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Avera St. Luke's

  • Avera St. Luke's (Surgical Infection Prevention)

Quality Reporting - Avera St. Luke's

To decrease the morbidity and mortality associated with postoperative infection in the Medicare patient population.

April 2009 - June 2009

 

 

 

Prophylactic Antibiotic Received within 1 Hour Prior to Surgical Incision

Technical  
Skin integrity provides a natural body defense against infection from harmful microorganisms. Surgical incisions breech these normal barriers thereby increasing the potential for microbes to invade the body. Prophylactic means to defend against or prevent infection. The goal of prophylaxis with antibiotics is to establish bactericidal tissue and serum levels at the time of skin incision. The evidence-base for surgical care continues to grow and has demonstrated reduced morbidity, mortality and decreased length of stay for patients receiving appropriate surgical care including antibiotic administer one hour prior to surgical incision.

Area/Measure Avera Facility HQID Ranking HQID Median HQA Median/ Average 

84 patients discharged; 81patients received prophylactic antibiotic withing one hour prior to surgical incision

96.43% 97.65% NA
 
Prophylactic Antibiotic Selection for Surgical Patients
Technical  

The goal of prophylactic antibiotics with surgery is the use of antibiotics that are safe, cost-effective and provide a spectrum of action for the most probable intraoperative contaminants. The antibiotic selection regimens are specific for the seven SIP surgery types and include alternative regimens for patient allergies to beta-lactam antibiotics.

Area/Measure

Avera Facility HQID Ranking

HQID Median

HQA Median/ Average 

84 patients discharged; 83 patients received prophylactic antibiotic selection

98.81% 98.73% NA
 
Prophylactic Antibiotics Discontinued within 24 hours After Surgery

Technical  
The goal of prophylactic antibiotics with surgery is to establish bactericidal tissue and serum levels at the time of skin incision and during the surgery. The continued administration of prophylactic antibiotics for more than a few hours after the surgical incision is closed offers no additional benefit to the surgical patient. Further, having no additional benefit, the discontinuation may reduce the risks associated with opportunistic infections such as C-difficile or the development of antimicrobial resistant pathogens.

Area/Measure Avera Facility HQID Ranking HQID Median HQA Median/ Average 

80 patients discharged; 76 patients received prophylactic antibiotic discontinuation within 24 hours after surgery

95% 95.61% NA
 
Recommended VTE Prophylaxis Ordered

Technical  
Venous thrombosis is a condition where a blood clot (thrombosis) forms in a vein. Venous clots may restrict blood flow and lead to swelling and pain. These clots occur more commonly in the lower extremities and pelvis and when these occur in "deep" veins the condition is referred to as "DVT" (deep vein thrombosis).

Area/Measure Avera Facility HQID Ranking HQID Median HQA Median/ Average 

35 patients discharged; 31 patients received prophylactic ordered

88.57% 95.56% NA
 
Received VTE Prophylaxis within 24 Hours Prior-24 Hours After Surgery End

Technical  
Due to the inherent variability related to the initiation of prophylaxis for surgical procedures, 24 hours prior to surgery to 24 hours post surgery was recommended by consensus of the Surgical Care Improvement Project (SCIP) Technical Expert Panel in order to establish a timeframe that would encompass most procedures.

Area/Measure

Avera Facility HQID Ranking

HQID Median

HQA Median/ Average 

33 patients discharged; 30 patients received prophylactic ordered within 24 hours - 24 hours after surgery end

90.91% 93.75% NA
 
Surgical Patients with Appropriate Hair Removal

Technical

Surgery patients with surgical site hair removal with clippers or depilatory or with no surgical site hair removal.

Area/Measure Avera Facility HQID Ranking HQID Median HQA Median/ Average 

115 patients discharged;114 patients received appropriate hair removal

99.13% 100% NA