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Rapid Response Teams	Pressure Ulcers
Acute Myocardial Infarction	High-Alert Medications
Medication Reconciliation (ADE)	Congestive Heart Failure
Central Line Infections	MRSA
Surgical Site Infections	Surgical Complications
Ventilator-Associated Pneumonia	Boards on Board

Use this table to quickly find a mentor for the reduction of Surgical Complications with demographics similar to your own, or use 'ctrl+f' in your web browser to search for specific key words on this page.

Baystate Medical Center – Springfield, MA
Availability Status: Available to answer requests
Licensed Beds: 636
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: April 23 2002
Mentor Contact Name: Jan Fitzgerald, RN
Mentor Contact Email: janice.fitzgerald@bhs.org
Mentor Contact Phone: 413-794-2531

Additional Information:

We have developed reliable processes/systems/interventions to administer ABs, screen and treat high risk patients with beta blockers and DVT prophylaxis and apply preventative strategies to preempt VAP and post op respiratory failure as well as a process to validate surgical PSI accuracy prior to external reporting. 

AB administration started at 11% (2002) within 60 m prior to incision and have been well over the national benchmark x 4 years
AB discharge at 24 hours <30% DC at 24 hours (2002) now >90% in all populations
Beta Blockers <20% (2002) now at 100% in eligible patients (x 3 years)
DVT prophylaxis <35% in 2003 now at 100% patients screened and >97% getting appropriate treatment based on risk
VAP rate has dropped significantly
Infection rates are lowest in 14 years 1.0-1.3 (surgical volume approximate  29,000/year
Preventable post-op MI and DVT rates are < 2-3%
[3/13/07]

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Brookwood Medical Center – Birmingham, AL
Availability Status: Available to answer requests
Licensed Beds: 550
Teaching / Non-Teaching Status: Non-teaching
Setting: Urban
Start Date of Intervention Work: January 2003
Mentor Contact Name: Alison R. Garretson, RN MBA
Mentor Contact Email: alison.garretson@tenethealth.com
Mentor Contact Phone: 205-877-2662

Additional Information:

The SCIP team at Brookwood Medical Center (BWMC) has been refining their SCIP processes since the beginning of 2003.  We meet monthly utilizing a PDCA framework to encourage a systematic approach. We implemented mandatory core measure training with the nursing staff which enabled them to gain a greater understanding of the importance of these measures to both our patients and facility. Departments own specific SCIP indicators and work diligently to see that their interventions provide for positive outcomes for our patients. The pre-op area and Anesthesia own pre-op antibiotic timing.  Anesthesia also owns perioperative beta-blocker administration and have even developed their own order sets.  Through our daily patient care conferences, in conjunction with case management and nursing, we are able to ensure core measure compliance on our patient populations for post op antibiotic timing and VTE. The OR owns clip vs. shave and assists with pre-op antibiotic timing.  The entire perioperative unit owns normothermia on all patients.  While one department may own a measure, it takes input from each department to ensure this ''machine" runs smoothly and each patient receives the quality care they deserve.

Over the last year (mid 2006 - 2007), we have been able to maintain high 90th percentile ratings in preop antibiotics and appropriate antibiotic selection. 
For post op antibiotics, we recognized a 12% increase over one month in our post operative antibiotic rate to 84.4% by having a pharmacist staffed in the PACU to review post operative medication orders and make changes per approved protocol.

For the last 3 months (July - September 2007), we have averaged the following results while implementing the Surgical Care Improvement Project:

•Percent of Surgical Patients with Prophylactic Antibiotic Received within One Hour Prior to Surgical Incision – Overall Rate 96%
• Percent of Surgical Patients with Appropriate Selection of Prophylactic Antibiotic – Overall Rate 100%
• Percent of Surgical Patients with Appropriate Prophylactic Antibiotic Discontinuation – Overall Rate 96.9%
• Percent of Major Cardiac Surgical Patients with Controlled Post-Operative Serum Glucose 93%
• Percent of Surgical Patients with Appropriate Hair Removal 100%
• Percent of Colorectal Surgical Patients with Normothermia in PACU 100%
• Surgery Patients on Beta Blocker Therapy Prior to Admission Who Received a Beta Blocker During the Perioperative Period 100%
• Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered 92.6%
• Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis Within 24 Hours Prior to Surgery to 24 Hours After Surgery 85%

We monitor our surgical site infection rates as well as incidence of adverse perioperative events.  Since implementing SCIP at BWMC, we have seen a marked decrease in SSI.  We identify infections and monitor each case type according to National Nosocomial Infection Surveillance System (NNIS) criteria and benchmarks for consistent and accurate identification and measurement.  Since 2003, our average overall infection rate per 100 cases has decreased from 0.78 to 0.55.  Additionally, any identified adverse perioperative event is evaluated in its appropriate physician-led process improvement committee.

