NYSPFP Project JOINTS: Pre-Operative Management to Prevent Surgical Site Infections after Orthopedic Surgery

Transcription

1 NYSPFP Project JOINTS: Pre-Operative Management to Prevent Surgical Site Infections after Orthopedic Surgery Good morning everybody and welcome to this special event of our New York State Partnership for Patients Surgical Site Infection Initiative. One of the things that many of you may know is that IHI has run a Project JOINTS Initiative for about four years, and New York State had the wonderful opportunity of being in cohort one of this program and the trial work that was being done a couple years back. And so as part of that, IHI offered to provide a free education to everyone as part of the, you know, sort of ending period that they re going through now. And so we did want to take advantage of that, because it s apropos, obviously, for our orthopedic surgical site infection program, and it also is very helpful in terms of giving you other hints and other strategies in terms of the free admission process. Interestingly enough, New York State has ended up with the most mentor hospitals in the IHI Project JOINTS program. And so today we have Lisa McDonald from Canton-Potsdam. Not only is she a New York State hospital but she s been taken across the country nationally to talk about the work done by IHI, so we re very proud of everything. I want to start by introducing Aka Kovacikova. I m going to kill the name here, and I apologize because, actually, my in-laws are all Czechoslovakian. I should be able to pronounce this. But Aka is acting as the IHI project director for the program, and she s going to sort of MC everybody today. So without further ado, I m going to turn it over to Aka. Thank you. Thank you so much, and good morning to you all. My name is Aka Kovacikova, and I m a project coordinator at IHI and have had the pleasure of being with Project JOINTS since the beginning. I have the honor of being joined today by Lisa McDonald, an orthopedic nurse first assist at Canton-Potsdam Hospital, and Debbie Yokoe, a physician and epidemiologist at Brigham and Women s Hospital, both of who will be able to give you their perspective and their lessons learned in implementing Project JOINTS in the field. The Project JOINTS team is so pleased to have this opportunity to speak with you and we look forward to not only sharing our best tips and trips but also about learning your experience in implementing these changes. So without further delay I m going to hand the ball off to Debbie Yokoe who will be able to speak with you about the literature and support behind Project JOINTS, as well as speak to the top ten lessons while working with these hospitals. Debbie. Thank you, Aka. So my name is Debbie Yokoe. I am an infectious diseases physician, and I m the hospital epidemiologist and medical director of infection control at Brigham and Women s Hospital in Boston. And I m very excited to be here with Lisa McDonald and with all of you this morning to talk about Project JOINTS. So, as many of you know, Project JOINTS is a research study that was sponsored by the agency for Health Care Research and Quality, and this project has three major goals. The first is to offer support to 1

2 participating health-care facilities around implementation of recommended interventions that are aimed at reducing the risk of surgical site infections following hip and knee arthroplasty procedures. Secondly, our second goal is to build a network of health-care facilities and hospital associations that can work together towards preventing surgical site infection, so literally joining organization in tackling SSIs, and, hence, the name of the project, Project JOINTS; and lastly, to test IHI s ability to spread evidencebased practices. So for Project JOINTS, in addition to basic SSI prevention practices that I m sure that all of you are familiar with that are part of the Surgical Care Improvement Project, or SCIP measures, such as appropriate use of perioperative antimicrobial prophylaxis and appropriate hair removal at the operative site. For Project JOINTS we also chose to focus on three additional new SSI prevention practices, and we chose these practices because these are practices that are not yet considered quite standard of care, where there s still a lot variability at the hospital, but where there is accumulating evidence that these are practices that can help to prevent SSIs, particularly after hip and knee arthroplasty procedures: And these three new practices are using an alcohol containing antiseptic agent for preoperative skin prep, encouraging patients to bathe or shower with chlorhexidine gluconate prior to surgery, and screening patients for staph aureus carriage and then decolonizing staph aureus carriers with nasal Mupirocin and chlorhexidine bathing prior to surgery. So we chose to focus on hip and knee arthroplasty because these are very, very common procedures. So over a million hip and knee arthroplasty procedures are performed in each year in the U.S. And all those these procedures are associated with a relatively low surgical site infection risk relative to many other types of other surgical procedures, because so many of these procedures are performed each year, this still translates into many SSIs that occur each year in the U.S., somewhere between 6,000 and 20,000 SSIs that occur annually. And these are infections that have significant long-term sequelae, so clearly financial sequelae. These are very expensive infections, so just looking at hospital costs alone, a hip prosthesis infection following hip arthroplasty is associated with hospital costs in the neighborhood of $100,000 to $150,000 per infection episode, so very expensive. And, of course, the most important reason to focus on preventing these infections is that these infections have substantial impact on our patients. So just, again, using that example of a hip prosthesis infection after hip arthroplasty, what typically happens is that that patient will need to be readmitted to the hospital, go back to the operating room, have that hip prosthesis removed, have a placer placed temporarily, and, during that time period, will have limited mobility, have to undergo a very long course of antibiotics, usually intravenous antibiotics; meaning, at least six weeks. And then if everything goes absolutely smoothly and that infection is cured, then the patient still needs to come back to the hospital, go back to the operating room, have a new hip prosthesis placed, and if things don t go absolutely smoothly, if that infection is difficult to control, then that often means very extended courses of antibiotics, multiple hospitalizations, multiple procedures, and sometimes very devastating 2

