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SCIP: Using Evidence and Collaboration To Make a Difference


Carolyn M. Clancy, MD
Director
AHRQ

Not long ago, most surgical procedures were performed through large incisions by surgeons who had relatively isolated clinical practices. Operations generally required long hospital stays, and the isolation of the practices limited the expansion and growth of new treatments and procedures. 

Over the last decade or so, surgery has evolved into more of a collaborative discipline, promoting strategies that are based on the best available science that can be refined and improved as new information becomes available. With this multidisciplinary approach, patient care is more of a team effort that uses multiple checks and communication techniques to generate the highest quality service. 

The Surgical Care Improvement Project (SCIP) is a product of the growing commitment to provide safer and higher quality surgical care. It is a national partnership of organizations that are committed to improving the safety of surgical care by providing hospitals, physicians, nurses and other care givers access to effective strategies for reducing post-operative complications. 

Complications need not be perceived as the accustomed hazard for receiving surgical care. However, the fact that they occur in as many as 40 percent of the 42 million surgical procedures that are performed annually in the United States,1 accounting for 2.4 million additional hospital stays and $9.3 billion in excess charges—and that postoperative complications have been found to be the cause of 22 percent of preventable deaths2—means more can be done to make our patients safer. 

Front line providers put in long hours, are frequently rushed, and are not always in a position to avail themselves of best practices and appropriate measures that are supported by research. SCIP is making it easier for them to implement procedures for reducing post-operative complications and tracking their occurrence. 

Evidence-Based Recommendations 

SCIP is a unique and active partnership of government agencies and national organizations, including the Centers for Medicare & Medicaid Services (CMS), Centers for Disease Control and Prevention (CDC), Veterans Affairs Department (VA), Agency for Healthcare Research and Quality (AHRQ), Quality Improvement Organizations (QIOs), American College of Surgeons (ACS), American Society of Anesthesiologists (ASA), American Hospital Association (AHA), and Association of periOperative Registered Nurses (AORN). By combining the most recent scientific evidence with a collective willingness to work together in taking concrete steps for reducing complications, the SCIP partners are optimistic that their goal of reducing surgical care complications by 25 percent3 can be realized.  

The primary tool of the project is a series of evidence-based recommendations that target areas where the incidence and cost of complications are particularly high. Included are surgical site infections (SSI), adverse cardiac events, venous thromboembolism, and respiratory complications. 

SCIP is a driver in a growing effort to limit complications. For example, the World Health Organization initiated a campaign recently to introduce surgical safety checklists worldwide.4 In addition, CMS began a pay-for-performance initiative in August 2007 that uses SSI rates as a performance measure. 

There are five SCIP process measures to be used for public reporting and possibly for determining incentive payments. Plans call for the measures to be refined and additional ones to be introduced as new evidence-based information becomes available. 

A new redosing measure, SCIP-Inf-8, will be introduced in April 2009. SCIP-Inf-8 calls for redosing of antibiotics if patients received a short-life antibiotic and the time between initiation of the first antibiotic and the end of surgery exceeds four hours. 

A second cardiac measure is also scheduled to come online with SCIP-Inf-8. SCIP-Card-2 addresses the issue of checking to make sure beta blockers are administered before surgery if needed. The new SCIP-Card-3 deals with whether these patients receive beta blockers on the first or second day after their operation if they are still hospitalized. 

Narrowing the Gap Between Theory and Practice 

SCIP-Inf-7, which addresses colorectal surgery patients with immediate postoperative normothermia (greater than or equal to 96.8° F) within the first hour after leaving the operating room, is undergoing review as a measure for discharges. Published research5 has linked slower wound healing, adverse cardiac events, altered drug metabolism and poor blood coagulation to unplanned perioperative hypothermia.  

At least two measures specific to hospital-based outpatient departments became effective with discharges beginning on April 1, 2008. The first was Outpatient 6, which involves antibiotic timing. It calls for antibiotics to be initiated within one hour of the first incision. The second, Outpatient 7, deals with the appropriate selection of antibiotics. 

SCIP closes the gap between theory and practice, creating a framework and a comprehensive—and achievable—action plan for reducing avoidable complications after surgery. It is a plan that can make the complications that occur on a regular basis today the exception rather than the norm.