Surgical site infections (SSIs) are a significant contributor to postoperative complications with 2.6 percent of nearly 30 million surgeries complicated by SSIs annually . The Centers for Medicare and Medicaid Services (CMS) introduced the Surgical Infection Prevention (SIP) project in 2002, which led to the Surgical Care Improvement Project (SCIP) in 2006. One of the goals of SCIP was to achieve a 25% reduction of the incidence of SSIs by 2010. Both initiatives sought to reduce the rate of postoperative surgical infections by developing standard processes that would encourage national compliance with infection prevention measures .
Quality improvement measures were developed and published in the Specifications Manual for National Inpatient Quality Measures, which is a manual that is continually updated to provide process guidelines for measuring, documenting, and tracking hospital and physician compliance with national standards of care . There are seven SCIP initiatives that apply to the peri-operative period that Rosenberger et al have summarized below:
“Prophylactic antibiotics should be received within 1 h prior to surgical incision (1), be selected for activity against the most probable antimicrobial contaminants (2), and be discontinued within 24 h after the surgery end-time (3); (4) euglycemia should be maintained, with well-controlled morning blood glucose concentrations on the first two post-operative days, especially in cardiac surgery patients; (6) hair at the surgical site should be removed with clippers or by depilatory methods, not with a blade; (9) urinary catheters are to be removed within the first two post-operative days; and (10) normothermia should be maintained peri-operatively.” .
Though the creation of these guidelines and recommendations were based on strong evidence for their efficacy, researchers analyzing the impact of SCIP have found that its efforts have not produced measurable improvements in the rate of SSIs [3, 4]. In fact, Stulberg et al. found that self-reported adherence to the individual SCIP measures was not associated with any decrease in post-operative infection [2, 5].
Experts analyzing SCIP have noted several possible explanations for its shortcomings including inability to quantify quality of care through dichotomous process measures as well as the initiative’s dependence on self-reported performance data that are incentivized in such a way that good performance metrics may not reflect actual quality care or adherence to guidelines. Schonberger et al. call for behavioral interventions to support quality improvement efforts as well as a culture of transparency and modesty, noting that “When an institution is interested in quality, it will highlight its deficiencies and address them. When an institution is motivated by pay-for-performance and public reporting, it will tend to highlight its successes.” . Individual care providers need to approach their practice with a focus on care, skill, and attention to detail one patient at a time. In the age of EHR and pay-for-performance reporting, it is vital that physicians renew their focus on personal accountability and ethical motivations for patient safety
1. Insight, H. Surgical Care Improvement Project (SCIP). Available from: https://healthinsight.org/nm-health-care-providers/192-nm-patient-safety/healthcare-associated-infections/163-scip.
2. Laura H. Rosenberger, A.D.P., Robert G. Sawyer, The Surgical Care Improvement Project and Prevention of Post-Operative Infection, Including Surgical Site Infection. Surgical Infections, 2011. 12(3): p. 163-168.
3. Schonberger, R.B.M., MA; Barash, Paul G. MD; Lagasse, Robert S. MD, The Surgical Care Improvement Project Antibiotic Guidelines: Should We Expect More Than Good Intentions? Anesthesia & Analgesia, 2015. 121(2): p. 397-403.
4. Mary T. Hawn, J.S.R., Catherine C. Vick, Timing of Surgical Antibiotic Prophylaxis and the Risk of Surgical Site Infection. JAMA Surgery, 2013. 148(7): p. 649-657.
5. Jonah J. Stulberg, C.P.D., Duncan V. Neuhauser, et al, Adherence to surgical care improvement project measures and the association with postoperative infections. JAMA, 2010. 303(24): p. 2479-2485.