What is the SCIP (Surgical Care Improvement Project) protocol for adult patients undergoing cardiac surgery?

SCIP Protocol for Cardiac Surgery

The Surgical Care Improvement Project (SCIP) for cardiac surgery focuses on four core infection prevention measures: prophylactic antibiotics within 60 minutes before incision with weight-based cefazolin, antibiotic discontinuation within 48 hours post-surgery, perioperative glycemic control, and appropriate hair removal techniques. 1

Core SCIP Infection Prevention Measures

Prophylactic Antibiotic Administration

Weight-based cephalosporin (cefazolin) must be administered fewer than 60 minutes before skin incision, with redosing required for cases longer than 4 hours. 1

• Cefazolin is the preferred first-line prophylactic antibiotic for cardiac surgery, with dosing based on patient weight 1, 2
• For procedures exceeding 4 hours duration, redose antibiotics intraoperatively to maintain therapeutic levels 1
• The evidence supports Level IA data for this timing and dosing strategy 1

Antibiotic Discontinuation

Prophylactic antibiotics should be discontinued within 48 hours after completion of cardiac surgery, with extension to 3-5 days only for procedures where infection would be particularly devastating (open-heart surgery, prosthetic valve replacement). 1, 2

• The standard 24-hour discontinuation rule for general surgery is extended to 48 hours specifically for cardiac surgery 1
• Prolonged prophylaxis beyond 48 hours increases antibiotic resistance without reducing infection rates 1
• If signs of infection develop, obtain cultures and transition to therapeutic (not prophylactic) antibiotics 2

Perioperative Glycemic Control

Maintain pre-meal blood glucose <7.8 mmol/L (140 mg/dL) and random glucose <10.0 mmol/L (180 mg/dL) throughout the perioperative period, with particular emphasis on the first two postoperative days in cardiac surgery patients. 1

• Hyperglycemia is harmful in routine perioperative care and increases surgical site infection risk 1
• Monitor blood glucose at regular intervals and adjust insulin therapy accordingly 1
• This measure is specifically emphasized for cardiac surgery patients as part of SCIP quality metrics 3

Hair Removal Protocol

Hair at the surgical site must be removed with electric clippers close to the time of surgery, never with razors or blades. 1, 3

• Clipping is preferred to shaving based on meta-analysis data showing reduced bacterial counts and infection rates 1
• Perform clipping immediately before surgery, not the night before 1
• Shaving with razors creates microscopic skin trauma that increases infection risk 1

Comprehensive Surgical Site Infection Bundle

Beyond core SCIP measures, implement a care bundle including topical intranasal mupirocin, chlorhexidine skin preparation, and postoperative normothermia to achieve maximal infection reduction. 1

Staphylococcal Decolonization

• Apply topical intranasal mupirocin universally to all cardiac surgery patients, as 18-30% are Staphylococcus aureus carriers with 3-fold higher infection risk 1
• Two studies validate significant reduction in S. aureus surgical site infections with mupirocin prophylaxis 1

Skin Preparation

• Use chlorhexidine-based skin preparation solutions for superior antimicrobial activity 1
• Preoperative chlorhexidine showers reduce bacterial counts but lack strong efficacy data as a standalone measure 1
• Remove sterile dressings within 48 hours and perform daily incision washing with chlorhexidine postoperatively 1

Temperature Management

• Maintain normothermia (body temperature >36°C) throughout the perioperative period using active warming devices and warmed intravenous fluids 4
• Hypothermia impairs immune function and increases surgical site infection risk 4

Additional SCIP Quality Measures

Urinary Catheter Management

Remove urinary catheters within the first two postoperative days to reduce catheter-associated urinary tract infections. 3

• Early catheter removal (postoperative day 1-2) is safe and reduces infection risk 4
• This applies regardless of epidural catheter duration 4

Venous Thromboembolism Prophylaxis

• Implement mechanical prophylaxis with well-fitting compression stockings 4
• Add pharmacological prophylaxis with low molecular weight heparin based on bleeding risk assessment 4

Evidence Quality and Implementation

SCIP compliance demonstrates improved outcomes when all measures are implemented together, though individual measures show variable independent effects. 1

• Complete adherence to all four core SCIP antibiotic guidelines independently decreases surgical site infection risk (odds ratio 0.43,95% CI 0.20-0.94) 5
• Patients adhering to SCIP guidelines develop fewer surgical site infections (17% vs. 33%) and have shorter hospital stays 5
• The "whole is greater than the parts" - bundled compliance shows superior outcomes compared to individual measure implementation 6

Critical Implementation Pitfalls

• Timing errors: Antibiotics given >60 minutes before incision or after incision lose prophylactic efficacy 1, 5
• Prolonged prophylaxis: Continuing antibiotics beyond 48 hours (or 3-5 days for high-risk procedures) increases resistance without benefit 1
• Incomplete bundle adoption: Implementing only some SCIP measures reduces overall effectiveness 6
• Inadequate redosing: Failure to redose antibiotics in prolonged procedures (>4 hours) creates gaps in coverage 1

Audit and Compliance Monitoring

Regular auditing of SCIP compliance and clinical outcomes is essential, with adherence directly correlating with improved patient outcomes in a linear relationship. 1

• Track compliance rates for each individual SCIP measure 1, 3
• Monitor surgical site infection rates as the primary outcome metric 3
• The SCIP initiative targeted a 25% reduction in surgical site infections from implementation through 2010 3