Project JOINTS: Joining Organizations IN Tackling SSIs

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Project JOINTS Joining Organizations IN
Tackling SSIs

• Instruct patients to bathe or shower with
  chlorhexidine gluconate (CHG) soap for at least 3
  days before surgery

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What is Project JOINTS?

• A new initiative funded by the federal government
  to give participants support from IHI in the form
  of in-person and virtual coaching on how to test,
  implement and spread the three new evidence-based
  practices to prevent surgical site infection for
  hip and knee arthroplasty as well as the two
  applicable Surgical Care Improvement Project
  (SCIP) practices.

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Support Contributions

• American Academy of Orthopaedic surgeons
  (AAOS/Academy)
• The JOINTS project is a remarkable endeavor and
  the Academy looks forward to working with you to
  accomplish the goal of eliminating preventable
  SSIs.
• AORN
• Hospitals already engaged in the new
  interventions

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Project JOINTS Website
http//www.ihi.org/ProjectJOINTS/
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• Evidence suggests three new practices to prevent
  surgical site infections in patients undergoing
  hip and knee arthroplasty.

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Interventions to Prevent SSIs for Hip and Knee
Arthroplasty

• New Practices
• Use of an alcohol-containing antiseptic agent for
  pre-op skin prep
• Instruct patients to bathe or shower with
  chlorhexidine gluconate (CHG) soap for at least
  three days before surgery
• Screen patients for Staphylococcus aureus (SA)
  and decolonize SA carriers with five days of
  intranasal mupirocin and bathing or showering
  with CHG soap for at least three days before
  surgery

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What evidence supports patient bathing or shower
with CHG soap for at least 3 days prior to
surgery?

• Studies show that repeated use of CHG soap
  enhances the ability of CHG to reduce bacterial
  counts on the skin
• not only during the immediate period after the
  shower but for a number of hours afterward
• Study results suggest that patients may benefit
  from bathing or showering with CHG soap for at
  least 3 days before surgery in order to achieve
  the most benefit.
• It is unknown whether using CHG soap for longer
  periods (e.g., five days) has additional benefit.

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Implementing pre-operative bathing or showering
with CHG soap for at least 3 days prior to
surgery

• Strategies to Accelerate Change

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Preoperative bathing or showering with CHG soap
for at least 3 days prior to surgery

• Provide patients with chlorhexidine soap or
  instruct them where they can purchase and have
  them use the soap in bathing or showering for at
  least three days before surgery.
• Key considerations to ensure reliable CHG bathing
  or showering 3 days prior to surgery
• Assess where most preoperative assessments
  currently take place in your setting, because
  that is the optimal time to discuss use of
  chlorhexidine soap with patients.
• Assess current preoperative communication between
  the hospital OR department and the orthropaedic
  surgeons offices to ensure patients receive
  consistent instructions on CHG bathing or
  showering.

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Preoperative bathing or showering with CHG soap
for at least 3 days prior to surgery

• Additional considerations to ensure reliable CHG
  preoperative bathing 3 days prior to surgery
• Decide whether its feasible to give
  chlorhexidine soap to all patients during the
  preoperative assessment visit. If not, provide
  information to the patients/families about where
  they can purchase and the approximate cost.
• Provide patients/families instructions on how to
  do preoperative bathing.
• Develop a simple form for patients to track days
  of CHG bathing or showering completion.

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Preoperative bathing or showering with CHG soap
for at least 3 days prior to surgery

• Additional key considerations in developing a
  reliable process for CHG bathing/showering 3 days
  prior to surgery
• Develop a process flow diagram, specific to your
  hospital setting
• define all necessary components of the process
  for patient bathing/showering for at least three
  days prior to surgery
• build into the pre-op assessment/visit a process
  for providing CHG or instructing patients on
  where to obtain and instructions for use.
• NOTE An example process flow diagram for Pre-Op
  CHG bathing or showering is available in the
  How-to Guide.

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Assessing Progress Over Time Recommended
Process Measure

• Percentage of patients undergoing hip or knee
  replacement surgery who have bathed or showered
  with chlorhexidine soap at least three days prior
  to surgery.

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FAQs CHG bathing or showering

• Are there disadvantages to recommending 5 days of
  CHG soap?The disadvantages are mainly practical,
  and include
• patients would need a larger, more expensive
  bottle of CHG soap or the even more expensive
  5-day supply of CHG wipes
• compliance with an additional two days of CHG
  showering/bathing could be even more challenging
  for patients.
• Should the whole body be bathed with the CHG soap
  or just the surgical site? The CHG bath/shower
  prior to surgery should include the whole body
  from the neck down to avoid soap getting into
  the eyes, ears, nose, or mouth. Patients should
  also be reminded not to wash genital areas with
  CHG solution.

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FAQs CHG bathing or showering

• Can chlorhexidine-impregnated wipes be used
  instead of chlorhexidine soap?
• If used correctly, the wipes may be better than
  chlorhexidine soap because the chlorhexidine
  doesn't get washed away in the shower or bath.
  One possible problem with the wipes is that many
  patients prefer showering to using the cloths
  which may reduce compliance.
• before using cloths, consider asking individual
  patients if they're willing to use the cloths
  instead of showering.
• Are there concerns about skin reactions to
  chlorhexidine bathing? Based on studies that
  have used chlorhexidine cloths for daily bathing
  of hospitalized patients (mainly in ICUs), skin
  reactions are very rare.

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FAQs CHG bathing or showering

• Can lotion be used following CHG bathing or
  showering?Lotions or moisturizers should not be
  used following CHG showering/bathing.
• Can CHG soap be purchased in a regular
  pharmacy?CHG soap can be found at most
  pharmacies and drug stores. Be sure to check your
  local area to confirm availability.

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For More Information

• The How-To Guide contains more information on all
  three interventions

http//www.ihi.org/knowledge/Pages/Tools/HowtoGuid
ePreventSSIforHipKneeArthroplasty.aspx