1. Innovative Strategies to Prevent Surgical Site Infection in Hip and Knee Arthroplasty “Screening Can be Fun!” Kathy D. Duncan, RN Faculty, Institute For Healthcare Improvement

2. The Case for Improvement 2 With over 1.1 million procedures done in 2008, knee and hip arthroplasty are two of the most commonly performed US surgeries. Knee arthroplasty surgical site infection (SSI) rates range from 0.68% to 1.60% and hip arthroplasty SSI rates range from 0.67% to 2.4% depending on patient risk. At these rates, between 6,000 and 20,000 SSIs occur annually in hip and knee replace­ments. The number of hip and knee arthroplasties will likely rise substantially in coming years due to an aging population staying more active. 15 states have mandated SSI reporting for arthroplastic surgery. Estimated hospital costs alone: hip arthroplasty $100,000 and knee arthroplasty $60,000 with 22 day increase in length of stay Surgical Site Infections a focus with CMS’s Partnership for Patients (Launched 4/12/11)

3. What is Project JOINTS? An 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 enhanced SSI prevention Bundle comprised of three new Evidence-based Practices as well as the two applicable Surgical Care Improvement Project (SCIP) practices. Two cohorts of 5 states with a 6 month intervention period. (May 2011-October 2012) 3

4. 4 Initial States Participation

5. Project JOINTS Team Kathy Duncan, RN Project Director Deborah Yokoe, MD Content Expert Kate O’Rourke Network Manager Brian Hamlin, MD Surgeon Expert Tony DiGioia, MD Surgeon Expert Richard Scoville, PhD Improvement Advisor Anila Hussaini Project Manager Aka Kovacikova Project Coordinator David Kim Project Coordinator

6. Support & Contributions 6 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.

8. Project JOINTS Offer implementation support to participants on the recommended interventions to reduce prevent hip and knee SSIs Build a network of facilities that are working together toward the same aim – literally Joining Organizations IN Tackling SSIs Test IHI’s ability to spread evidence-based practice

9. Plan for Today What is Project JOINTS? New Intervention and Evidence for SA Screening Implementation Strategies for SA Screening Resources Questions *Note: Pre-OP scrub and CHG Bathing was covered in earlier session

10. Project JOINTS interventions New Practices: – Use of an alcohol-containing antiseptic agent for preop skin prep – Preop bathing or showering with chlorhexidine gluconate (CHG) soap – Staph aureus screening and use of intranasal mupirocin and CHG bathing or showering to decolonize staph aureus carriers Applicable SCIP practices: – Appropriate use of prophylactic antibiotics – Appropriate hair removal

11. Screen patients for Staphylococcus aureus (SA) carriage and decolonize SA carriers with 5 days of intranasal mupirocin and at least 3 days of CHG soap prior to surgery

12. Why Worry About Staph Aureus Nasal Carriage? Staphylococcus aureus nasal colonization predisposes patients to invasive S. aureus infections – Nasal carriage of S. aureus is associated with a relative risk of 7.1 for developing SSI (Kluytmans J Infect Dis 1995) – Most cases of invasive S. aureus infection are due to endogenous strains (Von Eiff NEJM 2001, Huang CID 2008)

13. Does Using Mupirocin Eradicate S. Aureus Nasal Carriage? Systematic review (Ammerlaan HS, et al. CID 2009): 8 studies comparing mupirocin to placebo – Short-term nasal mupirocin (4-7 days) was an effective method for S. aureus eradication – 90% success at one week, 60% at longer (14-365 days) follow-up – 1% develop mupirocin resistance

14. Does Using Mupirocin Prevent SSIs? Meta-analysis (Kallen ICHE 2005): – 3 randomized and 4 before-after trials – Conclusion: Mupirocin use was associated with a small reduction in SSI rates for non-general surgery (cardiothoracic, orthopedic, neurosurgery: 6.0% vs. 7.6%) but not for general surgery 14

15. Does Using Mupirocin Prevent SSIs? Systematic review (van Rijen JAC 2008): Included 4 randomized controlled studies – Conclusion: Mupirocin use was associated with a significant reduction in S. aureus postoperative infection rates among S. aureus carriers (RR 0.55, 95% CI 0.34-0.89)

16. Randomized, double-blinded, placebo-controlled multicenter study of 6,771 patients in the Netherlands (Bode NEJM 2010) Rapid screening for MSSA/MRSA on admission Carriers randomized to mupirocin/CHG soap vs. placebo/bland soap x 5 days