3 consequences for our patients. So, clearly, anything that we can do to prevent these infections will substantially benefit our patients. July 9, 2013 So I m going to just quickly review some of the evidence to support our three Project JOINTS SSI prevention strategies, starting with using an alcohol containing antiseptic agent for preoperative skin prep. So as all of you know, pre-op skin prep is a basic practice for preventing surgical site infections, with a goal of decreasing microbial flora at the operative site and decreasing the risk that those microorganisms will make their way into the incision and cause a surgical site infection. And traditionally we have used an antiseptic agent with long-acting antimicrobial activity for preoperative skin prep such iodophor like Povidone iodine or chlorhexidine. So the question here is does adding alcohol, which has a quick kill effect, to a long acting agent, enhance the ability of the skin prep agent to prevent surgical site infection? And there s not a lot of great data on this topic. This is [inaudible] Medical Review that was published in 2009 on this topic, summarizing studies that looked at a variety of different skin prep regimens, and this systematic review concluded that there is insufficient evidence to support recommending the use of one antiseptic agent over another. But since that systematic review there have been a couple of studies that I think provide us with very useful information to guide us on this topic. So the first is a study by Swenson, et al. This was a study that compared three skin prep protocols. So this was a study performed at a single hospital. It was a sequential implementation study involving general surgery patients, where they compared three skin protocols. So during the first six months of the study they used a skin prep protocol that consisted of Povidone iodine, followed by alcohol, followed by Povidone iodine paint, which they called their triple-prep regimen. And then during the second six months of the study they used chlorhexidine plus alcohol, and then the last six months of the study they used iodine povacrylex plus alcohol. And what they found was that SSI rates during the two time periods where they used an iodophor were lower than the SSI rates for the period where they used chlorhexidine. So a couple of things that I think are important to point out about this study. The first is that during all three phases of the study, they used a regimen that included alcohol plus a long-acting agent. And the second is that this study does have some major limitations. It was an observational study so there was no control group for comparison, which makes it hard to tease out the impact of the skin prep protocol from other risk factors that may have varied during the course of the study, and, in fact, they talked about some changes in the patient population that may have impacted SSI risk during the study. And then there is this study that was published in the New England Journal of Medicine in early 2010, by Darouiche, et al, a comparison of chlorhexidine plus alcohol versus Povidone iodine, so this is a welldesigned randomized multicenter study of patients undergoing clean contaminated surgery, so mostly GI surgery procedures where, again, they compared Povidone iodine alone to chlorhexidine plus alcohol. And in this study they found that patients who were randomized to the chlorhexidine plus alcohol group had significantly lower risk for developing surgical site infections than patients who were randomized to 3

4 the Povidone iodine group. And so they concluded that chlorhexidine plus alcohol is better than Povidone iodine alone for preventing SSIs. So the caveat here is that they compared Povidone iodine alone to chlorhexidine plus alcohol, so we don t know whether the benefit was due to chlorhexidine or the combination of chlorhexidine plus alcohol, and we don t know how this would compare to an iodophor plus alcohol combination. So where do these studies leave us? So on this slide I ve summarized the results from the two studies, the Swenson and the Darouiche studies, and I think the bottom line here is that the risk for surgical site infections is significantly higher if you use Povidone iodine alone versus a combination of a long-acting agent plus alcohol, whether that long-acting agent is an iodophor or chlorhexidine. And so this is the data that formed the basis of our recommendation to use a skin prep agent that is a combination of a longacting agent plus alcohol. The second Project JOINTS recommendation is to ask patients to bathe or shower with chlorhexidine at least three times before surgery. And I ll say here that this is a recommendation with the weakest evidence base, but I will go over our rationale for including it. So we think about using chlorhexidine bathing or shower to prevent SSIs because we know that topical chlorhexidine is very effective of reducing bacterial counts on skin, and we know that chlorhexidine has a residual and a microbial effect, meaning that it s able to keep those bacterial counts low for some number of hours after application of chlorhexidine. Chlorhexidine is also attractive because we know that it has a potential to impact a broad range of pathogens, so not just one organism like staph aureus, but other gram positives, gram negatives, and even potentially yeasts such as Candida. We also know that chlorhexidine is well tolerated, so chlorhexidine has been used for various health-care applications in health care for over 50 years now, so we know that there is a low risk of skin reactions associated with use of topical chlorhexidine. And we recommend using chlorhexidine for at least three times, because we know that there is progressive reduction in bacterial counts on skin when chlorhexidine is used repeatedly up to three times preoperatively. This is data from one of those studies. So in this study they had volunteers shower using chlorhexidine soap on a daily basis and measured bacterial counts on their skin over time. So if you look at the graph on the Y axis we re looking at bacterial counts on skin, and on the X axis is time, so you can see that you start out with a relatively high bacterial count, then after that first chlorhexidine shower you can see that the counts drop way down. But then by six hours after that first shower you can see that the counts start to creep back up again. And then on day number two you start at a lower level, and then after the chlorhexidine shower the counts drop down again and remain at that lower level, out to six hours after that second shower. And then by day number five you re sort of at a lower level, drop way down and remain at that lower level. And so what the investigators describe in the study is that the effectiveness of chlorhexidine washes depends mainly on chlorhexidine s residual antimicrobial effect, which becomes increasingly more 4

