Surgery Measures

What is the source of these Clinical Data comparisons?
Measures of timely and effective care are calculated from data extracted from the medical records of eligible patients, following standard specifications for abstracting and reporting the information. Data submissions include auditing procedures and edit checks to assess whether data submitted are consistent with CMS's defined specifications.

Surgical Care Improvement Project (SCIP) measures listed below are a category of evidence-based metrics that assess the overall use of antibiotics for surgical infection prevention.

Antibiotic use before surgery
·A high number is better

What this means: This measures the overall percentage of patients who receive the appropriate antibiotic within one hour before surgery.

Why is it important: Patients who are given an antibiotic one hour before surgery generally have better outcomes.

Surgical Care Improvement Project (SCIP) - Antibiotic use before surgery
Jun '12 - Jul '13

* National Average: CMS - Hospital Compare Website

Antibiotic selection for surgical patients
·A high number is better

What this means: This measure focuses on the selection and use of antibiotics consistent with current guidelines for surgical patients.

Why is it important: The goal of administering antibiotics prior to surgery is to prevent hospital-acquired infections.

Antibiotic selection for surgical patients
Jun '12 - Jul '13

* National Average: CMS - Hospital Compare Website

Antibiotic use after surgery
·A high number is better

What this means: This measures the percentage of patients whose antibiotic is discontinued within 48 hours after surgery. Proper use of antibiotics can prevent wound infections but prolonged use offers no additional benefits. Overuse of antibiotics may actually raise the risk of an opportunistic infection or the development of a drug-resistant infection.

Why is it important: Patients whose antibiotic is discontinued within 48 hours after surgery generally have better outcomes.

Surgical Care Improvement Project (SCIP) - Antibiotic use after surgery
Jun '12 - Jul '13

* National Average: CMS - Hospital Compare Website

Cardiac surgery patient with controlled 6 a.m. postoperative blood glucose
·A high number is better

What this means: Blood glucose is a sugar that is carried in the blood stream and the body's main source of energy. When patient's blood glucose level is high they are at greater risk for complications. This measures how heart surgery patients are monitored for blood sugar.

Why is it important: Control of hyperglycemia (high blood sugar) can improve outcomes for heart surgery patients.

Cardiac surgery patient with controlled 6 a.m. postoperative blood glucose
Jun '12 - Jul '13

* National Average: CMS - Hospital Compare Website

Surgery patients with appropriate hair removal
·A high number is better

What this means: This measures the percent of surgery patients with appropriate hair removal from their surgical site, if needed. Hair removal with clippers or depilatory (hair removing cream) is considered appropriate. Shaving with a manual razor is considered inappropriate as it raises the risk of infection by scraping the skin.

Why is it important: As appropriate hair removal can reduce surgical site infections following proper guidelines is a sign of good patient care process.

Surgery patients with appropriate hair removal
Jun '12 - Jul '13

* National Average: CMS - Hospital Compare Website

Recommended VTE prophylaxis received within 24 hours
·A high number is better

What this means: Venous thromboembolism (VTE) includes the serious conditions caused by blood clots that detach and travel through the body; "prophylaxis" refers to actions taken to maintain health and avoid this complication. This measure assesses the percent of surgery patients who receive the recommended treatment within 24 hours.

Why is it important: There are many ways to treat suspected VTE; prompt treatment is a sign of good patient care process.

Recommended VTE prophylaxis received within 24 hours
Jun '12 - Jul '13

* National Average: CMS - Hospital Compare Website