The Joint Commission (TJC) and the Centers for Medicare and Medicaid Services (CMS) require accredited hospitals to collect and submit performance data so they can review clinical trends that have a significant effect on patient outcomes. The core measure data requirement was established to allow TJC to use collected informationto work with hospitals to improve the safety and quality of care and to support performance improvement.

Listed below are the TJC instituted core measures for surgical care improvement. Adherence to these guidelines will assist physicians to achieve positive patient outcomes and maintain compliance with TJC and CMS regulations.

1) Prophylactic Antibiotic Received Within 1 Hour Prior to Surgical Incision

Surgical patientsshould receive prophylactic antibiotics within one hour prior to surgical incision. Patients who received vancomycin or a fluoroquinolone for prophylactic antibiotics should have the antibiotics administered within two hours prior to surgical incision. Due to the longer infusion time required for vancomycin or a fluoroquinolone, it is acceptable to start these antibiotics within two hours prior to incision time.

2) Prophylactic Antibiotic Selection for Surgical Patients

Surgical patients who received prophylactic antibiotics consistent with current guidelines (specific to each type of surgical procedure).

3) Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time

Surgical patients whose prophylactic antibiotics were discontinued within 24 hours after surgery end time.

4) Cardiac Surgery Patients With Controlled 6 A.M. Postoperative Serum Glucose

Cardiac surgery patients with controlled 6 a.m. serum glucose ( 200 mg/dL) on postoperative day one (POD 1) and postoperative day two (POD 2) with Surgery End Date being postoperative day zero (POD 0).

5)Surgery Patients with Appropriate Hair Removal

Surgery patients with appropriate surgical-site hair removal. No hair removal, or hair removal with clippers or depilatory is considered appropriate. Shaving is considered inappropriate.

6)Colorectal Surgery Patients with Immediate Postoperative Normothermia

Colorectal surgery patients with immediate normothermia (96.8-100.4° F) within 15 minutes after leaving the operating room.

7) Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered

8) Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis Within 24 Hours Prior to Surgery to 24 Hours After Surgery

If you have any questions, contact Mary Jo D'Amico, Director, Perioperative Services, at (504) 897-8133, or at mary.damico@touro.com.