Project JOINTS:
Joining Organizations IN
Tackling SSIs
Instruct patients to bathe or shower with
chlorhexidine gluconate (CHG) soap for at least 3
days before 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 evidencebased 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
http://www.ihi.org/ProjectJOINTS/
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Evidence suggests three new practices to
prevent surgical site infections in
patients undergoing hip and knee
arthroplasty.
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 patient bathing or shower with
CHG soap for at least 3 days prior to surgery?
Studies show that repeated use of CHG soap enhances
the ability of CHG to reduce bacterial counts on the skin
 not only during the immediate period after the shower
but for a number of hours afterward
Study results suggest that patients may benefit from
bathing or showering with CHG soap for at least 3 days
before surgery in order to achieve the most benefit.
It is unknown whether using CHG soap for longer periods
(e.g., five days) has additional benefit.
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Implementing pre-operative bathing
or showering with CHG soap for at
least 3 days prior to surgery
Strategies to Accelerate Change
Preoperative bathing or showering with CHG
soap for at least 3 days prior to surgery
 Provide patients with chlorhexidine soap – or instruct them
where they can purchase – and have them use the soap in
bathing or showering for at least three days before surgery.
Key considerations to ensure reliable CHG bathing or
showering 3 days prior to surgery:
Assess where most preoperative assessments currently take
place in your setting, because that is the optimal time to
discuss use of chlorhexidine soap with patients.
Assess current preoperative communication between the
hospital OR department and the orthropaedic surgeons’
offices to ensure patients receive consistent instructions on
CHG bathing or showering.
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Preoperative bathing or showering with CHG
soap for at least 3 days prior to surgery
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Additional considerations to ensure reliable CHG
preoperative bathing 3 days prior to surgery:
Decide whether it’s feasible to give chlorhexidine soap to
all patients during the preoperative assessment visit. If
not, provide information to the patients/families about
where they can purchase and the approximate cost.
Provide patients/families instructions on how to do
preoperative bathing.
Develop a simple form for patients to track days of CHG
bathing or showering completion.
Preoperative bathing or showering with CHG
soap for at least 3 days prior to surgery
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Additional key considerations in developing a reliable
process for CHG bathing/showering 3 days prior to
surgery:
• Develop a process flow diagram, specific to your hospital
setting:
 define all necessary components of the process for patient
bathing/showering for at least three days prior to surgery
 build into the pre-op assessment/visit a process for providing
CHG or instructing patients on where to obtain and instructions
for use.
NOTE: An example process flow diagram for Pre-Op CHG bathing or
showering is available in the How-to Guide.
Assessing Progress Over Time –
Recommended Process Measure
Percentage of patients undergoing hip or knee
replacement surgery who have bathed or
showered with chlorhexidine soap at least three
days prior to surgery.
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FAQs – CHG bathing or showering
Are there disadvantages to recommending 5 days of CHG soap?
The disadvantages are mainly practical, and include:
patients would need a larger, more expensive bottle of CHG soap
or the even more expensive 5-day supply of CHG wipes
compliance with an additional two days of CHG showering/bathing
could be even more challenging for patients.
Should the whole body be bathed with the CHG soap or just the
surgical site?
The CHG bath/shower prior to surgery should include the whole body
“from the neck down” to avoid soap getting into the eyes, ears, nose,
or mouth. Patients should also be reminded not to wash genital areas
with CHG solution.
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FAQs – CHG bathing or showering
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Can chlorhexidine-impregnated wipes be used instead of
chlorhexidine soap?
If used correctly, the wipes may be better than chlorhexidine soap
because the chlorhexidine doesn't get washed away in the shower or
bath. One possible problem with the wipes is that many patients prefer
showering to using the cloths which may reduce compliance.
 before using cloths, consider asking individual patients if they're
willing to use the cloths instead of showering.
Are there concerns about skin reactions to chlorhexidine bathing?
Based on studies that have used chlorhexidine cloths for daily bathing
of hospitalized patients (mainly in ICUs), skin reactions are very rare.
FAQs – CHG bathing or showering
Can lotion be used following CHG bathing or
showering?
Lotions or moisturizers should not be used following CHG
showering/bathing.
Can CHG soap be purchased in a regular pharmacy?
CHG soap can be found at most pharmacies and drug
stores. Be sure to check your local area to confirm
availability.
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For More Information
The How-To Guide contains more information on all
three interventions
http://www.ihi.org/knowledge/Pages/Tools/Howto
GuidePreventSSIforHipKneeArthroplasty.aspx