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A Retrospective Study of the Accuracy of Surgical Care Improvement Project Metrics for Documenting Normothermia John M. Boyce, Linda Sullivan, Douglas Vaughn, Jessica Nuzzo and Kimberly A. Davis Infection Control & Hospital Epidemiology / Volume 35 / Issue 11 / November 2014, pp 1408 - 1410 DOI: 10.1086/678420, Published online: 16 January 2015
Link to this article: http://journals.cambridge.org/abstract_S0195941700094650 How to cite this article: John M. Boyce, Linda Sullivan, Douglas Vaughn, Jessica Nuzzo and Kimberly A. Davis (2014). A Retrospective Study of the Accuracy of Surgical Care Improvement Project Metrics for Documenting Normothermia. Infection Control & Hospital Epidemiology, 35, pp 1408-1410 doi:10.1086/678420 Request Permissions : Click here
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infection control and hospital epidemiology
november 2014, vol. 35, no. 11
A Retrospective Study of the Accuracy of Surgical Care Improvement Project Metrics for Documenting Normothermia John M. Boyce, MD;1 Linda Sullivan, RN;1 Douglas Vaughn, MD;2 Jessica Nuzzo, MPH;1 Kimberly A. Davis, MD, MBA1
A retrospective study of a systematic sample of 150 patients who underwent abdominal surgery revealed that 53 (35.3%) had all intraoperative temperatures in the hypothermic range (!36.0⬚C). Fiftytwo (98.1%) of the 53 patients met 1 or both surgical care improvement project criteria for normothermia. Improved metrics are needed to assure normothermia. Infect Control Hosp Epidemiol 2014;35(11):1408-1410
Unintentional intraoperative hypothermia is a risk factor for surgical site infections.1 As a result, from 2009 through 2013, the Centers for Medicare and Medicaid Services (CMS) Hospital Inpatient Quality Reporting Program required acute care hospitals to report their compliance with Surgical Care Improvement Project (SCIP) criteria (SCIP-INF-10) for patients undergoing surgical procedures.2 According to SCIP-INF-10 metrics, patients were classified as being normothermic if either active warming methods were used intraoperatively or the patient achieved a temperature of 36.0⬚C or greater within 30 minutes immediately before or 15 minutes after anesthesia end time.2 The measure applied to patients of all ages undergoing surgical procedures under general or neuraxial anesthesia for 60 minutes or longer. However, because adherence to SCIP normothermia metrics has not always resulted in reduced surgical site infections,3 we conducted a retrospective study to evaluate the ability of SCIP-INF-10 metrics to assure intraoperative normothermia.
methods The study included a systematic sample derived from 321 patients who underwent surgical procedures involving an abdominal incision at a university-affiliated hospital in November 2012. The first 50 patients who underwent surgery in operating rooms (ORs) located in each of 3 pavilions were selected; total sample included 150 (47%) of 321 eligible patients. Patient intraoperative temperatures recorded every minute electronically in an anesthesia database (Centricity Perioperative; GE Healthcare) were imported into a spreadsheet (Excel; Microsoft) for analysis. To determine the average time for temperature monitoring probes to equilibrate, we
analyzed the first 10 temperature readings for 50 consecutive procedures. The analysis revealed that it took an average of 5 minutes for initial temperatures to equilibrate. Accordingly, the first 5 temperature readings recorded in the OR for each patient were excluded from further analysis. Intraoperative temperatures were recorded in the vast majority of patients by using esophageal temperature probes. Patient temperatures in the postanesthesia care unit were obtained using infrared temporal artery technology. For each patient, we recorded the percentage of OR temperatures less than 36.0⬚C (!36.0⬚C is defined as hypothermia), percentage of OR temperatures less than 35.5⬚C, and the 2 lowest consecutive (nadir) temperatures, because a nadir intraoperative temperature less than 35⬚C has been shown to be predictive of subsequent surgical site infection.1 Patients were arbitrarily divided into 5 groups (groups 1–5) on the basis of the frequency of intraoperative temperatures in the hypothermic range (Table 1). The use of an active warming device (eg, forced-air warming device) and whether the patient achieved a temperature of 36.0⬚C or greater within 30 minutes before or 15 minutes after the end of anesthesia were obtained from an electronic database (3M Chart View). The types of surgical procedures performed and anesthesia start and end times were obtained from an electronic operating room database. Differences in proportions were evaluated by using x2 or Fisher exact tests.