17. (Continued) Bode NEJM 2010 Results: CHG bathing + mupirocin group had significantly lower SSI rates than the placebo group Conclusion: Preoperative identification of S. aureus carriers followed by 5 days of intranasal mupirocin plus CHG bathing reduced S. aureus SSIs by ~60%

18. Decolonization for Orthopedic Surgery This and next slide provided by Schweizer M, Perencevich E, Herwaldt L, Carson J, Kroeger J, Ward M

19. Now. What.About.Me? Improvement Sweet Improvement.

20. Assessing your current process In order to know where to focus attention, it is essential to: 1) take account of the unique situation in your hospital and surgeon’s office 2) consider both your past experience and success in implementing SCIP practices and 3) how well your hospital already performs in the practices recommended

21. Assessing your current process Assess the current reliability of each recommended intervention (% of cases where the intervention is accomplished) to determine the area most in need of improvement. Consider sequencing the three new elements of the bundle before implementing all of them together, since each intervention requires changes in different systems.

22. Assessing your current process Consider the complexity of the change: - Hospitals have found that changing to an alcohol- containing agent for preoperative skin antisepsis has often been less complex because the change takes place within a more controlled environment (the hospital) and is under the control of the OR and surgical management structure. - In contrast, developing processes to ensure preoperative showering or bathing with CHG and SA screening are more complex, as they start well before the patient comes to the OR and require working across additional settings (hospital, pre-op assessment, surgeon’s office, home). Review the results of any pilot testing of the intervention in your hospital to determine what changes are needed to enhance effectiveness before expanding the intervention more broadly.

23. Gather Your Team (or teams) Surgeon Champion Senior Leader On Board Small working/testing team for each intervention – Skin Prep – OR team, surgeon, CSR – CHG- PAT, surgery scheduler, surgeon rep, pre-op class – Screening – PAT, surgery scheduler, surgeon rep, pre-op class, lab rep, Plan for Process measures (Keep it simple)

24. Use an alcohol-containing antiseptic agent for preoperative skin preparation Adequate preoperative skin preparation to prevent entry of skin flora into the surgical incision is an important basic infection prevention practice. Preoperative skin preparation of the operative site involves use of an antiseptic agent with long-acting antimicrobial activity, such as chlorhexidine and iodophors. Two types of preoperative skin preparations that combine alcohol (which has an immediate and dramatic killing effect on skin bacteria) with long-acting antimicrobial agents appear to be more effective at preventing SSI than povidone-iodine (an iodophor) alone: – CHG plus alcohol – Iodophor plus alcohol.

25. Screen patients and Decolonize SA carriers w/5 days intranasal mupirocin & 3 days CHG Behavioral Objective: Screen all patients for Staphylococcus aureus prior to surgery, allowing enough time for those who screen positive to be decolonized with five days of intranasal mupirocin. Assess your current process and potential barriers: Assess where most preoperative assessments take place Tailor the intervention to the setting in which preoperative assessment is done Work with Lab to assure screening includes both MRSA and MSSA Develop a process to assure info on screening and decolonization is available at the time of surgery Develop a process flow diagram to define components of the process 25

26. Key Concepts to Consider Assess your current process and potential barriers Tailor the intervention to the setting in which the preoperative assessment is done Work with your laboratory – to ensure screening includes MSSA and MRSA and notification process – Understand culture/PCR process, possibilities and barriers – (PDSA) follow one class – thru notification process 26

27. Key Concepts to Consider Develop a process to ensure information on screening and decolonization is available prior to the time of surgery – (PDSA) follow one class – thru notification process – Test processes to provide mupirocin prescription – How do you assess compliance? Develop a process flow diagram – Define components (from your tests) 27

28. Lessons Learned Incorporate screening for SA and prescribing mupirocin into surgeons’ preoperative assessment orders Build on established preop assessment processes that require patient follow-up/treatment before surgery, such as positive urinalysis/urine culture requiring antibiotic treatment If PCR testing is available, assess the feasibility of providing screening results and prescription if needed, at the preop visit Create a flag system to be used during surgery for patients testing positive for MRSA to ensure Vancomycin is used preop 28

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31. 31 (Sparrow Hospital, Lansing, Michigan, USA)

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33. 33 (Exempla Lutheran Medical Center, Wheat Ridge, Colorado, USA)

34. Resources – www.ihi.org/projectjoints

35. Resources for you Call series How-to Guide Business case Patient instruction sheets and checklists Protocols for staff Evidence 1-pager Over 30 exemplars Listserv

36. Exemplar Hospitals

37. Surgery Data Tracker 37

38. IHI.org - projectjoints@Ihi.orgprojectjoints@Ihi.org Kathy Duncan kduncan@ihi.org 38

39. Questions?