Description Population
SCIP-Inf-1
Prophylactic Antibiotic Initiated
Within 1 Hour Prior to Surgical
Incision,(2 Hours if Using Vancomycin or a Fluoroquinolone)
DOCUMENT:
 Anesthesia Start Date
 Antibiotic Name
 Antibiotic Administration Date
 Antibiotic Administration Time
 Antibiotic Administration Route
 Surgical Incision Time
Inclusion:
 Selected Surgery
Exclusions:
 Less than 18 years of age
 Length of stay >120 days
 Hysterectomy and C-section during current stay
 Pre-operative infection
 Laparascopic procedure, entirely
 Participation in clinical trial
 Principal procedure prior to admission date
 Documented infection prior to surgery
 General or spinal anesthesia 3 days(4 for CABG/other cardiac surgeries) prior/after procedure of interest during this hospital stay
 Antibiotics more than 24 hours before surgery
 Antibiotics within 24 hours of arrival (except oral antibiotics for colon procedures)
Facility Notes
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Description
SCIP-Inf-2
Surgical Patients who Received
Prophylactic Antibiotics
Recommended for Their Specific
Surgical Procedure
DOCUMENT:
 Antibiotic Name
 Antibiotic Administration Date
 Antibiotic Administration Time
 Antibiotic Administration Route
 Antibiotic Allergies
 Surgeon must ALWAYS document reason when
Vancomycin is used in lieu of
Cefazolin or Cefuroxime.
Population
Inclusion:
 Selected Surgery
Exclusions:
 Less than 18 years of age
 Length of stay >120 days
 Diagnosis suggestive of preoperative infectious diseases
 Laparascopic procedure, entirely
 Participation in clinical trial
 Principal procedure prior to admission date
 Documented infection prior to surgery
 Perioperative death
 Antibiotics more than 24 hours before surgery
 Antibiotics within 24 hours of arrival (except oral antibiotics for colon procedures)
 No documentation of antibiotics before or during surgery, or within 24 hours after anesthesia end time
 No antibiotics during hospitalization
 Patients with reasons to extend antibiotics
Facility Notes
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Description
SCIP-Inf-3
Surgical Patients Whose
Prophylactic Antibiotics were
Discontinued Within 24 Hours After
Anesthesia End Time (48 Hours for
CABG or Other Cardiac Surgery)
DOCUMENT:
 Anesthesia End Time
 Confirm Order for
Discontinuation of Antibiotics
 Rationale for Continuation of
Post-Operative Antibiotics
 Post-Operative Infections
Population
Inclusion:
 Selected Surgery
Exclusions:
 Less than 18 years of age
 Length of stay >120 days
 Diagnosis suggestive of preoperative infectious diseases
 Laparascopic procedure, entirely
 Participation in clinical trial
 Principal procedure prior to date of admission
 Documented infection prior to surgery
 Joint revision
 Perioperative death
 Procedures requiring general or spinal anesthesia that occurred within 3 days (4 days for CABG or
Other Cardiac Surgery) prior to or after the procedure
 Antibiotics more than 24 hours before surgery
 Antibiotics within 24 hours of arrival (except oral antibiotics for colon procedures)
 No antibiotics during hospitalization
 Received urinary antiseptics only
 Infections diagnosed within 2 days (3 for CABG or other cardiac surgery) after anesthesia end date
Facility Notes
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Description
SCIP-Inf-4
Cardiac Surgical Patients with
Controlled 6 a.m. Blood Glucose
(≤ 200 mg/dL) on
Post-Operative Day 1 (POD1) AND
Post-Operative Day 2 (POD2)
DOCUMENT:
 Anesthesia End Date = Post-Op
Day Zero
 Controlled 6 a.m. Blood Glucose
(≤ 200 mg/dL) on POD1, AND
 Controlled 6 a.m. Blood Glucose
(≤ 200 mg/dL) on POD2
Population
Inclusion:
 Selected Surgery
Exclusions:
 less than 18 years of age
 Length of stay >120 days
 Diagnosis suggestive of preoperative infectious diseases
 Burn and transplant patients
 Laparascopic procedure, entirely
 Participation in clinical trial
 Principal procedure occurred prior to the date of admission
 Documented infection prior to surgical procedure of interest
 Perioperative death
Facility Notes
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Description
SCIP-Inf-6
Surgery Patients with Surgical Site
Hair Removal with Clippers or
Depilatory or with No Surgical Site
Hair Removal
DOCUMENT:
 Hair Removal with Clippers
 Hair Removal with Depilatory, Or
 NO Hair Removal
Population
Inclusion:
 Selected Surgery
Exclusions:
 Less than 18 years of age
 Length of stay >120 days
 Laparascopic procedure, entirely
 Participation in clinical trial
 Principal procedure occurred prior to the date of admission
 Patients who performed their own hair removal
Facility Notes
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Description