5 effective the more consecutive days that chlorhexidine is used, and then they postulate that at least three consecutive washes are needed to keep skin flora lower than baseline through a 24-hour period, which is what we may need to achieve in order to see a significant reduction in surgical site infection risk. So then why is this recommendation still controversial? So there was a Cochran systematic review on this topic, published in 2011, that concluded that there s no clear evidence based on randomized control trials that preoperative bathing with chlorhexidine reduces the incidents of surgical site infections. So why is there this disconnect between knowing that chlorhexidine is effective in reducing bacteria counts on skin and the lack of evidence that links the use of chlorhexidine to reduced SSI risk? And I think there are several reasons for this disconnect. So most of the studies that were included in this Cochran systematic review had major limitations. That used different SSI definitions and relatively short follow-up time periods. There was no monitoring of compliance with chlorhexidine use, so we don t actually know whether the participants were using the chlorhexidine, and, importantly, most of these studies only used one or two applications of chlorhexidine soap. And what we learned from those previous studies was that what we may need is repeated applications of chlorhexidine, so chlorhexidine at least three times prior to surgery in order to achieve those residual and microbial effects that are needed in order to impact SSI risk. So, again, controversial, but we felt that there was compelling enough evidence to include this as one of the Project JOINTS recommendations. The very good question that always comes up around this recommendation is should we be using the soap? Can we be using the chlorhexidine impregnated bathing cloth? And although there s very limited data on this topic, I think, at least theoretically, the chlorhexidine impregnated bathing cloths should be at least as good as the chlorhexidine soap because it s applied to skin and it s not rinsed off, and so you get higher levels of chlorhexidine on skin. So, you know, it can be particularly useful for situations where patients don t have access to running water for example. But whether you choose to use the chlorhexidine impregnated bathing cloths or the chlorhexidine soap, I think what we ve learned is that the most important thing is to make sure that you provide your patients with very clear instructions about how to use the chlorhexidine product. And then finally, our recommendation to screen patients for staph aureus carriage and then to decolonize staph aureus carriers with five days of nasal Mupirocin, and at least three days of chlorhexidine soap prior to surgery. So we worry about staph aureus nasal carriage because we know that patients who are staph carriers have a higher risk for developing invasive staph aureus infections, including surgical site infections. We also know that most cases of invasive staph aureus infection are due to strains of staph aureus that patients are already colonized with. So it makes sense to consider ways to eradicate staph aureus nasal carriage. So does Mupirocin actually eradicate staph aureus nasal carriage? This is a systematic review that was published in 2009 on this topic, comparing studies that compared Mupirocin to placebo, and they concluded that short-term nasal Mupirocin; meaning, using nasal Mupirocin twice a day for between four to seven days, is an effective method for staph aureus eradication, with a very high success rate, at least 5