[12/6/07]

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Centra Health – Lynchburg, VA
Availability Status: Available to answer requests
Licensed Beds: 403
Teaching / Non-Teaching Status: Non-teaching
Setting: Urban
Start Date of Intervention Work: October 2002
Mentor Contact Name: Kathy Traylor RN
Mentor Contact Email: Kathy.traylor@centrahealth.com
Mentor Contact Phone: 434-947-3465

Additional Information:

We are fortunate to have a surgeon and an anesthesia champion involved in the development of antibiotic prophylaxis policy for antibiotic timing and choice. We have 2 hospitals and both hospitals are assisting in SCIP project. As part of peer review and education, we send letters to the surgeons for any chart that has a SCIP indicator that failed. We also send quarterly outcomes with a breakdown of procedure specific so as to create some competition among cardiac surgeons, general surgeons and gyn.  For 2 years, Centra Health has been on the Healthgrades.com "Distinguished Hospital - Patient Safety" list (which includes a low rate of surgical complications as one of its measures). 

Centra is currently at 95 % for antibiotic timing, 95% antibiotic selection, 100% cardiac 6 am glucose, 100% hair removal 90% for post op temp for colorectal surgery.

Complication rate (2005 actual vs expected):  6.60% vs 10.2%
Complication rate (first six months of 2006 vs expected):  6.60 % vs 10.6%
[3/13/07]

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DuBois Regional Medical Center – DuBois, PA
Availability Status: Available to answer requests
Licensed Beds: 239
Teaching / Non-Teaching Status: Non-teaching
Setting: Rural
Start Date of Intervention Work: 2004
Mentor Contact Name: Carole Berger, RN, BSN, Performance Improvement Manager
Mentor Contact Email: cvberger@drmc.org
Mentor Contact Phone: (814) 375-3329

Additional Information:

Improved Timeliness of antibiotic prophylaxis for CABG cases from 79% to 97%; have spread intervention to all surgical cases requiring prophylaxis.

Improved compliance in other SCIP bundle elements including  post-op glucose management for CV cases, normothermia for colon cases, and post op betablocker.  These bundle elements are currently @ 100%.
Improvements planned to assure appropriate use of VTE and d/c of antibiotics per evidenced-based recommendations.

As improvements in antibiotics timing and glucose management improved for CABG patients, a reduction in SSIs was noted. We have not had a case of Mediastinitis in NNIS Risk Index 1 patients in over 22 months.

% of SSIs post CABG (NNIS Risk Category 1) and % who did not receive antibx prophy within 1hr:

Antibx not given w/in 1 hr	Overall SSI rate	Deep Sternal SSIs Rate
2002 21%	13.90%	3.00%
2003 6%	6.90%	2.40%
2004 5%	8.80%	1.20%
2005 3.80%	4.90%	1.20%
2006 2.70%	2.40%	0.00%

October - November 2006:

Prophylactic Antibiotic w/in 1 hr prior to incision-except Vanco   97.8%
Antibiotics stopped w/in 24 hrs of surgery end time-unless contraindicated  90.2%
Premier SIP Composite Score   94.0%

Appropriate Antibiotic   100.0%
Appropriate Hair removal   98.4%
Normothermia   100.0%
Cardiac Postop BG < 200   100.0%
VTE Ordered   87.9%
VTE Administered   87.9%
Beta Blocker Postop   100.0%
[3/13/07]

