ProjectJOINTSExemplarHospitalApplication

Forest Hills Hospital North Shore-LIJ Health System – New York, New York

Number of licensed beds: 312

Teaching

Urban

Exemplar Hospital Contact Name: Jancy Varguese RN, ANP or Cecilia Wilfinger RN

Email: ;

Phone: 718-830-4177 or 718-830-4259

We give permission to IHI to make public all the information on this Project JOINTS Exemplar Hospital application.

Enhanced Surgical Site Infections Prevention Bundleelement: Staphylococcus aureus (SA)screening and use of intranasal mupirocin and CHG showering to decolonize SA carriers

1. In 2009 hip replacements were identified as high risk secondary to New YorkState reportable SSI’s. The Orthopedic teamidentified key strategies and agreed to implement them on all knee and hip replacements as well as spinal surgeries in an effort to decrease surgical site infection risk in this population...

2We identified thehip and knee replacements and spinal surgeries as high risk procedures and implemented policies and procedures that required these patients receive MRSA nasal swab screening by PCR and be provided with CHG sponges to perform showersthenight beforeand the morning of surgery. If MRSA PCR swabs were reported as positive (results were received in 24 hours) the patient was told to shower 5 days before the scheduled surgery with CHG and fill a prescription for mupirocin nasal ointment to apply 5 days prior to the scheduled surgery. This initiative received immediate buy in as there were only 3 orthopedic practices and all surgeons were in agreement. >90% of the patients passed through Pre Surgical Testing (PST) so capturing this population was easily identified.

3At the commencement of the IHI Project Joint the pre surgical testing expanded to nares cultures for MSSA as well as MRSA. The protocol was easily adjusted to capture all staph positive patients and initiate thedecolonization protocol. There was surgeon buy in as theprocedures were already operationalized and required no change in practice on their part. CHG showers were decreased to 3 days with mupiocin nasal treatment remaining the same.

4Our hospital (PST department)supplies each patient with the CHG sponges for showering.Patients are also given instruction sheetsto supplement theeducation the nurse does in PST for the CHG showers and the application of mupirocin.

5The instruction sheet has an easy to follow check list attached for both the wash and nasal ointment. The patients are asked to bring the check sheet with them on the day of surgery so we can track patient compliance.

6Forest Hills Hospital had already successfully implemented pre surgical testing and decolonization for MRSA and the addition of one test for MSSA was easily marketed to physicians, nurses and patients with the assistance of patient education material. The implementation of this piece of the bundlehas resulted in good outcomes thus far and the staffis very dedicated to follow up studies related to the outcomeafter making these changes.

At the inception of this IHI project in July 2011 the procedures described above were rolled out to encompass MSSA as well as MRSA positive patients. Year to date 2011 reveals no surgical site infections in this patient population.

Indicate which statement best summarizes your organization’s level of implementation of this Enhanced Surgical Bundleelement:

[ x] This practice is used for at least 95% of hip/knee arthroplasty cases.

[ ] We have a well-tested protocol and use it for some hip/knee arthroplasty cases.

Enhanced Surgical Site Infections Prevention Bundleelement (identify one per sheet): Use of an alcohol-containing antiseptic agent for preoperative skin preparation

  1. In 2008 in an effort to improve our Class I & II surgical site infection rateand to comply with The Centers for Disease Control and Prevention (CDC), the use of Chloroprep™ was introduced as a pre-operative skin preparation. Results were impressive with an 18% decrease in one year. In the surgical arena the area is again cleaned with a surgical skin preparation which consists of 70% alcohol and chlorhexidine (Chloroprep™). Presently Chloroprep™ is used as surgical skin prep on all surgical procedures unless allergy or contraindication is present.

In a few sentences, describe in what ways your hospital has been successful in implementing this element of the Enhanced Surgical Bundle. Please answer the following questions:

What key changes did your organization make to incorporate or support use of an alcohol-containing antiseptic agent for preoperative skin preparation? What were the changes in existing processes your organization had to make in order for this to become part of the routine?

  1. At the introduction of this product to the hospital product education was doneby the company with all surgeons and other necessary staff in the operating room setting. All providine products wereexchanged from ‘routine’ use in the surgical setting. In 2011 at the time of Project Joint this practice was in full implementation in our surgical arena.

How did you roll out this practice?

We have reported our infection rates to our surgeons at monthly meetings. Here we also discussed actions that may be taken to reduce our rates of post operative infection. This was a proposed and subsequently approved initiative. Following the approval the routine use of betadine was exchanged in all surgical suites. At the start of the IHI Project Joint this practice required no change in the behavior of staff and we believe it continues to work at lowering infection rates.

Indicate which statement best summarizes your organization’s level of implementation of this Enhanced Surgical Bundle element:

[ X] This practice is used for at least 95% of hip/knee arthroplasty cases.

[ ] We have a well-tested protocol and use it for some hip/knee arthroplasty cases.