6 temporarily. So Mupirocin does appear to be effective in eradicating staph aureus nasal carriage. But of course the most important question is does it actually prevent surgical site infections? So this is a meta analysis that was published in 2005 that concluded that Mupirocin use was associated with a small reduction in SSI rates for non-general surgery procedures, specifically cardiothoracic, orthopedic, and neurosurgery procedures, but, interestingly, not for general surgery procedures. And then this systematic review that was published a few years later concluded that Mupirocin use was not associated with a significant reduction in staph aureus SSIs among all patients, but it was associated with a significant reduction in staff aureus postoperative infection rates among the substantive patients who were known to be staph aureus carriers, reducing their risk for infection by about 45%. And then this study was published in the same issue of the New England Journal of Medicine, that s the Darouiche study that I described previously. This is a study by Bodie, et al, a randomized, double-blinded, placebo-controlled multicenter study of mainly surgical patients in the Netherlands, and in the study they screened patients on admission to the hospital, looking for either Methoxazole insensitive or Methoxazole resistant staph aureus, and then they randomized staph aureus carriers to receive either five days of Mupirocin plus chlorhexidine soap, or five days of placebo plus bland society. And what they found was that patients who were randomized to the chlorhexidine bathing plus Mupirocin group had significantly lower SSI rates than the placebo group, and so they concluded that preoperative identification of staph aureus carriers followed by decolonization of carriers with five days of nasal Mupirocin plus chlorhexidine bathing reduced staph aureus SSIs by about 60%. And there have been some additional studies that have looked at the impact of staph aureus decolonization specifically for orthopedic surgery procedures. So most of these are observational studies. Some of these targeted patients who are known to be staph aureus carriers. Some of them targeted all patients undergoing orthopedic surgery. And overall what these studies show is that there is a significant protective effective of staph aureus decolonization, protective against development of staph aureus surgical site infections for patients undergoing orthopedic surgery procedures. So it s pretty compelling evidence that staph aureus decolonization can reduce the risk of surgical site infections for orthopedic surgery patients. So the very, very good question that always comes up in these discussions is then why not just use preoperative Mupirocin for all patients undergoing these procedures? Why go through the trouble of screening patients, looking for staph aureus carriage, and then just decolonizing those staph aureus carriers? And I ll say that the jury is not yet out on this issue. I think we re still learning a lot about the epidemiology of Mupirocin and Mupirocin resistance. But the major worry is that widespread use of Mupirocin may increase the risk for development of Mupirocin resistance among staph aureus isolates. And so until we have a better understand of the epidemiology of Mupirocin resistance, for Project JOINTS, we chose to recommend that patients undergo screening and then looking for staph aureus carriage, and then targeting those patients who will positive for decolonization. Since this is a subset of patients most likely to benefit from decolonization, and because by targeting the smaller group of patients, we re hoping to reduce the risk of promoting Mupirocin resistance. 6

7 I included this slide jus as an example from my hospital, Brigham and Women s Hospital, where, over a course of several months, we put together this staph aureus screening workflow. So I just wanted to bring up a couple of, I think, useful points. The first thing, we found it was critically important to identify an orthopedic surgeon champion. Without that champion it would have been hard to pull this group together and implement the process. So we started by identifying a surgeon champion and then got him excited about the project. We pulled together a multidisciplinary group that included some of the surgeon office staff, the presurgery testing center staff, microbiology lab staff, perioperative nursing, and infection control, and worked together to create a workflow that we thought made since and would be sustainable. And then we started out by testing out this process with the patients from our one orthopedic surgery champion and then learning from that pilot and then eventually expanding to all of our orthopedic surgery patients. So this is a segue to just a brief discussion about some of the lessons we ve learned from hospitals that have participated in Project JOINTS. So as I mentioned before, one of the major goals of Project JOINTS was to create a network of health-care facilities that could work together to prevent SSIs, and it was really amazing to watch the outpouring of questions and sharing of information, sharing of resources between participating hospitals. And many of those products are available on the IHI website. So I m just going to briefly go over some of, I think, the common lessons that we learned from the experience of those participating hospitals. So a picture is worth a thousand words. We found it was really powerful to give patients and their family members concrete products, concrete information that they could hold in their hand; so frequently asked questions and answers, some hospitals provided checklists, where they would have a grid with the actual dates leading up to the surgical procedure and what the patient should do on each of those days; you know, very specific instructions about how to perform the chlorhexidine bathing, so very concrete information that they could take home and read at their leisure. Knowledge is power. You know, providing, again, very concrete education about why these practices are important for preventing SSIs, how to actually do the bathing, what to do if the staph aureus screening results are positive. So this kind of information, this kind of education is really motivating. Identifying the positive patient, so what we found was that many hospitals were already screening patients for MRSA, but many hospitals were not screening for Methoxazole insensitive staph aureus. And what we know is that many more patients are going to be colonized with Methoxazole insensitive staph aureus than MRSA. And we know that MSSA infections can be just as devastating as MRSA infections, so important, if you re going to be doing the staph aureus screening, to include MSSA screening. Some hospitals use the results of that screening to help to guide their perioperative antimicrobial prophylaxis. Build on what you know. So what hospitals found was that it was very useful to build on preexisting processes. So for example if you also already have a process in place for MRSA screening the MSSA screening can relatively easily be added onto that process. If you already have a system in place for getting urine specimens from patients during their preoperative checks and then providing antibiotic prescriptions for the appropriate patients, build on that process for your staph aureus screening as a way to provide Mupirocin prescriptions if needed. Identify current educational resources that are well received, so, again, build on what you already have. 7

