for weaning. Provide mechanical or pharmacologic prophylaxis for VTE. Administer daily medication (such as a histamine2receptor inhibitor) to prevent peptic ulcer disease. Although the last two measures arent directly related to respiratory care, theyre included as part of the overall care plan for patients on ventilators and included in the 5 Million Lives Campaign.

Is your facilitys board on board?

Implementing lasting changes of any kind within a complex hospital organization can be a daunting task. Competing priorities and philosophies of care may result in differing opinions about the value and effectiveness of some of these interventions. Resistance to standardized or cookbook medicine is deeply ingrained in the medical profession. At the same time, hospital executives and administrators are searching for new ways to improve processes and reduce the risk of human error. Hospital leaders want to create a culture that minimizes blame and maximizes communication and teamwork. Bringing about significant, lasting change within a hospital requires a commitment by hospital leadershipwhat the IHI calls getting boards on One of the six new interventions in the 5 board. Million Lives Campaign, getting organizational boards on board requires the visible and unwavering commitment of hospital governing boards, especially when implementation requires coordination and cooperation across many different departments.9

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Improved care for surgical patients

How to initiate change A successful strategy for instituting change within hospitals requires a commitment by hospital leaders (See Is your facilitys board on board?) and the use of a designated team of experts from within the hospital, assembled for a specific purpose and a specific amount of time. For implementation of the SCIP recommendations, for example, a logical team leader would be a surgeon, whod be given clear ownership and accountability for the project. Other key team members might be a perioperative nurse, an anesthesia provider, a pharmacist, and a process improvement specialist. Hospital administrators should strongly support the project with a very public announcement disseminated throughout the organization outlining the goals, timetable, and assigned accountabilities. Implementing change across many different areas is guaranteed to elicit opposition, resistance, and challenges. Hospital leadership will need to develop a process to address issues and concerns immediately to resolve conflicts. The recommendations discussed in this article will soon be the standard of care for all hospitalized surgical patients. Help get your facility on board by learning about current best-practice recommendations from the IHI, SCIP, and other national authorities and work with others in your facility to implement them. OR

REFERENCES
1. MedQIC. Surgical Care Improvement Project (SCIP). About the Project. Available at: http://www.medqic.org/dcs/ContentServer?cid=11364957 55695&pagename=Medqic%2FOtherResource% 2FOtherResourcesTemplate&c=OtherResource. Accessed September 26, 2007. 2. Specifications Manual for National Hospital Quality Measures (version 2.1d), 2006. Available at: http://www.qualitynet.org/dcs/ Content Server?cid= 1157485287169&pagename=QnetPublic% 2FPage% 2FQnetTier3&c= Page. Accessed September 26, 2007. 3. Bratzler DW, Houck PM. Antimicrobial prophylaxis for surgery: An advisory statement from the National Surgical Infection Prevention Project. Am J Surg. 2005;189(4):395-404. 4. Dellinger EP, Hausmann SM, Bratzler DW, et al. Hospitals collaborate to decrease surgical site infections. Am J Surg. 2005; 190(1):9-15. 5. The Society of Thoracic Surgeons. Practice Guideline Series. Antibiotic Prophylaxis in Cardiac Surgery. Part I: Duration of prophylaxis (http://www.sts. org/sections/resources/practiceguidelines/antibioticguideline/) and Part II: Antibiotic choice (http://www.sts. org/sections/resources/practiceguidelines/antibioticguideline2/). Accessed September 26, 2007. 6. Institute for Healthcare Improvement. Getting started kit: Prevent surgical site infections how-to guide. Available at: https://www.ihi.org/users/login. aspx?returnURL=http%3a%2f%2fwww.ihi.org%2fihi%2fdownload. aspx% 3ffile%3d%2fNR%2frdonlyres%2fC54B5133-F4BB-4360A3E42952C08C9B59%2f0%2fSSIHowtoGuide.doc. Accessed October 4, 2007. 7. Centers for Disease Control and Prevention. Guideline for prevention of surgical site infection. 1999. Available at: http://www.cdc.gov/ncidod/dhqp/ gl_surgicalsite.html. Accessed September 26, 2007. 8. Geerts WH, Pineo GF, Heit JA, et al. Prevention of venous thromboembolism: The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004; 126(3, Suppl.):338S-400S. 9. Institute for Healthcare Improvement. Getting started kit: Governance leadership boards on board how-to guide. Available at: http://www. ihi.org/nr/rdonlyres/95eadb8f-3ad6-4e09-8734-fb7149cfdf14/ 0/boardhowtoguide.doc. Accessed September 26, 2007.
Susan M. Daniels is a nursing education specialist at the Mayo Clinic in Rochester, Minn. Reprinted with permission from: Daniels SM. Protecting patients from harm: Improving hospital care for surgical patients. Nursing2007. 37(8):36-41. The author has disclosed that she has no significant relationship with or financial interest in any commercial companies that pertain to this educational activity.

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Improved care for surgical patients

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