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OSF St. Joseph Medical Center – Bloomington, IL
Availability Status: Available to answer requests
Licensed Beds: 145
Teaching / Non-Teaching Status: Non-Teaching
Setting: Rural
Start Date of Intervention Work: June 2004
Mentor Contact Name: Kathy Haig
Mentor Contact Email: kathy.m.haig@osfhealthcare.org
Mentor Contact Phone: 309-662-3311, ext. 1347

Additional Information:

OSF St. Joseph Medical Center has consistently achieved compliance with Surgical Safety indicators included 95% or better with surgical prophylactic selection, administration within an hour, use of clippers, 90% or better normothermia, and 85% glycemic control with cabg procedures. This is a result of sustained success since our involvement with the IHI Surgical Safety project in 2004 in which the surgical change package was implemented.  These processes include those above as well as DVT assessment and intervention, bleeding risk assessment, use of perioperative blockade, increasing the FiO2 post-op in the PACU and standardization of preparation and recovery care for the surgical patient.

Prophylactic antibiotic within one hour of incision = FY2006 93-100%
Appropriate Selection of prophylactic antibiotic = FY2006 = 92-100%
Appropriate prophylactic antibiotic discontinuation = FY2006 = 69-86%
Cardiac Post op Serum Glucose FY2006, Quarter 4 = 80-100%
Percent of appropriate hair removal = 97%
Colorectal surgical patient with normothermia - 90%
DVT assessment and interventions = 100% consistently
[3/13/07]

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St. Clare Hospital (Franciscan Health System) – Lakewood, WA
Availability Status: Available to answer requests
Licensed Beds: 106
Teaching / Non-Teaching Status: Non-Teaching
Setting: Urban
Start Date of Intervention Work: March 2003
Mentor Contact Name: Estelle Villwock, MSM, BBA-MIS, BSN, RN
Mentor Contact Email: estellevillwock@fhshealth.org
Mentor Contact Phone: 253.426.6329

Additional Information:

Franciscan Health System is a three-hospital system in Washington State's South Sound:  3 hospitals with 3 cultures; regional committees and teams; one standard of care.  The SCIP project is a multifaceted project with teams established for all of the measures and a central committee that meets quarterly with representation from all teams. Each team reviews data on compliance and outcomes and address system changes to enhance the success of improvements in surgical care.  The SCIP initiative is a strong force in all of our hospitals, has reached the care provided at the bedside of patients and our successes and challenges are reviewed at all levels of our organization. St. Clare shared their preadmission procedures and expertise with Beta Blockers to help to create monitoring for Beta Blocker Administration preoperatively. We have incorporated a physician advisory panel of surgeons, anesthesiologists, and internists to facilitate process improvement.

We have achieved for this last quarter SCIP-Inf-1 Timing - FHS All-85%; St. Clare Hospital 87%.
For SCIP-Inf 2 Selection – FHS All 96%; St. Clare Hospital 96%.
For SCIP-Inf 3 Duration - FHS All 74%; St. Clare Hospital 84%.
[3/13/07]

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St. Francis Hospital (Franciscan Health System) – Federal Way, WA
Availability Status: Available to answer requests
Licensed Beds: 110
Teaching / Non-Teaching Status: Non-Teaching
Setting: Urban
Start Date of Intervention Work: March 2003
Mentor Contact Name: Estelle Villwock, MSM, BBA-MIS, BSN, RN
Mentor Contact Email: estellevillwock@fhshealth.org
Mentor Contact Phone: 253.426.6329

Additional Information:

Franciscan Health System is a three-hospital system in Washington State's South Sound:  3 hospitals with 3 cultures; regional committees and teams; one standard of care.  The SCIP project is a multifaceted project with teams established for all of the measures and a central committee that meets quarterly with representation from all teams. Each team reviews data on compliance and outcomes and address system changes to enhance the success of improvements in surgical care.  The SCIP initiative is a strong force in all of our hospitals, has reached the care provided at the bedside of patients and our successes and challenges are reviewed at all levels of our organization. We have incorporated a physician advisory panel of surgeons, anesthesiologists, and internists to facilitate process improvement.  Team members brought ideas from other hospital and we made changes such as replacing our tympanic thermometers with temporal arterial thermometers to assure that we were recording an accurate temperature and one that can possibly be compared to interoperative temperature.