SCIP-Inf-9
Surgical Patients with Urinary
Catheter Removed on
Post-Operative Day 1 (POD1) or
Post-Operative Day 2 (POD2) with
Day of Surgery Being Day Zero
DOCUMENT:
 Urinary Catheter Removal
 Rationale for Continuing Urinary
Catheterization
Population
Inclusion:
 Selected Surgery
Exclusions:
 Less than 18 years of age
 Length of stay >120 days
 Laparascopic procedure, entirely
 Participation in clinical trial
 Urological, gynecological or perineal procedure
 Principal procedure prior to the date of admission
 Procedures requiring general or spinal anesthesia that occurred within 3 days (4 days for CABG or
Other Cardiac Surgery) prior to or after the procedure
 Perioperative death
 Length of stay less than two days postoperatively
 Suprapubic catheter or intermittent catheterization preoperatively
 No catheter postoperatively
 Documentation of non-removal postoperatively
 Urethral catheter, a suprapubic catheter, or who were being intermittently catheterized prior to perioperative periods
Facility Notes
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Description
SCIP-Inf-10
Surgery patients for whom either active warming was used intraoperatively for the purpose of maintaining normothermia, or who had at least one body temperature equal to or greater than
96.8°F/36° C recorded within the
30 minutes immediately prior to or the 15 minutes immediately after
Anesthesia End Time.
DOCUMENT:
 Intentional Normothermia
(Active Warming) for the
Procedure
 Temperature
 Anesthesia End Time
Population
Inclusion:
 Selected Surgery
Exclusions:
 Length of stay >120 days
 Principal procedure prior to the date of admission
 Anesthesia < 60 minutes
 General or neuraxial anesthesia
 Documentation of Intentional
Hypothermia for the procedure
Facility Notes
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Description Population
SCIP-Card-2
Surgical Patients on Beta-Blocker
Therapy Prior to Arrival who
Received a Beta-Blocker During the
Perioperative Period
The perioperative period for the
SCIP Cardiac measures is defined as 24 hours prior to surgical incision through discharge from post-anesthesia care/recovery area
DOCUMENT:
 Patients Currently Taking Beta-
Blockers – Confirm Written Order
 Date and Time of Administration of Medication (Beta-Blocker)
 Rationale for Not Administering
Beta-Blocker Perioperatively
Inclusion:
 Selected Surgery
Exclusions:
 Less than 18 years of age
 Length of stay >120 days
 Laparascopic procedure, entirely
 Participation in clinical trial
 Principal procedure prior to the date of admission
 Perioperative death
 Pregnant patients taking a betablocker prior to arrival
 Documented reason for not administering Beta-Blocker perioperatively
Facility Notes
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Description
SCIP-VTE-1
Surgical patients with recommended venous thromboembolism (VTE) prophylaxis ordered anytime from hospital arrival to 24 hours after Anesthesia
End Time
SCIP-VTE-2
Surgical patients who received appropriate venous thromboembolism prophylaxis within 24 hours prior to Anesthesia
Start Time to 24 hours after
Anesthesia End Time
DOCUMENT:
 Confirm Physician Order for
Recommended VTE Prophylaxis by Surgery Type
 Anesthesia Start Time
 Anesthesia End Time
 Surgical Patient Receipt of
Appropriate VTE Prophylaxis
 Physician Documents Rationale for Not Administering VTE
Prophylaxis
Population
Inclusion:
 Selected Surgery
Exclusions:
 Less than 18 years of age
 Length of stay >120 days
 Burn patients
 Laparascopic procedure, entirely
 Participation in clinical trial
 Warfarin prior to admission
 Principal procedure prior to date of admission
 Surgery time ≤ 60 minutes
 Perioperative death
 Length of stay ≤ 3 calendar days
 Patients with reasons for not administering both mechanical and pharmacological prophylaxis
Exclusions for VTE-2:
 Patients who did not receive VTE prophylaxis
Facility Notes
This checklist is provided for Administrative Review Purposes Only and is not intended to be used in any way for clinical care.
All material presented or referenced herein is intended for general informational purposes and is not intended to provide or replace the independent judgment of a qualified healthcare provider treating a particular patient. Ohio KePRO disclaims any representation or warranty with respect to any treatments or course of treatment based upon information provided.
Publication No. 925000-OH-1795-10/2010. This material was prepared by Ohio KePRO, the Medicare Quality Improvement Organization for Ohio, under contract with the Centers for
Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.
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