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Surgical Quality & Patient Safety

Detailed SCIP Info ­

Reference Tables

Antibiotics

Vancomycin

Beta Blockers


ABX 1: Antibiotic Start 
Prophylactic antibiotic given within 1 hour prior to surgical incision.

Applies to all ADULT patients (18 years or over).

If giving Vancomycin or Clindamycin, administration may be within 2 hours prior to surgical incision time.

Documentation of a PRE-OPERATIVE infection or suspected infection is required prior to surgery start to deviate from these guidelines.  Notation in the H&P, Surgical Required Elements (green sheet) or pre-anesthesia evaluation is sufficient.  If preoperative infection is documented prior to surgery start,  all antibiotic measures will no longer apply. 

Examples of preoperative infection:

Acute abdomen
Bacteremia
Cellulitis
Free air in abdomen
H.pylori
Endometritis
Gangrene
Necrotic ischemia
Existing surgical site infection
Infarcted bowel
Sepsis
Penetrating abdominal trauma
PNA
UTI

Documentation of symptoms (i.e. fever, redness, elevated WBC count, etc.) does NOT suffice as documentation of infection.  "Infection" or "suspected infection" must be documented exactly as shown.

Immunosuppression, chemotherapy and chronic or recurrent infection will NOT exclude a patient from this measure.

Exception is made for patient's undergoing lower extremity original arthroplasty or revision who also have a benign or malignant tumor in the operative extremity.

If infection is found after the incision is made, this is considered a POST-OPERATIVE infection and will not have any bearing on pre-incision antibiotic administartion.  Post-operative infection or suspected infection should be documented in the surgeon's Operative Report, on the post-operative portion of the Surgical Required Elements (green sheet) and on the post-operative Antibiotic Order Form. 



ABX 2: Antibiotic Selection 
Correct prophylactic antibiotic selection based on the procedure type.

Applies to all ADULT patients (18 years or over).

Antibiotic must be given exactly as indicated in the Antibiotic Table.  Deviation from the antibiotic combinations shown will result in failure of this measure.

Documentation of a PRE-OPERATIVE infection or suspected infection is required prior to surgery start to deviate from the antibiotic guidelines.  Notation in the H&P, Surgical Required Elements (green sheet) or pre-anesthesia evaluation is sufficient.  If preoperative infection is documented prior to surgery start,  all antibiotic measures will no longer apply. 

Examples of preoperative infection:

Acute abdomen
Bacteremia
Cellulitis
Free air in abdomen
H.pylori
Endometritis
Gangrene
Necrotic ischemia
Existing surgical site infection
Infarcted bowel
Sepsis
Penetrating abdominal trauma
PNA
UTI

Documentation of symptoms (i.e. fever, redness, elevated WBC count, etc.) does NOT suffice as documentation of infection.  "Infection" or "suspected infection" must be documented exactly as shown.

Immunosuppression, chemotherapy and chronic or recurrent infection will NOT exclude a patient from this measure.

Exception is made for patient's undergoing lower extremity original arthroplasty or revision who also have a benign or malignant tumor in the operative extremity.

If infection is found after the incision is made, this is considered a POST-OPERATIVE infection and will not have any bearing on pre-incision antibiotic administartion.  Post-operative infection or suspected infection should be documented in the surgeon's Operative Report, on the post-operative portion of the Surgical Required Elements (green sheet) and on the post-operative Antibiotic Order Form.

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HAIR: Appropriate Hair Removal 
Documentation of appropriate hair removal
(Clippers only – NO RAZORS or SHAVING).

 

Applies to ALL PATIENTS. 

Hair removal with electric clippers is appropriate.  Razors and "shaving" are NOT acceptable and will result in SCIP measure failure.

If hair removal with clippers is documented by the RN in the O.R. Record without mention of hair removal in the surgeon's Operative Report, the measure will pass.  If hair removal with clippers is documented by the RN and “patient was shaved” is stated by the surgeon in the Operative Report, the measure will fail.  Any mention of shaving or razors will cause the measure to fail.

