Transcript November Node Call Agenda - Texas Center for Quality

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
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)
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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)
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Initial States Participation
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Project JOINTS Team
Kathy Duncan, RN
Project Director
Deborah Yokoe, MD
Content Expert
Kate O’Rourke
Network Manager
Brian Hamlin, MD
Surgeon Expert
Anila Hussaini
Project Manager
Tony DiGioia, MD
Surgeon Expert
Aka Kovacikova
Project Coordinator
Richard Scoville, PhD
Improvement Advisor
David Kim
Project Coordinator
Support & Contributions
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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
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
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
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
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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
Author,
Year
Kim,
2010
Price,
2008
Wilcox,
2003
Rao,
2008
Kalmeijer,
2002
Study
Design
Observational
Observational
Decolonized
Population
Only S. aureus
colonized
Only S. aureus
colonized
Decolonizing
Agent
Mupirocin and
CHG
Mupirocin
Observational
All Patients
Observational
Only S. aureus
colonized
Mupirocin and
Triclosan
Mupirocin and
CHG
RCT
All Patients
Mupirocin
This and next slide provided by Schweizer M,
Perencevich E, Herwaldt L, Carson J, Kroeger J,
Ward M
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 alcoholcontaining 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
.
Screen patients and Decolonize SA carriers w/5
days intranasal mupirocin & 3 days CHG
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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
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
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Key Concepts to Consider
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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)
Lessons Learned
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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
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(Sparrow Hospital, Lansing, Michigan, USA)
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(Exempla Lutheran Medical Center, Wheat Ridge, Colorado, USA)
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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
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Surgery Data Tracker
IHI.org - [email protected]
Kathy Duncan
[email protected]
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Questions?