Transcript November Node Call Agenda - Texas Center for Quality

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)
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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
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 longacting 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 PreOperative 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 :
1) Povidone-iodine scrub→alcohol→povidone
iodine paint (“triple prep”)
2) 2% chlorhexidine plus 70% isopropyl
alcohol
3) 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
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•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
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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
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Implementing use of an alcoholcontaining 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
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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
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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
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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
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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
Questions?
Questions?
IHI.org [email protected]
Kathy Duncan
[email protected]
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