Preventing postop infections need to be implemented as a package

by Kristina Fiore

Measures designed to prevent postoperative infections work if measured as a package, but looked at individually they provide no improvement, researchers found.

When analyzing the six components of the Surgical Care Improvement Project (SCIP) on an all-or-nothing basis, there was a 15% reduced risk of infection, according to Jonah J. Stulberg, MD, PhD, MPH, of Case Medical Center in Cleveland, and colleagues.

But the three core infection prevention measures taken in composite did not significantly decrease infection rates, nor did any of the measures individually, they reported in the June 23/30 issue of the Journal of the American Medical Association.

“The individual item performance rates reported publicly do not fulfill their stated purpose of pointing consumers toward high-quality hospitals,” the researchers wrote.

There are 20 SCIP measures covering various elements of patient care, nine of which focus on performance. Six of those nine focus solely on infection prevention.

Hospital participation in reporting SCIP measures isn’t mandatory, but the Centers for Medicare and Medicaid Services reduce reimbursements by 2% for hospitals that don’t report.

The data from these measures are then prepared and submitted for public report on the Hospital Compare website, in order to help consumers choose the right hospital for them.

Yet there’s been no assessment of the impact of the SCIP performance measures on clinical outcomes, which has lead to debate over the necessity for participation in the effort.

So Stulberg and his team conducted a retrospective cohort study of discharges between July 1, 2006, and March 31, 2008, which included 405,720 patients from 398 hospitals across the U.S.

They looked at each measure individually, as well as at the three original infection-prevention measures as a group (S-INF-Core) and all six together (S-INF).

The core measures include the timing of prophylactic antibiotic administration, appropriate prophylactic antibiotic choice, and discontinuation of prophylactic antibiotics within 24 hours. The other three are controlled postoperative blood glucose for cardiac surgery patients, appropriate surgical site hair removal, and immediate postoperative normothermia for colorectal surgery patients.

There were 3,996 documented postoperative infections, and adherence rates on the individual measures ranged from 80% to 94%.

The researchers found that when adherence to the six infection prevention processes was looked at as an all-or-none global measure it predicted a significant decrease in postoperative infection rates — from 14.2 to 6.8 per 1,000 discharges (OR 0.85, 95% CI 0.76 to 0.95).

Although adherence to the three core measures also trended toward a decrease in postoperative infection rates (from 11.5 to 5.3 per 1,000 discharges) the finding was not statistically significant (OR 0.86, 95% CI 0.74 to 1.01).

Nor were any of the individual SCIP measures significantly associated with a lower probability of infection, even though that is the format in which performance data is publicly reported.

The researchers said that the measure for appropriate prophylactic antibiotic selection came the closest to approaching statistical significance, with a decrease in infections from 21.0 to 7.5 postoperative infections per 1,000 discharges (OR 0.83, 95% CI 0.69 to 1.00).

“The individual item performance rates reported publicly do not fulfill their stated purpose of pointing consumers toward high-quality hospitals,” they wrote. “However, when taken in aggregate, improved performance on our global all-or-none composite measure is associated with improved outcomes at the discharge level.”

They added that, although there’s extensive literature in support of SCIP measures, much of the data were based on early clinical trials and aren’t “reflective of current actual practices or measure effectiveness.”

The study was limited by the use of ICD-9 codes, and by the potential for under-reporting in administrative data sets. It also couldn’t account for infections that occur after discharge.

In an accompanying editorial, Mary T. Hawn, MD, MPH, of the University of Alabama Birmingham, wrote “it appears that investing resources in SCIP reporting is no longer cost-effective.”

“Current mandated surgical quality-improvement processes such as SCIP focus on incremental and narrow process measures that are purported to measure the overall quality of an episode of surgical care,” she added. “Despite enormous resources committed to these measures and marked improvement in adherence, the evidence to date suggests that SCIP has not improved surgical outcomes.”

Kristina Fiore is a MedPage Today staff writer.

Originally published in MedPage Today. Visit for more infection control news.