We have achieved for this last quarter SCIP-Inf-1 Timing - FHS All-85%; St. Francis Hospital 82%.
For SCIP-Inf 2 Selection – FHS All 96%; St.Francis Hospital 96%.
For SCIP-Inf 3 Duration- FHS All 74%; St. Francis Hospital 81%.
[3/13/07]

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St. Joseph Medical Center (Franciscan Health System) – Tacoma, WA
Availability Status: Available to answer requests
Licensed Beds: 320
Teaching / Non-Teaching Status: Non-Teaching
Setting: Urban
Start Date of Intervention Work: March 2003
Mentor Contact Name: Estelle Villwock, MSM, BBA-MIS, BSN, RN
Mentor Contact Email: estellevillwock@fhshealth.org
Mentor Contact Phone: 253.426.6329

Additional Information:

Franciscan Health System is a three-hospital system in Washington State's South Sound:  3 hospitals with 3 cultures; regional committees and teams; one standard of care.  The SCIP project is a multifaceted project with teams established for all of the measures and a central committee that meets quarterly with representation from all teams. Each team reviews data on compliance and outcomes and address system changes to enhance the success of improvements in surgical care.  The SCIP initiative is a strong force in all of our hospitals, has reached the care provided at the bedside of patients and our successes and challenges are reviewed at all levels of our organization.  SJMC piloted flagging the medication reconciliation record for Beta Blockers preoperatively and communicating whether or not Beta Blocker was taken to Anesthesia. We have incorporated a physician advisory panel of surgeons, anesthesiologists, and internists to facilitate process improvement.

We have achieved for this last quarter SCIP-Inf-1 Timing - FHS All-85%; St.Joseph Medical Center 86%.
For SCIP-Inf 2 Selection – FHS All 96%; St. Joseph Medical Center 96%
For SCIP-Inf 3 Duration- FHS All 74%; St. Joseph Medical Center 71%. 
For our new measures for our cardiac surgery patients, our SCIP-Inf- 4 PostOp Glucose Control Rate is at 97.4%.  For glucose control, we have establised a protocol based on the Portland Protocol and are measuring our outcomes at 120mg/dl.
[3/13/07]

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St. Joseph's Mercy Health Center – Hot Springs, AR
Availability Status: Available to answer requests
Licensed Beds: 279
Teaching / Non-Teaching Status: Non-Teaching
Setting: Rural
Start Date of Intervention Work: April 2005
Mentor Contact Name: Lynn Pellegrino, RN, MSN, APRN-BC
Mentor Contact Email: lpellegrino@htsp.mercy.net
Mentor Contact Phone: (501) 622-1840

Additional Information:

Keys to our success include:
 
• The development of an interdisciplinary team chaired by the Director of the Operating Room and the Inpatient Diabetes Clinician.
• Concurrent chart review
• Weekly outcome reports to administration
• Administrative support to implement hospital processes, hospital ministry goals and physician committee integration.

Our proactive approach in tracking these measures and sharing our trends through a Dash Board approach to our Executive PI Council and Hospital Board, celebrating our victories and discussing our challenges with physicians, nursing staff and ancillary departments has improved quality as it relates to decreased surgical site infections.

We implemented the four components of the Surgical Site Infections intervention and the additional three measures with the Surgical Complications module through the following:

Appropriate use of antibiotics and timing of antibiotics prior to surgery and timely discontinuation post-surgery was accomplished through development of standing orders; hospital-based formulary antibiotic tables for physicians and nurse practitioners; physician/staff education; color-coded alert cards with measures placed outside the chart; daily concurrent reviews and weekly/monthly reporting to Administration, the PI Council and Executive PI Council and the hospital board. Additionally, a stop card is placed outside each surgical case to alert staff and physician when the 24 and/or 48 hour window for antibiotic discontinuation is due. The PACU staff communicates to the pharmacy when the last dosage of antibiotic is given in the OR to begin the 24-48 hour clock of antibiotic administration following surgery.

Appropriate hair removal was accomplished by removing razors throughout the hospital, training on clipper use, and updating all documentation forms to reflect current practice of no shaving.