8 Connect to a story. So it can be incredibly motivating to link these prevention activities to actual patient stories. So if you look at the IHI website you ll find a video of an actual patient, Rosie Bartell. So she tells her story of developing a surgical site infection following total knee replacement, and in an incredibly articulate and moving way. And, again, it can be really motivating and can really help to get your staff excited about SSI prevention activities by linking these activities to actual patients and to improving the care of their patients. There are other examples. There was a very nice Wall Street Journal article that was published. I think the link is on the IHI website. Just last week there was a very nice news clip from Tennessee about Project JOINTS and the benefits for patients. So, again, connect these prevention activities to actual patient stories. Preoperative class time is magical, so what many hospitals found was that they were able to make use of preexisting preoperative classes, so patients and their families could go to these classes to learn about what to expect during their hip or knee replacement surgery, and they were able to add on to these preoperative classes education about the Project JOINTS recommendations. Some of these hospitals were even able to add on the staph aureus screening to the preoperative class time. Remember that your staff need education too, so remember to provide your staff with in services or educational materials about the Project JOINTS practices, including chlorhexidine bathing tips, how to apply the preoperative skin prep, frequently asked questions from patients, and some answers that they could provide if asked these questions, and create a system that s flexible enough to accommodate new staff as they come on. And then finally, testing is fun, so important to start out small, so attend one patient class, follow one patient through the whole process so you understand the steps, identify one surgeon champion, and then test out the process with that surgeon s patient during one specific week to identify the potential issues and obstacles, and learn from those to revise a process, and then expand out. Map out the process, so make a flow map so that you know what all the steps are and then test improvements on one step at a time, so start small and then expand. So as I mentioned, there s a lot of information available on the Project JOINTS website. This is the URL. So it includes those videos, a very nice video from an orthopedic surgeon, a lot of materials. There s a How-To Guide. There are many sample frequently asked questions and screening forms and instructions that have been provided by the participating health-care facilities. So feel free to take a look at the IHI website. So now I m going to turn the discussion over to Lisa McDonald. Thank you and good morning to all of the New York State Hospitals participating this morning. I m so happy to be here with you this morning and share our experience with Project JOINTS. We were involved with the first cohort, so that was early So we ve been at this now for over two years, almost twoand-a-half years, and it s been a very successful program for our hospital and our patients. 8

9 From my bio, you know that I m an operating room nurse, so not a normal role for an operating room nurse, but our hospital is a small rural hospital, and living in this town, I have a lot of outside contacts with my patients, and I get to hear all of their experiences, whether they re good experiences or bad experiences. And I had a desire to make a difference and hear more good experiences. So I think at a small rural hospital, even though our numbers are smaller, there are less loops to jump through to get a lot of this started. I know that I didn t have a lot of specifics when I started. There were a lot of decisions to make. I know you ll be able to print this PowerPoint so I have included a lot of our forms for education and for tracking. And we ve learned a lot along the way. We ve revised a lot. Hopefully you ll be able to learn something from our experience. I ll try to include questions from being part of IHI s list serve of participating hospitals, and at the end I have some of our results that I d like to share with you. Lisa, just click on the presentation with your mouse first. Okay. And then you can use your arrow key. Perfect. So where do you start when you re beginning this project? We had to look at what measures did we already have in place. We had already began some initiatives. We had standardized our OR prep to ChloraPrep, but whether you use a chlorhexidine or an iodine-based prep with the alcohol, they both have different instructions. The DuraPrep, which is the iodine and alcohol, is just painted on, versus the ChloraPrep has to have a gentle 30-second friction scrub at the incision site and then extending to the periphery. So it s important that the nurses that are performing that prep have the proper information so that they re performing it correctly. We had also started using Sage wipes for skin decolonization. We were just doing one set the night before surgery and one set the morning of surgery. We had not started any form of MRSA testing on these patients for MRSA or MSSA. So that was really the biggest piece that we needed to figure out how to implement. And where was that testing going to take place? At the time that we began Project JOINTS, most of our total joint patients were receiving a phone call from the pre-op nurse. Most were not coming from an inperson interview with either the pre-op nurse of anesthesia, so we had to figure out how was the process going to happen. My initial thought was that the patients could get swabbed in the doctor s offices. Bt with outlying offices and the logistics of getting the specimens back to the lab, we eventually came to the conclusion that it would be better if we could get all of our patients to come for an in-person interview with the pre-op nurse and anesthesia, get their labs drawn at the same time, and try to coordinate this at a two-week outpoint from their day of surgery so that they could also attend the pre-op total joint class on the same day. So that is what wound up happening. 9

