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

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.

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

Project JOINTS Website http://www.ihi.org/ProjectJOINTS/

Evidence suggests three new practices to prevent surgical site infections in patients undergoing hip and knee arthroplasty.

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

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.

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

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. A summary of the evidence is available in the Project JOINTS How-to-Guide

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 it’s 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. A summary of the evidence is available in the Project JOINTS How-to Guide. The Project JOINTS website contains helpful tools, checklists and patient education materials.

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. A summary of the evidence is available in the Project JOINTS How-to-Guide

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. One method of assessing compliance that hospital’s have recommended: provide patients with a form/check sheet to track their CHG bathing/showering

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.

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.

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.

For More Information The How-To Guide contains more information on all three interventions http://www.ihi.org/knowledge/Pages/Tools/HowtoGuidePreventSSIforHipKneeArthroplasty.aspx