Maintenance of postoperative glucose control has been through our Diabetes Advisory Committee, Inpatient Diabetes Clinicians and the inclusion of our perfusionist on the SCIP Team through the use of a tight sliding scale protocol, measuring and graphing blood glucose control prior to surgery, throughout surgery and post surgery; updating standing orders to reflect a Post Day 1 and Post Day 2 blood sugar on non-diabetics; use of the Glucomander (insulin calculator which bases insulin titration on blood glucose values) during and following surgery to obtain tight blood sugar control. 

Maintenance of postoperative normothermia has been through the use of Bear Huggers, use of warmed fluids and warming blankets starting from pre-assessment, controlling temperatures in the OR, and most importantly changing to a Temporal artery thermometer. Temperatures are being tracked on all surgeries and our forms have been updated with the 96.8-100.4 range.

Additional measures for Surgical Complication Reduction have been the following:

Beta Blockers for patients on Beta Blockers prior to admission have been addressed through staff and physician education, daily concurrent review, inclusion of beta blocker administration on the OR check list and inclusion in the time-out prior to surgery. The importance of documentation of home use of beta blockers has been incorporated into medication reconciliation and is a component of our pre-assessment education process for patients.

VTE prophylaxis has been undertaken through establishing a sub-committee of the existing SCIP committee. One of our hospitalists has become the champion for this project. To date, standing orders have been updated, physician/staff education undertaken through our QIO. Future plans include incorporation into our Physician Order Entry System.

For all the above measures, data is tabulated weekly per surgery type based on concurrent 100% chart reviews shared with administration. Physicians who fail measures are sent a personal letter indicating the medical record # that failed and a copy of the current guidelines for that measure. Teachable moments have been a successful tool to work collaboratively and positively with the unit managers when process breakdowns occur.

Our hospital has improved its compliance from 68% to 91% in discontinuation of antibiotics within 24 hours and has achieved greater than 90% discontinuation within 48 hours for cardiac surgeries.

Antibiotic within 24 hours of incision time has increased from 75% to over 90%.

Hair removal without shaving is currently at 100% following removal of razors, training of staff on clippers and changing of internal processes.

Normothermia compliance has increased through staff education to intervene when temperature ranges are low from pre-assessment.

Blood Glucose control compliance has increased through use of the Glucomander to deliver calculated IV insulin through blood glucose reading during surgery and following.

Surgical Site Infection rate has decreased from 1.5% to .6% from April 05-February 06.
[3/13/07]

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St. Mary's Hospital and Medical Center – Grand Junction, CO
Availability Status: Available to answer requests
Licensed Beds: 356
Teaching / Non-Teaching Status: Teaching
Setting: Rural
Start Date of Intervention Work: March 2003
Mentor Contact Name: Cathy Roberts, RN, MS, Performance Improvement Manager
Mentor Contact Email: cathy.roberts@stmarygj.org
Mentor Contact Phone: 970-244-2566

Additional Information:

St. Mary's began work on the SIP project in 2003 with the Colorado Foundation for Medical Care sponsored SIP Collaborative.  We initially focused on our CABG population, but within a year we had spread the focus to include orthopedics.  In 2003, we joined the Premier/CMS Hospital Incentive Demonstration Project which included the CABG, hip and knee populations.  By early 2004, we developed a SIP team to look at the following populations: CABG, hips/knees, and laminectomy and by 2005 we had expanded our focus to all SCIP populations.  We have been very successful by involving key staff and physicians in this process.  We have developed tools that have supported this success. Additionally, we track our outcomes and report process indicators to our team and physician champions monthly.

St. Mary's has been successful with administration of prophylactic antibiotics within one hour of incision time.  We currently perform at or above 95% for all populations.  Our OR staff and anesthesiologists play a big role in our success. We also implemented a tool to prompt for antiobiotics documentation during the time out process.  Providing ongoing feedback to physician champions has also assisted in our success. 
Discontinuation of the prophylactic antibiotics within the 24-hour time frame (48 hours for CABG) has also been a challenge, but we found that pre-printed order sets developed in collaboration with the physician groups has really led to our success in this area.  We currently perform consistently above 90% and again provide monthly feedback.

