SCIP-Inf-10 inpatient measure applies to “all surgical patients, regardless of age”

by Troy Bergstrom

A systematic approach to quality improvement is particularly important today as both public and private healthcare organizations, including the Institute for Healthcare Improvement (IHI), the Joint Commission and the Centers for Medicare and Medicaid Services (CMS) among others, lead national initiatives designed to accelerate improvement in patient care.

The Surgical Care Improvement Project (SCIP), a CMS initiative, targets the reduction in surgical complications through evidence-based care. SCIP sets specific guidelines to help hospitals reduce the incidence of postoperative surgical site infections, perioperative cardiac events, deep vein thrombosis, and postoperative ventilator-associated pneumonia, all of which have been identified as major contributors to surgical complications.

The future financial success of hospitals may depend, in part, on its ability to comply with these measures and reduce the costly complications these measures were designed to address.

On July 31, 2009, the Centers for Medicare and Medicaid Services (CMS) issued a final rule that revises policies and payment rates for general acute care hospitals that are paid for inpatient services under the Inpatient Prospective Payment System (IPPS). Reporting under the measure started with discharges on or after October 1, 2009 and mandatory reporting began on January 1, 2010.

The IPPS FY 2010 final rule includes a new chart-abstracted measure, SCIP Infection 10—Surgery Patients with Perioperative Temperature Management.

SCIP-Inf-10

SCIP -Inf-10 measures the proportion of patients (any age) for, “whom either active warming was used intraoperatively for the purpose of maintaining normothermia or who had at least one body temperature equal to or greater than 96.8°F (36.0°C) recorded within the 30 minutes immediately prior to or the 15 minutes immediately after anesthesia end time.”¹

The measure applies to all patients regardless of age undergoing surgical procedures under general or neuraxial anesthesia one hour or longer. Forced-air warming, the most prominent method of warming surgical patients in the United States, is one of the modalities hospitals can use to actively warm. Forced-air warming meets the measure’s goal regardless of how it is applied, i.e. over-the-body, under-the-body or forced-air gowns. ¹  Measures are intended to strengthen the relationship between payment and quality of services for Medicare beneficiaries. Facilities may be actively warming more surgical patients than previously. A prior measure, SCIP-Inf-7, recommended patient warming for colorectal surgery patients. SCIP-Inf-10 supplants SCIP-Inf-7 and applies to a much broader patient population.

SSIs All-too Common

Recent data from the CDC found that surgical site infections are the second-most common hospital-acquired infection (290,485) and the most expensive, with average attributable per-patient costs of $11,087 to $34,670 when adjusted to 2007 dollars. Approximately 8,000 patient deaths are associated with these infections each year, while the aggregate cost is estimated at $3.2 to $10 billion. ²

Despite these figures, an estimated 65 percent of U.S. hospitals surveyed by The Leapfrog Group were not in full compliance with all of its recommended standards for preventing many of the most common hospital-acquired infections. ³

Normothermia’s relationship to surgical site infections (SSIs) has garnered special attention in recent years, with numerous evidence-based initiatives citing normothermia maintenance as a tool in SSI reduction efforts.

Inadvertent perioperative hypothermia is a frequent, yet preventable, complication of surgery. Hypothermia can triple the rate of wound infection (SSIs), ⁴ extend recovery time and length of stay(4) and increase mortality rates. ⁵

Studies have also suggested that maintaining normothermia can result in savings of $2,500 to $7,000 per patient⁶ that might otherwise be spent treating the complications of unintended hypothermia. Yet some estimates say 50 percent or more of all surgical patients are hypothermic upon admission to recovery. ⁷

Ironically, maintaining normothermia is one of the easiest, least expensive and most effective benefits you can offer to your patients.

A recent editorial published in the journal Anesthesia & Analgesia stated that, “Maintaining normothermia is usually easy, with hospital cost typically being less than $10; furthermore, the most commonly used warming systems are remarkably safe. There are few, if any, anesthetic interventions that have been proven to so markedly improve the outcome of surgery with so little effort, risk, and cost …”⁸

Warm Every Patient

Ideally, every surgical patient would be warmed, regardless of age, condition or duration of surgery.

One of the greatest contributors to surgical hypothermia is the physiological effects of anesthesia itself, which disrupts the body’s ability to regulate temperature. ⁹ This means any patient undergoing anesthesia, no matter their age or physical condition, is susceptible to hypothermia during surgery.

Prewarming, or increasing the total heat content of the periphery before surgery, is an effective way of preventing intraoperative hypothermia in surgeries lasting less than one hour. ¹⁰ Forced-air warming devices have been established as an extremely effective method to prevent or treat heat loss in patients. In addition, combining prewarming with intraoperative forced-air warming can prevent unintended hypothermia in longer procedures.

Warming from Start to Finish

But how does a facility begin to implement an effective patient warming program to warm these patients efficiently? Here are a few suggested tips and tactics to get the process started.

