Kathy D. Duncan, RN Faculty, Institute For Healthcare Improvement Innovative Strategies to Prevent Surgical Site Infection in Hip and Knee Arthroplasty Kathy D. Duncan, RN Faculty, Institute For Healthcare Improvement

The Case for Improvement 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)

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)

Initial States Participation Arkansas; California; Colorado; Maryland/Washington, DC; Michigan; Mississippi; New York; Oregon; Tennessee; and Wisconsin

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

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 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

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

Plan for Today What is Project JOINTS? New Interventions and Evidence for Pre-op Scrub and CHG Bathing Implementation Strategies for Pre-op Scrub and CHG Bathing Resources Questions *Note: Staff Aureus Screening will be covered in detail in the next hour.

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 at least 3 times prior to surgery Staph aureus screening and use of intranasal mupirocin and CHG bathing or showering to decolonize staph aureus carriers

#1: Use an alcohol-containing antiseptic agent for preoperative skin preparation

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 Requires use of an antiseptic agent with long-acting antimicrobial activity, such as chlorhexidine (CHG) or iodophors Is one long-acting agent better than another? Does adding alcohol help?

Cochrane Systematic Review 2009: Does Pre-Operative Skin Antisepsis Prevent SSI? CHG vs. PI (Berry 1982): Higher SSI rate with PI PI vs. iodophor-alcohol (2 studies): No significant difference Single vs. multiple-step application (4 studies): No significant difference Iodophor-impregnated drapes vs. regular drapes (4 studies): No significant difference Conclusion: Insufficient evidence to support recommending the use of one antiseptic agent over another

Comparison of 3 Skin Antisepsis Protocols Single institution sequential implementation study design involving 3,209 general surgery patients (Swenson ICHE 2009) comparing : Povidone-iodine scrub→alcohol→povidone iodine paint (“triple prep”) 2% chlorhexidine plus 70% isopropyl alcohol Iodine povacrylex in isopropyl alcohol

Povidone-Iodine vs. CHG-Alcohol vs. Iodine Povacrylex-Alcohol Time Sequence Study Swenson. ICHE 2009; 30:964-971

Darouiche. NEJM 2010;362:9-17

Povidone-Iodine Versus CHG-Alcohol Randomized, multicenter study of 849 patients undergoing clean-contaminated surgery (Darouiche NEJM 2010). Povidone-iodine scrub and paint vs. CHG-alcohol scrub.

Darouiche. NEJM 2010;362:9-17

(Continued) Darouiche NEJM 2010 Conclusion: SSI rates for patients prepped with CHG-alcohol were significantly lower compared with povidone-iodine Caveat: No comparison with CHG without alcohol or iodophor-alcohol

Summary of Swenson and Darouiche results Clean-contaminated procedures Swenson. ICHE 2009; 30:964-971 Darouiche. NEJM 2010;362:9-17

#2: Ask patients to bathe or shower with CHG soap at least 3 times before surgery

Why consider preoperative CHG bathing or showering to prevent SSIs? Topical chlorhexidine significantly reduces bacterial counts on skin and has a residual antimicrobial effect Impacts a broad range of potential pathogens Low risk of skin reactions There is progressive reduction in counts when used serially up to 3 times preoperatively Hayek J Hosp Infect 1987 Kaiser Ann Thor Surg 1988 Garibaldi J Hosp Infect 1988, Paulson AJIC 1993 24

Effectiveness of CHG washes depends mainly on the residual antimicrobial effect, which is increasingly effective the more consecutive days it is used At least 3 consecutive washes are needed to keep skin flora lower than baseline through a 24-hour period Paulson DS. Efficacy evaluation of a 4% chlorhexidine gluconate as a full-body wash. Am J Infect Control 1993;21:205-209.

Does CHG Bathing Prevent SSIs? Cochrane Systematic Review 2011 CHG vs. placebo: No significant SSI reduction (RR 0.91, 95% CI 0.80-1.04) CHG vs. bar soap: No significant SSI reduction (RR 1.02, 95% CI 0.57-1.84 CHG vs. no washing: Significant SSI reduction for one large study (RR 0.35, 95% CI 0.17-0.79)

Why is this recommendation controversial? Cochrane Systematic Review 2011: no clear evidence based on RCTs that preop bathing with CHG reduces the incidence of SSI Studies had many limitations: Variable SSI definitions and follow-up No monitoring of compliance with CHG use Most used only 1 or 2 applications of CHG soap May need repeated applications (i.e., showering with CHG at least 3 times prior to surgery)

#3: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

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)

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

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 31

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)

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

(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%

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

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

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

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.

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.

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)

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 .

Strategies to Accelerate Change Implementing use of an alcohol-containing antiseptic agent for preoperative skin preparation Strategies to Accelerate Change

Use an alcohol-containing antiseptic agent for preoperative skin preparation Behavioral Objective: Change the operating room skin prep for hip and knee arthroplasty to a long-acting antiseptic agent in combination with alcohol. Assess your current process and potential barriers: Identify surgeons currently using an alcohol-based skin prep to champion the change in practice with their peers. Determine the high-volume surgeons and focus your efforts on working with them. Conduct brief interviews with representative surgeons to identify any misconceptions or key barriers to using an alcohol-based skin prep.  Provide a brief summary of the scientific evidence supporting change to an alcohol-containing skin prep to influence change of habit/tradition.

Use an alcohol-containing antiseptic agent for preoperative skin preparation Design strategies to accelerate change: Tools and materials: Provide a brief summary of the scientific evidence supporting change to an alcohol-containing skin prep to influence change of habit/tradition. Develop a skill guide or quick reference outlining the importance of key practices related to use of alcohol-based skin preps, based on the CMS guidance on the Use of Alcohol-based Skin Preparations in Anesthetizing Locations (see excerpt in How-to-guide).

Changes in Practice Ensure the alcohol-based skin prep is applied correctly: Skin prep should be completely dry prior to draping. Cleanse the incision area for 30 seconds and then paint the rest of the extremity. Consider use of a tinted CHG-alcohol prep (orange or teal) for greater visibility. Avoid pooling of the skin prep. Incorporate alcohol-based skin prep into the individual surgeons’ preference cards as agreement is reached regarding use of alcohol-based skin prep

Next Steps New Process: Find a champion Test available long acting antiseptic containing alcohol agents to assess acceptability and surgeon buy-in –considerations include: “drippiness,” packaging, drying time, manufacturer instructions and warnings, etc

Ask patients to bathe or shower with chlorehexidine gluconate (CHG) for at least 3 days prior to surgery Behavioral Objective: Provide patients with chlorhexidine soap, and have them use the soap in bathing or showering for at least three days before surgery. Assess your current process and potential barriers: Assess where most preoperative assessments take place Assess current preoperative communication between the hospital OR department and the offices of orthropaedic surgeons inside and outside the hospital. Tailor the implementation process to your setting Develop a process flow diagram to define all components of the process

Key Concepts to Consider Patients must understand why CHG bathing is important Patients need to understand How to do CHG bathing Access to CHG for pre-op bathing How will we know if CHG baths were completed?

Lessons Learned Pre-Op class Weekly, same time, same place Discuss processes Multidisciplinary Education materials (Screening for MSSA and MRSA) Education Material What product to use, provide if possible How to use CHG Measure: How many patients completed the 3 baths prior to surgery How many patients completed the 3 baths prior to surgery Checklists Admit process/holding area

Resources – www.ihi.org/projectjoints

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

Exemplar Hospitals

Surgery Data Tracker

Questions?

Questions? IHI.org - projectjoints@Ihi.org Kathy Duncan kduncan@ihi.org