We closely monitor our Surgical Site infection rates and in 2004 we saw an overall decrease of 30%.
[3/13/07]

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Sioux Falls VA Medical Center – Sioux Falls, SD
Availability Status: Available to answer requests
Licensed Beds: 45 acute care, 58 transitional care
Teaching / Non-Teaching Status: Teaching
Setting: Urban (serving a large, rural population)
Start Date of Intervention Work: May 2007
Mentor Contact Name: Michelle Laska, RN 
Mentor Contact Email: michelle.laska@va.gov
Mentor Contact Phone: (605) 336-3230 - ext. 6528

Additional Information:

By focusing on improving the culture of teamwork and communication peri-operatively and increasing compliance with the infection, VTE, and Cardiac SCIP measures, the team at the Sioux Falls VA Medical Center sought to decrease the number of intra-operative and post-op surgical complications.  Our pilot population for this collaborative was defined as all inpatient, elective surgery patients in all surgical specialties performed which included general, vascular, thoracic, orthopedic, urologic, ENT, plastic, and gynecologic.

Our overall aim was to decrease peri-operative harm by 50% in the pilot population within one year with the implementation of systems that reliably deliver recommended peri-operative surgical care.  Our main focus was the prevention of cardiovascular events and improvement of the culture of safety in the peri-operative system.  Sioux Falls VA was a member of a previous collaborative that focused on preventing surgical site infections in the clean surgical case population and we maintained those changes from this earlier work.  As a result, we began this project with a high level of compliance on the following five measures:  On-time antibiotic prophylaxis, appropriate prophylactic antibiotic, timely prophylactic antibiotic discontinuation, appropriate hair removal, and normothermia in post-anesthesia care unit.

Although performing reasonably well with the SCIP VTE-2 measure, we sought to improve the process by providing a centralized location for ordering, using the SCIP guidelines. There were primarily three steps in our plan to ensure compliance: 1) Education of the surgeons on this measure; 2) Development of an inpatient VTE prophylaxis computerized ordering template created according to the recommended SCIP guidelines (used post-operatively); and 3) Creation of a pre-operative planning template so the scheduling surgeon can request a VTE prophylaxis dose be given by anesthesia pre-incision.

During the collaborative, we discovered that we had an unreliable process in the beta blocker measure.  After drilling down, we noted documentation inconsistentcies.  Specifically, beta blockers were not being properly documented when patients were admitted through SDS.  We simply added a question to their pre-operative evaluation form that asked when the patient took their beta blockers.  As a result, compliance percentages reached 100% consistently after this was implemented.

Achieving higher levels of effective communication and teamwork were also crucial to our success: 
- A pre-operative planning template is embedded in the computerized patient record system (CPRS).  Surgeons utilize this template when scheduling surgery.  The surgeons are able to indicate specific information on this template such as pre-op antibiotics, required anesthesia, bowel prep, special equipment needs, positioning in the OR, and about 13 other items.  This information can then be accessed in CPRS by the scheduling clerk, the SDS nurses, anesthesia, and the OR nurses.  This, in turn, has reduced phone calls and questions each of these areas might have had previously.  (We were unable to obtain "buy-in" to institute a “pre-procedural briefing,” so this template is our solution.)
- We did the traditional "time out" for the last few years to verify the right patient, right surgery, right site, right x-rays, and the right implants.  However, early in the collaborative, we renamed this process the "time in" to coincide with the  patient entering the room.  We now perform what we call a "time out" immediately after surgical closure and before the surgeon or any other team members leave the OR. Verification is done regarding the surgical procedure, post-op diagnosis, specimens, wound class, blood loss, and if the counts are correct.  Accuracy in recording operative information has greatly improved.
-  We used a failure mode and effects analysis (FMEA) for “uncontrolled bleeding in the OR.”  Using a multidisciplinary approach, creative thinking, and great leadership, this FMEA on a hypothetical problem was a very positive and successful experience.  Ten employees were part of this experience, and the team appreciated being included, and being given the opportunity to make a difference.  Seven action plans were developed in response to the failure modes identified during this process.  An executive summary was presented to leadership for their review.

Here are five main contributors to our success in this collaborative:
1.  Appoint team members who are driven and support your aim.  They must be those who are in authoritative roles and can initiate change.
2.  Meet regularly and keep meetings informative and productive.  Invite a multidisciplinary panel when discussing change in practice or process.  Use evidence-based research when proposing major changes in practice.
3.  Educate, educate, educate!  Continual reinforcement is necessary when changes are made.  Follow up with those assigned with tasks.
4.  Monitor compliance to changes made.  Post results for staff to monitor improvement and encourage commitment.
5.  Evaluate results and note trends.  Find out what is working and what isn't.  Make changes for continual improvement and to achieve a high level of compliance.

