At Sky Ridge Medical Center, measurement of compliance in the following areas began in early 2006 and is ongoing. SCIP measure results are shared internally within HCA quarterly and are publicly reported.

Prophylactic Antibiotics Received within 1 hour Prior to Surgical Incision:

2 hours for Vancomycin+Quinolone. Documentation of antibiotic dose must be complete.

If converted from lap to open, use incision time of open

Prophylactic Antibiotic Selection for Surgical Patients:

Documentation of antibiotic dose must be complete. See attached table.

Prophylactic Antibiotic Discontinued within 24 hours after Surgery End Time:

48 hours for cardiac surgeries unless documented reason for extending (see attached)

Beta Blocker:

Surgery patients on Beta Blocker therapy prior to admission who receive Beta Blocker during the perioperative period meet SCIP compliance, unless a contraindication to the Beta Blocker is documented by the physician.

Peri-op period is 24 hours prior to surgical incision through PACU or 6 hours post ICU.

Cardiac Surgery Patients with Controlled 6 a.m. Postoperative Blood Glucose:

Blood glucose values of < 200 mg/dL are considered compliant with SCIP measures. Glucose results closest to

6 a.m. on postoperative day 1 and postoperative day 2 are collected.

Surgery Patients with Appropriate Hair Removal:

If hair is removed at the surgical site, hair removal with clippers, scissors or depilatory is considered in compliance.

Surgery Patients with Perioperative Temperature Management:

Patient temperature of greater than or equal to 96.8 F 30 minutes prior to or 15 minutes after anesthesia end time, and/or warming device used intraoperatively.

Surgery Patients with Recommended Venous Thromboembolism Prophylaxis (VTE) ordered:

Order the recommended VTE prophylaxis – see Table included.

Surgery Patients Who Have Appropriate VTE Prophylaxis Ordered and Received from Hospital Arrival to 24 hours After Anesthesia End Time:

Documentation of timely recommended VTE exists in the medical record.

Urinary Catheter removed on Postoperative day 1 or Day 2 with day of Surgery being day Zero:

Catheter needs to be removed by midnight of POD #2 unless documented reason why left in.