The Surgical Infection Prevention Project: Processes, Outcomes, and Future Impact

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Abstract
Background: Appropriate usage of antibiotics is a crucial aspect of optimized outcomes and the prevention of bacterial resistance. Surgical site infection (SSI) is common after surgery, but the risk can be minimized in part by appropriate prescribing of prophylactic antibiotics. However, evidence indicates that prophylactic antibiotics are mis-prescribed widely, including choice of inappropriate agents, timing of administration, and duration of prophylaxis Methods: The Surgical Infection Prevention (SIP) project is a collaborative effort of the Centers for Medicare and Medicaid Services (CMS) and the U.S. Centers for Disease Control and Prevention (CDC). The processes and outcomes to date are described, and pertinent supporting literature is reviewed. Three performance measures were developed: Administration of the prophylactic agent within 60 min prior to incision; selection of an agent from a roster of suitable agents chosen for narrow spectrum and safety; and discontinuation of prophylactic antibiotics by 24 h after conclusion of the operative procedure. Baseline performance was defined by a nationwide retrospective study of 788 operations selected randomly from each U.S. state and territory from the Medicare Part A claims database (total, >35,000 claims reviewed) Results: Compliance with the "administration within 60 min" standard was poor, at 56%. Compliance with the second performance measure, choice of an appropriate agent, was much better, at 93%. However, results from the third measure, discontinuation within 24 h, were most problematic: Only 41% of regimens were discontinued on a timely basis. State-based performance improvement initiatives resulted in dramatic improvements when reassessed after 12 months. The incidence of SSI decreased by 27% Conclusions: The SIP performance measures have been accepted by the Joint Commission for the Accreditation of Healthcare Organizations, and hospitals face penalties in Medicare reimbursement for non-compliance with mandatory reporting. The incorporation of SIP into the Surgical Care Improvement Project (SCIP) portends further expansion of mandatory reporting, as pay-for-reporting yields to pay-for-performance or even penalty-for-complications. Fortunately, in the case of SIP and appropriate use of prophylactic antibiotics, doing the right thing is easy and improves surgical outcomes demonstrably. Unfortunately, a concerted effort will likely be necessary to sustain the improvement in prescribing practices