Project JOINTS: J oining O rganizations IN T ackling S SIs

1. Project JOINTS: Joining Organizations IN Tackling SSIs Use of an alcohol-containing antiseptic agent for pre-op skin prep

2. 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 practicesto prevent surgical site infection for hip and knee arthroplasty as well as the two applicable Surgical Care Improvement Project (SCIP) practices.

3. 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

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

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

6. 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

7. . 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.

8. . Use an alcohol-containing antiseptic agent for preoperative skin preparation 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: • Chlorhexidine plus alcohol • Iodophor plus alcohol

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

10. Use an alcohol-containing antiseptic agent for preoperative skin preparation • Change the operating room skin prep for hip and knee arthroplasty to a long-acting antiseptic agent in combination with alcohol. Key considerations in changing to (or expanding) use of an alcohol-containing antiseptic agent: • 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. • Interview representative surgeons to identify misconceptions or key barriers to using an alcohol-based skin prep.

11. Use an alcohol-containing antiseptic agent for preoperative skin preparation Strategies for ensuring reliable use of an alcohol-containing antiseptic agent: • Conduct pilot testing of available agents to assess acceptability and surgeon buy-in, considering: drippiness, packaging, drying time, visibility, etc. • Ensure recommended alcohol-based skin prep is stocked in all surgical theaters for hip and knee arthroplasty cases. • Ensure the alcohol-based skin prep is applied correctly, following manufacturer’s instructions.

12. Assessing Progress Over Time –Recommended Process Measure Percentage of patients undergoing hip or knee replacement surgery with skin antisepsis at the surgical site using an alcohol-containing preoperative skin antisepsis agent.

13. FAQs – Alcohol-based skin prep Which is more effective – a CHG-alcohol product or an iodine-based alcohol product? There is currently no specific evidence that CHG-alcohol or iodophor-alcohol is more effective. Are there concerns about sensitivity reactions to alcohol-based skin prep? It’s important to ensure manufacturers’ instructions for use understood and followed to minimize the likelihood of reactions. Reports of sensitivity issues are rare and most often related to inappropriate application and/or drying time.

14. FAQs – Alcohol-based skin prep Some of our surgeon’s have reported that surgical drapes don’t stick well after using alcohol-based skin preps. How can this be addressed? This concern is addressed in the CMS “Use of Alcohol-based Skin Preparations”: “It’s important to make sure that the alcohol-based skin prep solution is completely dry prior to draping. This may take a few minutes or more, depending on the amount and location of the solution. The prepped area should be inspected to confirm it is dry prior to draping”

15. FAQs – Alcohol-based skin prep Are there safety/fire concerns with using alcohol in the surgical suite?The Centers for Medicare & Medicaid Services (CMS) addresses risk reduction techniques to permit safe use of alcohol-based skin preparations in inpatient or outpatient anesthetizing locations in their “Use of Alcohol-based Skin Preparations in Anesthetizing Locations”. http://www.cms.hhs.gov/SurveyCertificationGenInfo/downloads/SCLetter07-11.pdf

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