Effective with October 1, 2009 Discharges - Inpatient Surgical Care Core Measure Changes:
-Deletion of SCIP-Inf-7: Colorectal Surgery Patients with Immediate Postoperative Normothermia
-Addition of Two New SCIP Measures:
SCIP-Inf-9: Surgical Patients with Urinary Catheter Removed on Postoperative Day 1 or Postoperative Day 2 with Day of Surgery being Day Zero.
- Patients less than 18 years of age
- Patients whose ICD-9-CM principal procedure was performed entirely by Laparoscope
- Patients enrolled in clinical trials
- Patients who had a urological, gynecological or perineal procedure performed
- Patients who had other 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 of interest (during separate surgical episodes) during this hospital stay
- Patients with physician/APN/PA documented infection prior to surgery
- Patients who had a suprapubic catheter or had intermittent catheterization preoperatively.
- Patients who had physician/APN/PA documentation of a reason for not removing the urinary catheter postoperatively.
-Documentation that the urinary catheter was removed on Postop Day 1 or Postop Day 2.
- Documentation that the patient was in the intensive care unit (ICU) AND receiving diuretics.
- Physician/advanced APN/PA documentation of reasons for not removing the urinary catheter postoperatively.
- A physician order to leave the catheter in place is not sufficient documentation of reasons for not removing the urinary catheter. There must be documentation such as “Continue catheter. Patient is on total bed rest.”
- Physician documented reasons for not removing the urinary catheter must be documented on Postop Day 1 or Postop Day 2.
- Patient refusal of catheter removal is NOT an acceptable reason to continue catheterization.
- High risk of falls is NOT an acceptable reason to continue catheterization.
SCIP-Inf-10: Surgery Patients with Perioperative Temperature Management
This measure includes all surgeries that fall into SCIP category, and will apply to all age groups, including Pediatric cases.
- Patients whose length of anesthesia was less than 60 minutes
- Patients who did not have general or neuraxial anesthesia
- Patients with physician/APN/PA documentation of Intentional Hypothermia for the procedure performed.
Documentation that active warming was used intraoperatively for the purpose of maintaining normothermia. Documentation of body temperature within the 30 minutes prior to Anesthesia End Time to 15 minutes after Anesthesia End Time.