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Surgical Care Quality Measures
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The Surgical Care Improvement Project (SCIP) is a nationwide initiative to improve surgical care by reducing complications such as infection, heart attack, and blood clots. Hospitals around the country have joined in the SCIP partnership.

The SCIP initiative analyzes eight different surgical procedures:

There are proven standards of care that reduce the risk of complications and help ensure a good quality of life after surgery. Those standards are listed in the first column of the table below.* Click on each term to learn what it means. The next columns show how well Memorial University Medical Center met these standards of care.

A higher score is better.

  2006
Total**
2007
Total
2008
Total
2009
Total
2010
Total
2011
Jan. - Sept.
Quality Measure (Click on each term to learn more)
Antibiotic Within 1 Hour of Cut Time 87.94% 84.94% 85.07% 92.64% 97.73% 97.04%
Antibiotics Discontinued in 24/48 Hours 76.41% 87.15% 90.70% 94.81% 93.99% 97.37%
Appropriate Antibiotic Selection 95.09% 96.14% 96.78% 97.65% 97.49% 96.36%
Appropriate Method of Hair Removal 100% 97.48% 99.68% 99.55% 99.64% 99.75%
Normothermia 56% 53.49% 71.74% 70.73% 99.77% 100%
Perioperative Beta Blocker Received 88.24% 81.05% 86.78% 88.29% 90% 93.48%
VTE Prophylaxis Ordered 95.38% 95.47% 97.04% 97.01% 98.74% 98%
VTE Prophylaxis Received 93.85% 91.29% 94.72% 95.81% 98.11% 98.99%
Controlled PostOp Glucose 53.06% 90.09% 87.29% 91.55% 89.38% 89.16%

*Please note that not every measurement applies to every one of the eight surgeries analyzed.

**Represents the last quarter of 2006 only, which is when we began submitting data.

Memorial Health Vs. National Average

The graphs below show how Memorial Health compares to other hospitals nationwide. The national average is pulled from all hospitals submitting data to the Centers for Medicare and Medicaid Services (CMS) during a specific time frame. The numbers below represent 2010 data. Click on the blue tabs to see the average for each category. A higher number is better.

  • Antibiotic Within One Hour
  • Antibiotics DC
  • App. Antibiotic Selection
  • App. Method of Hair Removal
  • Peri. Beta Blocker Received
  • (VTE) Ordered
  • (VTE) Received
  • Controlled PostOp Glucose

Antibiotic Within One Hour of Cut Time

Quality Measure Percentage of surgical patients who received antibiotic drugs one hour before the first surgical incision.
Why is this important? Antibiotics help prevent wound infections after surgery. When patients receive antibiotics more than one hour before surgery, or after surgery begins, the drugs are not as effective.

 


Antibiotics Discontinued Within 24 to 48 Hours

Quality Measure Percentage of patients who stopped receiving preventive antibiotics within 24 to 48 hours after surgery. Preventive antibiotics should begin one hour before surgery.
Why is this important? If there is no infection after surgery, the antibiotics can be stopped within one day, or two days for heart surgeries. Taking antibiotics when they are not needed can lead to harmful side effects or antibiotic-resistant bacteria.

 


Appropriate Antibiotic Selection

Quality Measure Percentage of patients who received appropriate antibiotic drugs before and after surgery at Memorial University Medical Center.
Why is this important? Specific antibiotics are used to treat or prevent various infections. The surgeon must determine which antibiotics are most appropriate for each patient’s surgery.

 


Appropriate Method of Hair Removal

Quality Measure Percentage of surgery patients who had appropriate hair removal before surgery.
Why is this important? Studies have shown that shaving a surgical site with a razor can cause cuts that may become infected. Instead of shaving, healthcare providers should clip the hair or use a depilatory cream to remove it.

 


Perioperative Beta Blocker Received

Quality Measure Patients who received a beta blocker before, during, or after surgery at Memorial.
Why is this important? Beta blockers lower blood pressure by slowing the heart rate and opening blood vessels throughout the body. Patients who regularly take a beta blocker drug at home should take their beta blocker within 24 hours of their surgery. They should also continue their beta blocker after surgery unless their doctor tells them otherwise.

 


Venous Thromboembolism (VTE) Prophylaxis Ordered

Quality Measure Percentage of patients at Memorial University Medical Center for whom drugs to prevent venous thromboembolism are ordered.
Why is this important? Venous thromboembolism occurs when a blood clot forms in the deep veins in the legs, travels to another part of the body, and blocks blood flow to vital organs such as the lungs. Drugs to prevent the formation of blood clots should be ordered for patients who do not have other clotting disorders.

 


Venous Thromboembolism (VTE) Prophylaxis Received

Quality Measure Percentage of patients at Memorial University Medical Center who received drugs to prevent dangerous blood clots following surgery.
Why is this important? Venous thromboembolism occurs when a blood clot forms in the deep veins in the legs, travels to another part of the body, and blocks blood flow to vital organs such as the lungs. Drugs to prevent the formation of blood clots should be ordered for patients who do not have other clotting disorders.

 


Controlled PostOp Glucose

Quality Measure Percentage of patients who had their blood glucose (blood sugar) levels checked at regular intervals after surgery.
Why is this important? Changes in blood glucose levels after surgery can lead to complications or death.

 

 

 

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Memorial University Medical Center hospital campus: 4700 Waters Avenue, Savannah, GA 31404 - 912-350-8000