Project JOINTS: Joining Organizations IN Tackling SSIs Screen patients for Staph aureus (SA) carriage and decolonize SA carriers with five days of intranasal mupirocin and at least three days of CHG soap prior to surgery

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

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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

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Project JOINTS Website 4

http://www.ihi.org/ProjectJOINTS/

Evidence suggests three new practices to prevent surgical site infections in

patients undergoing hip and knee arthroplasty.

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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

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What evidence supports Staph aureus screening and use of intranasal mupirocin and CHG bathing or showering to decolonize Staph aureus carriers?

Patients who carry Staph aureus in their nares or on their skin are more likely to develop Staph aureus SSIs. This is true for methicillin-resistant as well as methicillin-sensitive Staph aureus.

Kluytmans JA, Mouton JW, Ijzerman EP, Vandenbroucke-Grauls CM, Maat AW, Wagenvoort JH, et al. Nasal carriage of Staphylococcus aureus as a major risk factor for wound infections after cardiac surgery. J Infect Dis. 1995;171:216-9.

Huang SS, Platt R. Risk of methicillin Staphylococcus aureus infection after previous infection or colonization. Clinical Infectious Diseases. 2003;36(3):281-5.

Rao N, Cannella BA, Crossett LS, Yates AJ, McGough RL, Hamilton CW. Preoperative Screening/Decolonization for Staphylococcus aureus to Prevent Orthopedic Surgical Site Infection. J Arthroplasty 2011.

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What evidence supports Staph aureus screening and use of intranasal mupirocin and CHG bathing or showering to decolonize Staph aureus carriers?

Staph aureus carriers treated with five days of intranasal mupirocin and CHG washes before surgery have a 60% lower Staph aureus SSI rate than the placebo group.Bode LG, Voss A, Wertheim HF, et al. Preventing surgical-site infections in nasal carriers of Staphylococcus aureus. N Engl J Med. 2010;362(1):9-17.

Preoperative screening/decolonization was associated with fewer SSIs after elective TJARao N, Cannella BA, Crossett LS, Yates AJ, McGough RL, Hamilton CW. Preoperative Screening/Decolonization for Staphylococcus aureus to Prevent Orthopedic Surgical Site Infection. J Arthroplasty 2011.

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Does using mupirocin eradicate Staph aureus nasal carriage?

Short-term nasal mupirocin (4-7 days) is an effective method for Staph aureus eradication

90% success at one week 1% develop mupirocin resistance

Source: Systematic review (Ammerlaan HS, et al. CID 2009): 8 studies comparing mupirocin to placebo

Does using mupirocin prevent SSIs?

Mupirocin use was associated with a significant reduction in Staph aureus postoperative infection rates among Staph aureus carriers

Source: Systematic review (van Rijen JAC 2008): Included 4 randomized controlled studies

Implementing screening patients for Staph aureus carriage and decolonize carriers with 5 days of intranasal mupirocin and at least 3 days

of CHG prior to surgery

Strategies to Accelerate Change

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Screen patients for Staph aureus carriage and decolonize carriers with 5 days of intranasal mupirocin and at least 3 days of CHG prior to surgery

Screen all patients for Staph aureus (methicillin resistant and methicillin sensitive) prior to surgery, allowing enough time for those who screen positive to be decolonized with five days of intranasal mupirocin.

Key considerations to ensure reliable screening and decolonization:Assess when most preoperative assessments take place in your setting, to evaluate whether there is sufficient time to screen and decolonize carriers for 5 days prior to surgery. Assess preoperative communication between the hospital, OR department and the orthopaedic surgeons’ offices to ensure that information on patient screening for Staph aureus and decolonization is available at the time of surgery.

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Screen patients for Staph aureus carriage and decolonize carriers with 5 days of intranasal mupirocin and at least 3 days of CHG prior to surgery

Additional considerations in establishing a reliable screening and decolonization process

Develop a process flow diagram, specific to your hospital setting:

define all necessary components of the process for patient screening and decolonization prior to surgery

build a process into the pre-op assessment/visit for obtaining cultures and reliably reporting results to facilitate intranasal mupirocin, as needed

NOTE: An example process flow diagram for Staph aureus screening & decolonization is available in the Project JOINTS How-to Guide

Assessing Progress Over Time –Recommended Process Measure

Percentage of patients undergoing hip or knee replacement surgery:

who have had preoperative nasal swabs obtained to screen for Staph aureus carriage.

with nasal swabs positive for Staph aureus who have received five days of intranasal mupirocin prior to surgery

NOTE: screening needs to include both methicillin resistant (MRSA) and methicillin sensitive (MSSA) staph

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FAQs – Staph aureus screening and decolonizationAre there any disadvantages to decolonizing all patients with mupirocin before hip/knee arthroplasty (versus screening patients for Staph aureus prior to decolonization)?

It’s recommended that mupirocin use be limited to those known to be colonized with Staph aureus.Considerations with treating ALL patients (universal use):1) The emergence of mupirocin resistance associated with widespread use of mupirocin in some parts of the world 2) Cost of mupirocin – Universal mupirocin use would mean that many patients would be using and paying for mupirocin without clear benefit.

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FAQs – Staph aureus screening and decolonizationIs it necessary or recommended to re-culture after mupirocin to confirm eradication? It’s not clear that re-culturing after preoperative mupirocin provides information that is useful for SSI prevention.

Key considerations related to re-culturing: Nearly all patients who receive a course of intranasal

mupirocin have negative nasal screening cultures at one week follow-up.

It would be logistically difficult for hospitals to re-culture patients on surgery admission and then act on these results prior to the surgical procedure.

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FAQs – Staph aureus screening and decolonizationIf a patient does not complete the entire five days of mupirocin prior to surgery, should the remaining days be completed following surgery? Currently, there is no data to support a recommendation on this. While it’s theoretically possible that it may be beneficial to complete the course of treatment postoperatively, the logistics of implementing this (i.e., determining the number of days the patient received mupirocin preoperatively, ordering the remaining doses, informing the patient/family, etc.) could be challenging.

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FAQs – Staph aureus screening and decolonizationShould surgery be delayed if the entire five days of mupirocin are not completed?

It’s not recommended that surgery be delayed Every effort should be made to complete the full five days of

mupirocin before surgery A process should be established to provide adequate time for

patients to do this whenever possible

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For More InformationThe How-To Guide contains more information on all three interventions

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http://www.ihi.org/knowledge/Pages/Tools/HowtoGuidePreventSSIforHipKneeArthroplasty.aspx