The Surgical Care Improvement Project (SCIP) was initiated in 2005 out of the Surgical Infection Prevention (SIP) project. Recognized as an American multi-year partnership, the project aimed to reduce perioperative morbidity and mortality.
The SCIP guidelines were adopted and published in the Specifications Manual for Joint Commission National Quality Core Measures (Specifications Manual). This continually evolving manual was created by the Centers for Medicare & Medicaid Services (CMS) and the Joint Commission. Despite the multitude of participating organizations and noble aim of the project, recent evidence has challenged the association of adherence to process measures with good surgical outcomes.
General SCIP recommendations are as follows:
Controlled 6am postoperative blood glucose level in cardiac surgery patients.
Use clippers or depilatory methods, not a blade, to remove hair from the surgical site immediately before surgery.
Remove urinary catheters within the first 2 postoperative days except when required by specific clinical circumstances.
Standardize antibiotic choices based on type of surgery and patient factors (see Specifications Manual: Prophylactic Antibiotic Regimen Selection For Surgery and also see table Antibiotic Regimens for Certain Surgical Procedures).
As of December 31, 2015, hospitals accredited by The Joint Commission are required to follow the Oryx® Performance Measurement Initiative by The Joint Commission for reimbursement purposes; however, nearly all hospitals continue to rely on SCIP as good clinical practice and for developing internal quality standards.
Perioperative care is based on individual as well as general recommendations. Many drugs can interact with anesthetic drugs or have adverse effects during or after surgery. Thus, usually before surgery the patient's drugs are reviewed and which should be taken on the day of surgery is decided.
Recently, Enhanced Recovery After Surgery (ERAS) protocols have been developed and validated with the aim of standardizing perioperative care and improving overall surgical outcomes for various surgical specialties (see ERAS Society).
Anticoagulants and antiplatelets
1).
warfarin (called bridging anticoagulation—see Deep Venous Thrombosis). Because it takes up to 5 days for warfarin to achieve therapeutic anticoagulation, it can be started the day of or after surgery unless the risk of postoperative bleeding is high. Patients should receive bridging anticoagulation until the INR has reached the therapeutic target.
Corticosteroids
Diabetes
On the day of surgery, patients with insulin
Drug dependence
Heart disease
Patients with known coronary artery disease or heart failure should undergo preoperative evaluation and risk stratification by their cardiologist. If patients are not medically optimized, they should undergo additional testing before elective surgery.
Pulmonary disease
Preoperative pulmonary function tests can help quantify the degree of obstructive, restrictive, or reactive airway disease. Pulmonary function should be optimized by carefully adjusting the use and doses of inhalers, other drugs, and airway clearance techniques.
Other drugs that control chronic disorders
Most drugs taken to control chronic disorders, especially cardiovascular drugs (including antihypertensives), should be continued throughout the perioperative period. Most oral drugs can be given with a small sip of water on the day of surgery. Other drugs may have to be given parenterally or delayed until after surgery. Anticonvulsant levels should be measured preoperatively in patients with a seizure disorder.
Smoking
Smokers are advised to stop smoking as early as possible before any procedure involving the chest or abdomen. Several weeks of smoking cessation are required for ciliary mechanisms to recover. An incentive inspirometer should be used before and after surgery.
Upper airway
Before intubation, dentures must be removed. Ideally, before patients are moved from the preanesthetic holding area, they should give dentures to a family member. Patients with a deviated septum or another airway abnormality should be evaluated by an anesthesiologist before surgery requiring intubation.
Preprocedural checklist
In the operating room, before the procedure begins, a time out is held during which the team confirms several important factors:
Patient identity
Verification of correct procedure and location and side of the operative site
Availability of all needed equipment
Verification of administration of indicated prophylaxis (eg, antibiotics, anticoagulants, beta-blockers)
Reference
1. Fleisher LA, Fleischmann KE, Auerbach AD, et al: 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: A report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. J Am Coll Cardiol 64(22):e77-e137, 2014. doi:10.1016/j.jacc.2014.07.944