In less than 12 months we reduced our complication rate by over 50% and we have reached our target goal in all measures we monitored over the last year!

Number of perioperative adverse events per 100 surgical admissions:  We sought to decrease peri-operative adverse events by 50%.  We started at 60% and have been under 30% for the last 6 months!

Our target monthly goals for all the measures were 95% or better.

Percent of opportunities for anti-SSI measures that were completed successfully:  We have been maintaining between 95-100% compliance throughout the collaborative!

Percent of surgical patients who receive all appropriate anti-SSI measures:  Out of 16 months, we reached our goal 13 times.

SCIP VTE-2:  Percent of surgical patients who received appropriate VTE prophylaxis within 24 hours before or after the start of surgery:  For the last 8 months we have met our goal.

SCIP Card-2:  Percent of surgical patients admitted on beta blockers for whom beta blockade was continued during the hospital stay:  This was an unreliable process at the beginning but after process changes were made, we have achieved 100% compliance for the last 5 months!

SCIP INF-1:  Percent of patients with on-time prophylactic antibiotics administration:  Over the last 16 months, we reached our goal 14 times.

SCIP INF-2:  Percent of patients with appropriate prophylactic drug administered:  We have maintained 100% compliance with this measure due to computerized templates designed according to the SCIP recommendations for antibiotic administration.

SCIP INF-3:  Percent of patients with timely prophylactic antibiotic discontinuation:  We have had 100% compliance with this measure for the last 10 months!

SCIP INF-6:  % cases with appropriate hair removal:  We have had 100% compliance with this measure over the last 16 months!

SCIP INF-7:  % of colorectal (or all) patients with normal body temperature on arrival at the Post-Anesthesia Care Unit (PACU) - we measured all patients:   Fifteen of the last sixteen months, we have met our goal.

For more information (including charts), see the Sioux Falls VA Medical Center Improvement Story

[11/13/08]

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Transylvania Community Hospital – Brevard, NC
Availability Status: Available to answer requests
Licensed Beds: 25
Teaching / Non-Teaching Status: Non-Teaching
Setting: Rural
Start Date of Intervention Work: May 2003
Mentor Contact Name: Scotta L. Orr, RN, BSN, MPH, Director of Quality/Accreditation Services
Mentor Contact Email: sorr@tchospital.org
Mentor Contact Phone: 828-862-6383

Additional Information:
The SIPP team includes an Infection Control Practitioner, Director of Surgical Care Services, Director of Quality, Case Management, and Anesthesiology.

Staff and public were educated:  Patients were educated regarding use of Hibiclens shower prior to surgery.  Staff were educated as to who (and where) would start the preoperative prophylactic antibiotic; appropriate antibiotic choices for surgery; and discontinuation of antibiotic within 24 hours after surgery end time.

• In 2005, a normothermia campaign was initiated. Preoperatively, patients receive warmed fluids, forced air warming blankets and socks.

• Pharmacy added alert to MAR stating to “discontinue prophylactic antibiotic within 24 hours of surgery end time.”

• The evolution of Bedside Medication Verification created the need for revisions to the process which were implemented.

• 99% of patients are normothermic throughout the operative experience.

• June 2007:  prophylactic antibiotic within 1 hour prior to surgery was 100%; up from 48% compliance in May 2003.

• Appropriate prophylactic antibiotics are administered 100% of the time and has held at high compliance since May 2003.

• Discontinuation of prophylactic antibiotics within 24 hours of surgery end time was 100% in June 2007 compared to a compliance rate of 74% in May 2003.

• Razors have been removed from the surgery areas.

• Patients continue to receive Hibiclens and an education tool at their pre-op visit.

• Protocols for DVT prophylaxis and glucose control have been implemented and are being monitored and revised as needed.

• Transylvania Community Hospital’s inpatient surgical site infection rate has been consistently below 2.7% for the past three consecutive years.
[2/8/08]