We'd seen the studies showing that patients who bathed with chlorhexidine gluconate (CHG) for 3 days before surgery had fewer surgical site infections than those who followed the traditional night-before-and-morning-of bathing protocol. But we knew it would be a challenge to get patients to embrace the idea. So when we decided to go for it, we set what we thought was a fairly optimistic goal of 90% compliance. Now, more than a year later, I'm proud to say we've exceeded that goal in every month, have had 100% compliance in several of those months, and overall, have had a 98% success rate. Here's how we did it.
We'd been talking to our joint center team for 2 years about how to better prevent SSIs. We knew the organisms causing infections within our hip and knee patients were predominantly related to patient skin flora. Naturally, we already did pre-op bathing on the morning of surgery, but it wasn't enough. When we got word that the Institute for Healthcare Improvement's Project JOINTS (Joining Organizations IN Tackling SSIs) Collaborative was accepting a second cohort of hospitals, it was a no-brainer for us. We joined in the spring of 2012.
The 3 days of CHG application is one of the key components of the Project JOINTS "enhanced surgical bundle" to prevent infections. And joining the initiative gave us access to a wealth of educational tools, ?compliance tracking method-ologies, ?and presentations to help ensure success. ?Our rollout was ?pretty smooth. Because our joint center team already had pre-op educational classes in place for all hip and knee patients twice a month, there was no need to reinvent the wheel. Our classes had primarily focused on educating patients about the procedure and what to expect post-op. Now we began to really focus on the prevention aspect, too.
The Project JOINTS program is now a national project and anybody can register on the IHI website (www.ihi.org) and gain access to helpful educational material. If you're just now thinking about initiating a pre-op bathing or showering protocol, I recommend starting small. Begin providing bathing or showering instruction to a small group of your highest-risk patients. You may want to start with one kind of surgery, like knees or shoulders. Choose a subset of some sort and make sure you have the process down before you spread it to other service lines.
For those just starting, the IHI recommends selecting 2 patients, discussing the value of CHG bathing before surgery and asking if they'll help you with a process improvement. Doing so gives them an opportunity to have input into their care, and you can point out that they may help improve the care of others. Give them a copy of the patient CHG checklist (available on the IHI website) to complete and bring back before surgery. Then, before surgery, follow up with the patient or patent's family to assess compliance and ask for suggestions.
We got a significant boost in our efforts when our joint center coordinator was able to include the CHG wipes in her fiscal year budget. That meant we didn't have to rely on patients to find and buy their own. Instead, we handed them out during classes or mailed them, along with instructions, to patients who either were coming back for a revision or to have a second knee done. We learned, incidentally, that we needed to get them in the mail as early as possible. There were times in the early going that wipes delivered via snail mail didn't arrive in time. We also do everything we can to give patients personal instruction. If they can't make it to a class, our joint center coordinator is available to provide one-on-one training.
Including the instruction in our classes is a key component of our success. One of the reasons we'd spent so much time talking about improving our procedure, but hadn't done it, was that we'd had trouble conceptualizing how best to distribute the wipes and other materials. The classes take the pressure off, because we don't have to get in touch with all the surgeons' offices and work through them. It was a lot easier to implement because it's centralized. Once we modified the classes to add the focus on prevention, very little tweaking was needed. The education we provide is very thorough and is undoubtedly responsible for the high compliance rates we've seen. ? If our patients have any problems, they know what to do and whom to call. As a final assurance, we also have representatives from our surgical department ?call and remind patients when it's time to start using the wipes.
SOAPS AND WIPES DONE RIGHT
Pre-Op Showering Tips
Pre-op showering or bathing for 3 days with chlorhexidine gluconate (CHG) soap or wipes is part of the Institute for Healthcare Improvement's (IHI) "Enhanced Surgical Site Infection Prevention Bundle" for hip and knee arthroplasty providers. Here are some of the IHI's recommendations, if you're interested in implementing the practice:
- Tailor the implementation process to your setting. Determine where most pre-operative assessments currently take place, because that's the optimal time to discuss CHG soap or wipes with patients.
- Consider whether it's feasible to give CHG soap or wipes to all patients during their pre-operative assessments. If not, tell patients specifically where they can get them and about how much they'll cost. (Weigh costs from both the patient perspective and the facility perspective. It might make economic sense to provide the materials.)
- Develop a guide or quick reference for staff, to ensure that patients always get the same message and understand why 3 days of CHG showering/bathing is important.
- Provide instructions to the patient or family. Tell them to wash the whole body from the neck down and to avoid getting soap in eyes, ears, nose, or mouth; to concentrate on the area to be operated on; not to wash genital areas with CHG soap; and not to use lotions or moisturizers afterward.
- To promote compliance, consider offering patients either soap or wipes. Some patients prefer wipes, but others prefer showering and want the soap.
- Develop a simple form that patients can use to track the number of days they've bathed or showered with CHG and tell them to bring it with them on the day of surgery.
When time is limited
Naturally, unexpected add-on cases can be a challenge. If we have only a few days' advance notice, there's very little time to properly educate patients and get 3 days' worth of bathing done. So we make it a priority to work closely with the surgical scheduler and surgeons' offices and to convey how important it is for patients to get to class and get the prevention guidance they need. Fortunately, patients are coming to us more educated these days. AARP published an article a while ago explaining the benefits of CHG bathing, so we've even had patients come in asking about the wipes.
Our 98% compliance rate would be even higher, but we tend to get about 1 or 2 patients a month who complain that the wipes cause them uncomfortable itching. When that happens, we contact the surgeons, many of whom tell us to tell the patients to stop using the wipes. That's because if they're causing a rash, surgery might have to be delayed. But it's a very small number of patients who are affected, and even then, the patients have usually had a couple of days' worth of treatment. Clearly, we're getting the message across, because we've now had almost 400 patients go through the training, and only 2 have flat-out refused the bathing protocol.
Is it working? We won't know for sure whether our reduction in infections is statistically significant or not until the end of calendar year 2013, but so far this year, infection rates for both hip and knee procedures are less than 1%, and we feel confident that hip-related infections in particular have been reduced.