Documentation of hair removal is ALWAYS required.  If hair removal is not necessary or if the patient performed their own hair removal prior to surgery, documentation of "none" is required for the measure to pass.  The RN must ensure "none" is documented on the O.R. Record.

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TEMP: Intra-Operative Warming 
Documentation of intraoperative temperature management.

SCIP temp measure is now retired by Joint Commission (1/1/2014).

 

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FOLEY: Post-Operative Removal 
Foley catheter removal on POD 1 or POD 2
(within 48 hours of surgery end time).

  • Applies to all ADULT patients (18 years or over) in ALL surgical categories who have a foley catheter placed in the operating room. 

 

  • Urologic and gynecologic surgery patients are excluded from this measure.
  • If the foley is indicated beyond 48 hours, documentation is required by a MD/NP/PA on POD 1 or POD2.  Documentation to continue the foley CAN NOT be done on the day of surgery (POD 0).

 

  • ICU patients, patients in a comatose state, patients on PCEAs are NOT exempt – justifying documentation must occur on POD 1 or POD 2 for the measure to pass.
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SUGAR:
Cardiac Surgery patients with controlled 6 a.m. blood glucose.
(≤ 180mg/dL within 18 to 24 hours after anesthesia end)

Applies to all ADULT patients (18 years or over) undergoing Cardiac Surgery.

 

  • The blood glucose result may be from a bedside testing device (Accucheck) or from a laboratory specimen

 

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DVT 1:
Documentation of SCDs during surgery
(in the Operating Room Record).

DVT 2:
MD/NP/PA order for appropriate pharmacologic DVT prophylaxis
on the post-op order set.

Applies to all ADULT patients (18 years or over) undergoing major surgery.
        

  • Patients who receive neuraxial anesthesia or have a documented reason for not administering pharmacological prophylaxis may pass the performance measure if either appropriate pharmacological or mechanical prophylaxis is ordered. 
  • Unless specifically stated below, MECHANICAL prophylaxis is sufficient - application of compression devices in the operating room and MD/NP/PA order for compression devices on the postoperative orders allows the measure to pass.
  • PHARMACOLOGIC prophylaxis is required as stated below unless contraindicated and documented within 24 hours of surgery end time (i.e. patient at increased risk of bleeding outside of the usual surgical risk or blood products received within 24 hours after surgery start).

 

GENERAL SURGERY
ALL PROCEDURES require written order for compression device (i.e. SCDs) and one of the following:

  • Low dose unfractionated heparin
  • Low molecular weight heparin
  • Factor Xa Inhibitor (Fondaparinux)

ORTHOPAEDIC SURGERY
TOTAL HIP requires written order for compression device (i.e. SCDs) and one of the following:

  • Coumadin
  • Factor Xa Inhibitor (Fondaparinux)
  • Low molecular weight heparin

HIP FRACTURE surgery requires written order for compression device (i.e. SCDs) and one of the following:

  • Coumadin
  • Factor Xa Inhibitor (Fondaparinux)
  • Low molecular weight heparin
  • Low dose unfractionated heparin
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DVT 3:
RN initiation of DVT prophylaxis within 24 hours of surgery end
(SCD documentation on Essentris &/or administration of pharmacologic DVT agents documented on the MAR)

Applies to all ADULT patients (18 years or over) undergoing major surgery.

  • For patients only requiring mechanical prophylaxis (see DVT Prophylaxis table) application of compression devices in the operating room and documentation in the O.R. Record is appropriate.  Continued application of mechanical prophylaxis postoperatively should be documented every shift by the RN in Essentris.

 

  • For patients requiring pharmacologic prophylaxis (see DVT Prophylaxis table) documentation of medication administration on the MAR must occur within 24 hours of surgery end time for the measure to pass.

 

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