10 We did find that we needed to increase our pre-op nursing staff in order to accommodate this, as patients need a lot of education as to why we re doing this, how to do it correctly. So education of the pre-op nurses is integral to all of this. The other thing that we were doing was we were giving the appropriate antibiotic at the right time. We did wind up changing our protocol as far as the antibiotics a little bit once we started Project JOINTS, and I ll get to that in a later slide. But I can t stress enough that this is a group project. All of those areas of the hospital are involved in this and need continuing education. The infection prevention specialist actually does a lot of continuing education with our staff floor nurses. Because of new staff, there are still constantly questions. If I had to pick the one thing, there are still constantly questions are on MSSA and MRSA. What s the difference, who gets what antibiotic, even from anesthesia still questions, and who gets contact precautions, just continual questions as to staff aureus? So we constantly try to update everyone on that. There s a lot of decisions that are involved when starting this and a lot that you have to work through. But I would say the most important thing, as you ve heard already, is to pick a surgeon champion. The surgeon -- having one person to go to with all of the questions, IHI gives recommended guidelines but the specifics of what are going to be your protocol at your hospital and your orders are decided by the individual facility. So I d say what I tried to do was to use what I have with one of my surgeons who was the most unwilling to change, and we had a joint space infection a few months before starting Project JOINTS. So because we re a small hospital, our numbers are -- we probably do 150 total joints a year, so our numbers are not large, but the theme for Project JOINTS is One is not zero. So we were trying to prevent one infection. And I spoke to that joint space infection as a way to bring this project onboard. I also think we tried to develop a standardized protocol for pre-op, intra-op, and post-op for all of our surgeons so everybody was on the same page. It s been my experience that if you can lessen the degree of variation you have less errors, and it s easier to get everybody onboard doing the same thing if there is one set of orders versus a different set of orders for each surgeon. So this is our team, and there s our logo there, the Project JOINTS logo, One is not zero. We do not have a joint program coordinator or a navigator. I d say I ve coordinated this program, and most of the questions come back to me from the pre-op nurses to the office, and then I ve worked very closely with our infection prevention specialist. That s not my background to gain a greater understanding of this. All of our docs are very different and from different backgrounds, one s Canadian, one s from Georgia, and one was trained in New York City. But we were able to get them all on the same set of orders with this. So what exactly should your protocol be? What is our protocol? We re going to test all of our patients within 30 days of surgery for MRSA and MSSA. How are we going to test them? We decided to go with a routine culture insensitivity, which takes two to three days to get results. Our facility, we have the capability of doing a rapid screen or [inaudible] screen for MRSA. We don t have the module to do a rapid screen for MSSA, so that s not an option for us. 10

11 Also, as far as looking at costs, the cost for routine culture insensitive, the patient charge is $49. The charge for rapid screen MRSA only is $160 at our facility. Then we re going decolonize MRSA and MSSA patients with five days of Mupirocin and three days of -- we chose to do go with, at this stage, chlorhexidine cloth. We re now looking at also expanding that option so that patients have a choice between taking showers or using the cloth. The cloth has been good for us because we are located at the northern edge of the Adirondack Park in one of the forest counties in New York State, and some of our patients don t have access to running water, and the cloths are a great option for patients to still be compliant with pre-op instructions, even if they can t shower. But we ve also, with the cloths, patients are using them the night before their surgery and then they re not taking a shower the morning of surgery. They re coming into the hospital and they re doing another set of the cloth. Some of our patients, I believe, and I know if I was a patient I would want to take a shower the morning of surgery, so I think in order to increase patient compliance with the pre-op process, it is important to offer choices, and we re going to be adding a CHG kit, which has the soap and three sponges are included with that. It s called a Start clean kit. I m sure other companies make it, but we re going to start to offer that as an option to our patients also. Then the antibiotics, what are you going to use for MRSA? Are you going to use Vancomycin? Is it going to be one gram or is it going to be weight based. We decided to go with 15 milligrams per kilo for the Vancomycin. Are you giving going to give Vancomycin alone or Vancomycin plus Ancef? The Vancomycin and Ancef is what we chose to go with. And then for MSSA we re going to decolonize them, and they re going to have Ancef as their preoperative antibiotic. I think with the SCIP measures moat places were clipping rather than shaving hair at the surgical site. I think it s also important to not have patients shave preoperatively. Once they start -- what our pre-op nurses tell them is once they start prep wipes they re done shaving. And then the last thing is preparing the surgical site with an antiseptic that contains CHG and alcohol. So I included a lot of our order sheets. This first one, we started out with a pre-op order sheet that has everyone on one and decided it was too confusing and switched to three different standardized orders; that the pre-op nurses start this order sheet, and it continues to day of surgery with their antibiotic, so there are no questions. This is the one for MRSA, so it has the decolonization orders, and then it has both antibiotics ordered on there. And then this is the one for our Methoxazole insensitive staph aureus so it has the decolonization and just the Cephalosporin, unless patients are allergic. This has also been an area that has been questioned by our pre-op nurses. When are we giving Vancomycin? Are we giving Vancomycin if patients have a rash with penicillin, or is it an anaphylactic reaction to penicillin that is going to have us give Vancomycin or an allergy to Cephalosporin, so we tried to clarify that with our wording, you know, that we re only going to be using Vancomycin if they have an allergy to Cephalosporins or anaphylactics to penicillin. Now if they have a mild rash from penicillin we can still give Ancef. And then we also tried to address re-dosing of the antibiotics. If we have greater than a thousand CCs of blood loss or surgery goes longer than three-and-a-half hours, we are re-dosing our Ancef. Then this last 11