results Of the 150 procedures performed, 112 were general surgery, 36 were gynecologic procedures, and 2 were access procedures for implantation of orthopedic hardware. At least 28 procedures (cholecystectomies and gastric sleeve resections) mandated the use of a gastric tube on continuous suction, which may have impacted the accuracy of the esophageal temperature probe. Anesthesia times were greater than 60 minutes for all 150 procedures. Analysis of intraoperative temperatures for groups 1 through 5 is summarized in Table 1. Fifty-three patients (35.3%; groups 4 and 5 combined) had all intraoperative temperature readings less than 36.0⬚C. Esophageal temperature probes were used in 89% of the 53 patients. Twenty-two (41.5%) of the 53 persistently hypothermic patients had nadir temperatures less than 35.0⬚C. Analysis revealed that 96.2%–100% of groups 1–5 met 1 or both of the SCIP metrics for normothermia (Table 1). An active forced-air warming device was used in 45 (84.9%) of group 4 and 5 patients, compared with 85 (87.6%) of patients in groups 1–3 (P 1 .05). Patients in groups 4 and 5 were significantly less likely to have a temperature of 36.0⬚C or greater within 15 minutes of the end of anesthesia compared with patients in groups 1–3 (43 [84.3%] of 51 vs 92 [96.8%]
accuracy of scip metrics for normothermia
table 1. Range of Intraoperative Temperatures for 150 Patients Undergoing Abdominal Surgery and Percentage of Patients Meeting Surgical Care Improvement Project Criteria Metrics for Normothermia No. (%) of patients in group No. (%) of all patients
Active warming used
All ≥36.0⬚C 1%–49% of readings !36.0⬚C 50%–99% of readings !36.0⬚C All readings !36.0⬚C, some were 135.5⬚C All readings !35.5⬚C All patients
26 (17.3) 41 (27.3)
21 (80.8) 39 (95.1)
25 (96.2) 38/39b (97.4)
25 (96.2) 41 (100)
19 (12.7) 150 (100)
17 (89.5) 130 (86.7)
15 (78.9) 135/146 (92.5)
19 (100) 147 (98)
Group 1 2 3 4 5 6
Active warming used or met temperature metrica
Range of intraoperative temperature readings
Met 1 temperature metrica
Achieved temperature greater than or equal to 36.0⬚C within 30 minutes before the end of anesthesia or within 15 minutes after the end of anesthesia. b Temperature within 15 minutes after the end of anesthesia not available for 2 of 41 patients. c Temperature within 15 minutes after the end of anesthesia not available for 2 of 34 patients.
of 95; P p .02). The proportion of patients who met 1 or both SCIP metrics for normothermia was similar for patients in groups 4 and 5 (52 [98.1%] of 53) and those in groups 1–3 (95 [97.9%] of 97).
discussion This study demonstrated that a substantial proportion of patients who underwent surgical procedures involving an abdominal incision were hypothermic throughout the time period in which their temperatures were monitored intraoperatively. However, 98% of these patients met one or both SCIP-INF-10 criteria for maintenance of normothermia. High rates of compliance with normothermia metrics have also been reported by others.4 Our data confirm previous studies which demonstrated that use of active warming devices does not assure that normothermia is maintained intraooperatively.5 Lack of adequate patient prewarming and cool OR temperatures may have contributed to hypothermia despite the use of active warming devices.6,7 Furthermore, 84.3% of our persistently hypothermic patients met the SCIP-INF-10 criteria because they had at least 1 temperature 36.0⬚C or greater in the immediate postoperative period. Rewarming after discontinuation of anesthesia, transfer to a postanesthesia care unit with warmer ambient temperature, or use of a different temperature monitoring technology, may have contributed to an immediate postoperative temperature greater than or equal to 36.0⬚C in these patients. Our data suggest that a single temperature greater than or equal to 36.0⬚C in the immediate postoperative period may not be a reliable metric for assuring intraoperative normothermia. Our findings might help explain previous reports that adherence to SCIP normothermia temperature metrics has not always correlated with reduction in surgical site infection rates.3
Our study has several limitations. The study was conducted in a single hospital and included a small, systematic sample of patients who underwent abdominal surgery in a single month. However, we have no reason to believe that the systematic sample was biased toward selection of procedures resulting in unintentional hypothermia. No data were available on the level of placement of esophageal temperature probes, which could underestimate core body temperature.8 No data were available on the duration of gastric suction during the procedures, which could have yielded spuriously low esophageal temperature readings.9 Because gastric suction is usually intermittent during such procedures at our facility, and only 28% of patients who were persistently hypothermic underwent procedures that were likely to have used gastric suction during most of the procedure, we doubt that gastric suction would account for the high proportion of hypothermic intraoperative temperature readings. Because of our findings, we were surprised to find that CMS announced in August 2013 that hospitals will no longer be required to report SCIP-INF-10 data, because CMS considered SCIP-INF-10 to have “topped-out” (ie, its performance “is uniformly high nationwide, with little variability among hospitals”).10,p50679 This statement implies that normothermia is being achieved in most surgical procedures and that further monitoring is unnecessary. To the contrary, we suggest that it is reasonable to remove SCIP-INF-10 from the list of reportable performance measures, because the metrics may not serve as reliable proxies for normothermia during a variety of surgical procedures. In conclusion, our study suggests that SCIP-INF-10 performance metrics for normothermia do not accurately reflect achievement or maintenance of normothermia during surgical procedures involving an abdominal incision. Additional studies are needed to develop improved intraoperative tem-
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perature metrics that more accurately reflect intraoperative normothermia. 3.
acknowledgments Potential conflicts of interest. J.M.B. reports being a consultant to 3M and having received research funding from 3M. All other authors report no conflicts of interest relevant to this article. All authors submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest, and the conflicts that the editors consider relevant to this article are disclosed here. Affiliations: 1. Department of Quality Improvement Support Services, Yale-New Haven Hospital, New Haven, Connecticut; 2. Department of Perioperative Services, Yale-New Haven Hospital, New Haven, Connecticut. Address correspondence to John M. Boyce, MD, Hospital Epidemiology and Infection Control, Yale-New Haven Hospital, 20 York Street, New Haven, CT 06510 ([email protected]
). Received March 1, 2014; accepted July 3, 2014; electronically published September 29, 2014. 䉷 2014 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2014/3511-0012$15.00. DOI: 10.1086/678420
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