Background and Development of SCIP
Surgical site infections (SSIs) have long been a significant concern in healthcare, contributing to increased patient morbidity, prolonged hospital stays, and higher healthcare costs. In the late 1990s, SSIs were recognized as the third most common type of nosocomial infection, and the most frequent among surgical patients, with a substantial portion of SSI-related deaths directly attributed to the infection itself. Recognizing the need for standardized and improved infection prevention practices, the Centers for Medicare & Medicaid Services (CMS) partnered with the Centers for Disease Control and Prevention (CDC) to launch the Surgical Infection Prevention (SIP) project in 2002.
This initial project aimed to address the inconsistent application of proven infection prevention measures in surgical settings. The core goal was to develop and implement quality improvement measures that would standardize peri-operative processes and consequently enhance compliance with best practices. Building upon the foundation of the SIP project, the Surgical Care Improvement Project (SCIP) was established in 2006. SCIP further refined and formalized process measures designed to minimize surgical complications, particularly SSIs. These measures are meticulously detailed in the Specifications Manual for National Inpatient Quality Measures, a dynamic document continuously updated to reflect the latest evidence-based standards of care. This manual serves as a crucial resource for healthcare providers, offering standardized quality measures to ensure consistent documentation and tracking of care standards across institutions.
Key SCIP Performance Measures
The Specifications Manual outlines a series of SCIP performance measures, with seven specifically focused on the peri-operative period. These measures, designated as SCIP-INF (infection) measures, are designed to monitor hospital adherence to nationally recognized standards of surgical care. Each measure is grounded in evidence demonstrating its impact on patient outcomes, although many were initially derived from expert consensus and recommendations from leading medical societies.
Table 1. Surgical Care Improvement Project (SCIP) Performance Measures Applicable to the Peri-Operative Period
| SCIP Infection Measure Designator | Performance Measure Title |
|---|---|
| INF-1 | Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision |
| INF-2 | Prophylactic Antibiotic Selection for Surgical Patients |
| INF-3 | Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End-Time |
| INF-4 | Cardiac Surgery Patients with Controlled 6 am Postoperative Blood Glucose |
| INF-6 | Surgery Patients with Appropriate Hair Removal |
| INF-9 | Urinary Catheter Removed on Postoperative Day 1 or Postoperative Day 2 |
| INF-10 | Surgery Patients with Peri-operative Temperature Management |
SCIP-INF 1: Timely Prophylactic Antibiotic Administration
The first SCIP infection measure, INF-1, emphasizes the critical timing of prophylactic antibiotic administration. Administering antibiotics within one hour prior to surgical incision is crucial for achieving adequate tissue concentrations at the time of incision, maximizing their effectiveness in preventing SSIs. Early research highlighted the impact of timely antibiotic administration. A study in 1985 demonstrated that utilizing computer-generated prompts to remind clinicians about pre-operative antibiotic timing significantly reduced SSI rates. This study underscores the importance of system-level interventions to ensure adherence to this seemingly simple yet vital step in surgical care. The study found a significant improvement in compliance, with antibiotic administration within 2 hours pre-operatively increasing from 40% to 58% following the introduction of the computer prompt system.
SCIP-INF 2: Appropriate Prophylactic Antibiotic Selection
SCIP-INF 2 addresses the selection of the most appropriate prophylactic antibiotic. The choice of antibiotic should be tailored to the specific surgical procedure and the likely microbial contaminants associated with that procedure. Guidelines from organizations like the Hospital Infection Control Practices Advisory Committee (HICPAC) and the Infectious Diseases Society of America (IDSA) recommend selecting antibiotics that offer coverage against the most probable pathogens, possess favorable pharmacokinetic properties for adequate tissue penetration, demonstrate a strong safety profile, and are cost-effective.
Cephalosporins are frequently the preferred class of antibiotics for surgical prophylaxis due to their broad-spectrum activity against common surgical pathogens and their well-established safety and efficacy. Cefazolin is often the agent of choice for clean surgeries, while second-generation cephalosporins like cefoxitin, offering anaerobic coverage, are recommended for procedures such as colon surgeries. For patients with cephalosporin allergies, alternatives like clindamycin or vancomycin can be used for gram-positive coverage, and clindamycin or metronidazole for anaerobic coverage. Complex surgeries, such as transplants, cardiac, or orthopedic procedures, may necessitate more specialized antibiotic selection based on likely pathogens, emphasizing the need for surgeons to consult relevant guidelines and resources.
SCIP-INF 3: Discontinuation of Prophylactic Antibiotics
SCIP-INF 3 focuses on the duration of prophylactic antibiotic therapy, advocating for discontinuation within 24 hours after the surgery end-time. Prolonged post-operative antibiotic administration offers no additional benefit in preventing SSIs and may contribute to the development of antibiotic resistance and secondary infections, such as Clostridium difficile-related disease. The rationale behind this measure is that prophylactic antibiotics aim to reduce the bacterial load at the surgical site to a level manageable by the patient’s immune system, rather than sterilizing tissues. Multiple studies comparing single-dose versus multi-dose prophylactic antibiotic regimens have concluded that a single dose is generally sufficient for prophylaxis, further supporting the 24-hour discontinuation guideline. Studies have shown that implementing protocols incorporating these first three SCIP measures significantly improves outcomes related to SSIs.