12 order sheet is for a negative screen, and just kind of helped us here to separate them just to lessen the questions that we had on the day of surgery. So, again I talked to some of this already. The logistics of really rolling this out, where are you going to have the screening done, because the screening, I think, was the most difficult part for a lot of the hospitals that were participating. Is the lab ready to do this testing? I know our lab, when we started, said we don t even have a mnemonic to do those tests, so we had to work through that whole process. Are the doctors offices -- we decided that a two-week lead time was really what we needed in order to get all of this done. Two weeks allows for the patient to come in, have their swab done, have the results, get the results back in two to three days, and then somehow the patient has got to get the Mupirocin and the CHG to decolonize. Our hospital, we decided that this was a low-cost infection prevention measure for us, so we are providing the Bactroban and the sage wipes for patients. I know other facilities are writing a script for those for the patients to pick them up at their pharmacy. We ll do that if it s for patients that live quite a distance from the hospital that don t want to come back in and do that, we will write a script to their pharmacy and do it that way. And then will you have standard orders for your whole group of surgeons or are your orders going to be different? Choices of [inaudible] showers or prep cloths, ChloraPrep, DuraPrep, and then how are we going to track our compliance and record the results? So what did we need? What did I need for my nursing director to get all of this done? I needed time and I needed support. I needed time out of the operating room because this is going to take away from time that you spend doing your regular job. It really does, at least in the beginning, need a lot of time to set up. And then this is what our lab is doing with the specimen, is the lab ready to do the tests, and how are we going to test for the procedure? So we were very successful with this. Our physicians really understand now that we do need the twoweek lead time in order to accommodate the testing. The pre-op nurses are very well informed of the instructions that they need to give the patient. They have a lot of patient education forms. Our patients actually, from the physician s office, get a packet, and in that packet it tells them about staph aureus and the testing that they re going to get, so it s not a surprise to them when they come into the preadmission testing; that they re going to have the nasal swab, because they ve already gotten some information about it. This is the form that our patients get from the doctor s office, and what is MRSA, what is staph, what happens if my test is positive. Our pre-op nurses found that patients, when they do test positive, this is something extra that you re adding to them, to the stress of before the surgery. They re not expected to test positive. So when they come back in to see the pre-op nurse and she explains to them how to use the Bactroban and how decolonize their skin, they re very concerned and they really need a lot of preoperative education that they don t have an infection, that they re not going to be able to spread it to their family. There are a lot of questions. 12

13 This is our patient education form for using the Sage prep wipes. If you use the wipes, the writing on the packages is very small, and our elderly patients had a hard time reading that. Even if it was explained to them, we still felt like they needed more information. So this is the form that we use with our wipes, and it kind of breaks down, it s got six cloths in the packages. It shows you the six areas and where you re supposed to be using those wipes. We did find, at the beginning, when we were just explaining it to people without giving written information that the wipes come in three packages and there s two wipes in each package; that they were just choosing one package with two and coming back to the hospital with the other two packages on the day of surgery. And then also really important to them to know that their skin is going to feel sticky until the wipes dry, until the CHG dries on their skin, and also to sleep in a clean pajamas and clean linen on their bed. And this form, we also use the CHG wipes for our inpatients that are coming to surgery, so this form kind of goes for both. It has the home use on it and also hospital use. This is a decolonization checklist that we use. The pre-op nurses actually write the date next to these lines with the green checkmarks so the patients know exactly what day to start what, what day to start their Bactroban and what days they re use the prep wipes, how to use the ointment. And they bring this checklist. We ask them to bring this checklist back with them on to the hospital on the day of surgery. Our infection control specialist, as I said earlier, has been really a key person, and this is ours providing education to the rest of the hospital, for staff nurses, on an ongoing basis. More checklists: These are checklists that are started by the pre-op nurses and continue through the surgery with the antibiotics, the prep, and the surgical start time. These are on the patient s chart, and they come back to me for logging of the cases for the log. And I just keep a log, which is a simple Excel spreadsheet. Probably, we are looking at right now, if Meditech can pull all of this data for the future, for a project. We re hoping to write a paper on this, and it would be nice if we didn t rely on our written log, if Meditech could pull all of this data. So in real time this worked pretty well. We did have some cases that fell out, patients that came from out of state, that if their testing, staph aureus testing was ordered from this doctor from out of state, we still got MRSA testing, or patients that were prisoners that it s hard coordinating with corrections to get all of this done. But for the most part, we have not had any patient that refused to be tested. Our surgeons ordered the protocol for all of their patients. The pre-op nurses, like I said, were so important in collecting the swabs, doing the swabbing consistently the same way, checking the results, and then, you know, getting the results back to the doctor s office. So here are some of our results. This was our screening just over -- we started, I think, April 2011; that s why our volume for 2011 was only 110, because that s when we started our screening. In 2011, we captured 19% with a nasal screen of MRSA and MSSA combined, and that was still a little lower. In 2012, we had 14.4%, which was really low. So did that impact our infection rate last year? Is that part of the reason our infection rate was lower, because we didn t have as high of a population that had this? Were we just lucky? We don t really know why our numbers were that low last year. This year our total MSSA and MRSA so far is 31%, and that is right along in the literature what they say we should be seeing about 30%, so one-third of patients, and so we are much higher this year. 13