• Conduct a temperature audit.* Determine how many of your patients currently are normothermic upon arrival at PACU. Some estimates say 50 percent or more of all surgical patients are hypothermic upon admission to the recovery room. ⁷
• Implement consistent, accurate patient temperature recording processes. The measure calls for at least one body temperature ≥36°C to be recorded within the 30 minutes immediately before or the 15 minutes immediately after anesthesia end time. Simple tools like temperature tracking stickers adhered to patient charts can encourage data recording habits consistent with the measure.
• Actively prewarm patients. Anesthetized patients are susceptible to unintended hypothermia because core temperature drops by as much as 1.6°C within the first hour of general anesthesia induction. ⁹ In shorter-duration surgeries, you may not have enough time to actively re-warm a patient to normothermia intraoperatively. Prewarming patients before surgery can help avoid this significant drop in temperature, essentially stopping hypothermia before it might otherwise begin. ¹¹
•  Make warm the norm. Choosing a system that is easy to implement and use can help improve staff compliance. Forced-air warming is present in more than 85 percent of U.S. hospitals. The equipment is already available in most facilities and staff is already familiar with how to use it. By choosing a forced-air warming system that can easily accommodate your diverse surgical population or standardizing to patient warming gowns, you can effectively improve your success.
• Expand the use of perioperative warming. Risks associated with unintended hypothermia include higher mortality rates, ⁵ longer hospital stays⁴ and an increased rate of wound infection.⁴ Forced-air warming is a simple, proven, cost-effective method to prevent unintended hypothermia and its complications. Maintaining normothermia also is cited by healthcare initiatives around the world as a key factor in helping reduce the rate of surgical site infections.
• Use forced-air warming. More than 100 scientific papers have been written about the benefits of forced-air warming and prevention of hypothermia. Studies have found forced-air warming to be the most effective method in general for preventing and treating unintended hypothermia. ¹² Also, the goal of the measure is to help patients avoid unintended hypothermia and its complications, so be sure to have the most effective tools available.

*For more information on how to conduct temperature audits for your facility, contact an Arizant Healthcare representative.

NOTE: The Specifications Manual for National Hospital Inpatient Quality Measures [Version 3.0b, August, 2009] is the collaborative work of the Centers for Medicare & Medicaid Services and The Joint Commission. The Specifications Manual is periodically updated by the Centers for Medicare & Medicaid Services and The Joint Commission. Users of the Specifications Manual for National Hospital Inpatient Quality Measures must update their software and associated documentation based on the published manual production timelines.

References

1. Fact Sheet: Medicare adds quality measures for reporting by acute care hospitals for inpatients stays in FY 2010. Centers for Medicare and Medicaid Services. www.cms.hhs.gov. Published July 31, 2009.
2. Scott, D. The Direct Medical Costs of Healthcare-Associated Infections in U.S. Hospitals and the Benefits of Prevention. Centers for Disease Control and Prevention website; www.cdc.gov/ncidod/dhqp/pdf/Scott_CostPaper; Accessed April 15, 2009.
3. The Leapfrog Group. 2008 Leapfrog Hospital Survey Results. www.leapfroggroup.org; Accessed April 15, 2009.
4. Kurz, A. Sessler, DI. Lenhardt, R. Perioperative Normothermia to Reduce the Incidence of Surgical Wound Infection and Shorten Hospitalization. New England Journal of Medicine. 334(19): 1263-1264. 1996.
5. Tryba, M. Leban, J. et al. Does active warming of severely injured trauma patients influence perioperative morbidity? Anesthesiology. 1996; 85: A283.
6. Mahoney, CB. Odom, J. Maintaining intraoperative normothermia: A meta-analysis of outcomes with costs. AANA Journal. 67(2): 155-164. 1999.
7. Young, V. Watson, M. Prevention of Perioperative Hypothermia in Plastic Surgery. Aesthetic Surgery Journal. 2006; 551-571.
8. Hannenberg, A. Sessler, D. Improving Perioperative Temperature Management (editorial). Anesthesia & Analgesia. Nov. 2008: 107(5) 1454-1457.
9. Sessler, DI. Current Concepts: Mild Perioperative Hypothermia. New England Journal of Medicine, 336(24): 1730-1737; 1997.
10. Sessler DI, et al. Optimal Duration and Temperature of Prewarming. Anesthesiology. Vol. 82. No. 3; 674-680. 1995.
11. Sessler, DI. Schroeder, M. Merrifield, B. Matsukawa, T. Cheng, C. Optimal Duration and Temperature of Prewarming. Anesthesiology. Mar 1995: 82(3); 674-681.
12. Sessler, DI. Consequences and treatment or perioperative hypothermia. Anesthesiology Clinics of North America. Vol. 12. Philadelphia: W.B. Saunders Company. 1994.

Troy Bergstrom is the communications manager for Arizant Healthcare Inc., the manufacturer of Bair Hugger therapy, the Bair Paws patient adjustable warming system and Ranger fluid warming systems. Arizant created forced-air warming in 1987 and has warmed more than 125 million patients. The company remains a worldwide leader in temperature management for surgical patients. To learn more about Arizant’s surgical temperature management solutions, visit the company’s Web sites at www.bairhugger.com, www.bairpawsflex.com, or www.rangerfluidwarming.com.