SCIP-INF 4: Postoperative Glucose Control in Cardiac Surgery Patients
SCIP-INF 4 specifically targets cardiac surgery patients, recommending the maintenance of euglycemia, or controlled blood glucose levels, in the early postoperative period. Specifically, it measures whether cardiac surgery patients have controlled morning blood glucose concentrations on the first two postoperative days. Elevated postoperative blood glucose has been linked to increased SSI risk, particularly in cardiac surgery. While early studies suggested the benefits of tight glycemic control in critically ill patients, subsequent research, including the NICE-SUGAR study, has indicated potential risks of intensive insulin therapy, such as hypoglycemia. However, meta-analyses have shown a potential benefit of intensive insulin therapy in surgical ICU patients specifically.
In the context of SSI prevention, studies have demonstrated that implementing postoperative intravenous insulin therapy protocols in diabetic patients undergoing open heart surgery can reduce sternal SSI rates. Similarly, continuous insulin infusions have been shown to be more effective than subcutaneous injections in achieving better glucose control and reducing deep sternal SSI rates in diabetic cardiac surgery patients. Furthermore, studies in colorectal surgery patients have shown that maintaining mean capillary glucose concentrations ≤ 200 mg/dL in the first 48 hours postoperatively is associated with lower SSI rates compared to higher glucose levels.
SCIP-INF 6: Appropriate Surgical Site Hair Removal
SCIP-INF 6 addresses the method of hair removal at the surgical site, recommending against the use of razors. Shaving with razors can cause skin micro-abrasions, increasing the risk of bacterial colonization and subsequent infection. The measure promotes the use of clippers or depilatory methods for hair removal when necessary. A prospective trial comparing electrical clipping versus manual shaving before open heart surgery demonstrated a significantly lower rate of mediastinitis in the clipped group. A Cochrane review further supports the benefit of clipping or depilatory creams over razors in reducing SSIs. Clipping on the day of surgery versus the day before appears to have no significant impact on SSI rates.
SCIP-INF 9: Timely Urinary Catheter Removal
SCIP-INF 9 focuses on minimizing the duration of urinary catheterization in surgical patients to prevent catheter-associated urinary tract infections (UTIs). The measure recommends removing urinary catheters by postoperative day 1 or 2, with the day of surgery being considered day 0. The risk of UTI directly correlates with the duration of catheter use. Analysis of data from the National Surgical Infection Prevention Project revealed that patients with catheters in place for more than two days postoperatively had twice the risk of UTI compared to those with shorter catheterization periods. While direct evidence of SCIP’s impact on UTI reduction is still developing, increased awareness of this measure is expected to improve compliance with timely catheter removal, thereby reducing UTI risk.
SCIP-INF 10: Peri-operative Temperature Management
SCIP-INF 10 emphasizes the importance of maintaining peri-operative normothermia, or normal body temperature, to reduce SSI risk. Hypothermia, or low body temperature, during surgery can lead to peripheral vasoconstriction and impaired immune function, increasing susceptibility to infection. A randomized controlled trial in colorectal surgery patients demonstrated that active warming during surgery, aimed at maintaining normothermia, significantly reduced SSI rates compared to standard temperature management. While robust outcome data specifically for SCIP-INF 10 is still emerging, a study demonstrated a decrease in postoperative hypothermia rates following implementation of a bundle of surgical infection prevention strategies, including temperature management. The Kurz et al. trial remains a key study validating this measure, highlighting the direct link between active warming, normothermia, and reduced SSIs in colorectal surgery. However, it is important to note that some research suggests maintaining normothermia alone may not independently reduce SSI risk in all surgical populations, indicating the complexity of multifactorial infection prevention strategies.
Discussion and Impact of SCIP
The Surgical Care Improvement Program has played a crucial role in raising awareness and standardizing practices related to surgical infection prevention. Numerous studies have confirmed that SSIs contribute significantly to patient morbidity, mortality, and healthcare costs. The implementation of SCIP measures, designed to standardize key peri-operative processes, has generally been associated with a reduction in SSI rates, although not universally across all studies.
The success of SCIP is likely multifaceted. The focused attention on these measures, coupled with public reporting and performance monitoring, has increased awareness among healthcare providers and institutions. This heightened awareness, potentially influenced by the Hawthorne effect (where observation itself can alter behavior), may contribute to improved adherence to best practices and subsequently better patient outcomes. Furthermore, the financial implications linked to SCIP compliance, with potential reimbursement reductions for non-adherence, provide an additional incentive for hospitals to prioritize these measures.
However, it’s important to acknowledge that some studies have questioned the direct correlation between strict adherence to certain SCIP measures and improved outcomes. These studies highlight the complexity of surgical infection prevention and the need for ongoing evaluation and refinement of performance measures. As healthcare evolves, with more procedures being performed in outpatient settings and an increasing focus on value-based care, the methods for recording, evaluating, and reporting surgical outcomes must also adapt.
Despite some limitations and ongoing debates, SCIP has undeniably driven significant progress in surgical patient safety. The initial goal of a 25% reduction in SSI rates by 2010 was ambitious, and while the exact achievement of this goal may be debated, SCIP has undoubtedly contributed to a substantial decrease in preventable surgical infections. Moving forward, continuous evaluation of process measures, robust study designs, and a focus on broad-scale efficacy are essential to further refine infection prevention strategies and ensure optimal patient outcomes. The healthcare community must continue to engage in critical evaluation of existing measures, identify areas for improvement, and collaboratively develop and implement evidence-based practices that truly enhance surgical care and minimize patient harm. The future of surgical care improvement lies in a dynamic, data-driven approach, where surgeons and scientists work together to ensure that best practices are not only implemented but are also continuously evaluated and adapted to meet the evolving needs of patients and the healthcare landscape.
Author Disclosure Statement
Dr. Rosenberger and Dr. Politano have no disclosures to report. Dr. Sawyer is a consultant for Merck and Pfizer.
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