14 So our joint infections then and now: So in 2007 our total joint infection rate was 4%. That s five total joint infections out of 123 that were done that year. I know these numbers are small, but it s still significant. Four out of five of the infections were staph aureus. In 2008, we had started using ChloraPrep and started using the Sage wipes. Our infection rate was 2.3% for total joint replacement. We did have one organ spaced MRSA infection. One joint space infection -- I like the phrase 25 years to gain your reputation and five minutes to lose it. In this small community hospital one organ space infection news travels fast, so these are infections that we really want to prevent. In 2009, another organ space staph aureus infection. Our infection rate overall was 2%. In 2010, now I m including bipolar or partial hip replacements in this slide, because our infection rates, as far as what s reportable to New York state for total joint replacements, also includes partial hip replacement. So bipolar hip replacements are done for a fracture. These are not patient that is go through the whole Project JOINTS protocol, but they are infection that is we have to claim and we have to report. So it has been my recommendation to our hospital infection control committee that we should expand our program to all of our hip fracture and hip and femur fracture patients. That s what I d like to see going forward. In 2011, which is when we started Project JOINTS, we had one infection, which was [inaudible]. We had no staph aureus infections. 2012, here we go again with another organ space staph aureus infection on a bipolar hip replacement. And then for 2013 we have had one superficial staph epi surgical site infection, and that patient was not compliant with using -- that was our first patient who was noncompliant with using the Sage wipes preoperatively. So we ve had no reportable staph aureus surgical site infections on elective total joint replacements to report since beginning Project JOINTS. We did have one late onset staph aureus infection this year that presented to our ER 11 months after the date of the surgery. After a non-event postoperative course she had a knee fusion that was aspirated in the ER, and that was a staph aureus infection, and she has had washout and liner replacement this year. Greater than two years with zero elective joint staph infections. And we do realize this is a great achievement but that we re not going to be able to prevent everyone s infection. Thank you so much, Lisa. We really appreciate your sharing the Canton-Potsdam experience. This is Wing Lee, one of the project managers from the New York State Partnership for Patients. I think I speak on behalf of everyone when I say thank you so much, Dr. Yokoe, for providing such a comprehensive overview of the evidence behind the Project JOINTS recommendations, and, Lisa, for sharing hour you ve actually gone about to implement those. I know we re at the hour; however, if you are able to stay onto ask a couple of questions of our wonderful faculty, Deborah and Lisa, please either raise your hand or type them into the Q&A and I can ask them on your behalf. But thank you again, Dr. Yokoe and Lisa, that was really, really wonderful. Joan, are you seeing any question ins if Q&A. 14

15 No, I m not seeing anything? Okay. Oh, wait, hold on. I just got one. Is there evidence to support patient use of antibacterial soap for two weeks prior to surgery; for example, Dial? So this is Debbie Yokoe, and it s good question. The chlorhexidine soap or the chlorhexidine impregnated wipes, those are the antimicrobial cleansing agents that we re recommending, mainly because those are the agents associated with the most published data. I know that some of the soaps like the Dial antimicrobial soap, they claim to be antimicrobial. They have a little bit of antimicrobial content, but probably less impact than something like chlorhexidine, like Hibiclens soap. So I wouldn t use it as a substitute. I m not seeing anything else, Wing. I m not seeing anything on my end either. So if you do have any questions, please feel free to either e- mail your project manager or Aka has just provided an . If you do have questions about anything that either Lisa or Dr. Yokoe presented, please feel free to ProjectJOINTS@IHI.org. And thank you again, Lisa and Dr. Yokoe. I think I speak on behalf on everyone on the webinar, it was really enlightened, and we re so delighted that you could join us today to share. Otherwise, thank you again, and have a great day everyone. Thank you. Thank you everyone. Bye. Bye. Bye. 15