Project JOINTS:
Joining Organizations IN
Tackling SSIs
Use of an alcohol-containing antiseptic agent for
pre-op skin prep
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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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.
.
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Use an alcohol-containing antiseptic agent
for preoperative skin preparation
Two types of preoperative skin preparations that
combine alcohol (which has an immediate and
dramatic killing effect on skin bacteria) with longacting antimicrobial agents appear to be more
effective at preventing SSI than povidone-iodine
(an iodophor) alone:
–Chlorhexidine plus alcohol
– Iodophor plus alcohol
.
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Implementing use an alcoholcontaining antiseptic agent for
preoperative skin preparation
Strategies to Accelerate Change
Use an alcohol-containing antiseptic agent for
preoperative skin preparation
 Change the operating room skin prep for hip and knee
arthroplasty to a long-acting antiseptic agent in combination
with alcohol.
Key considerations in changing to (or expanding) use of an
alcohol-containing antiseptic agent:
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.
Interview representative surgeons to identify misconceptions
or key barriers to using an alcohol-based skin prep.
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Use an alcohol-containing antiseptic agent for
preoperative skin preparation
Strategies for ensuring reliable use of an alcoholcontaining antiseptic agent:
Conduct pilot testing of available agents to assess
acceptability and surgeon buy-in, considering:
drippiness, packaging, drying time, visibility, etc.
Ensure recommended alcohol-based skin prep is
stocked in all surgical theaters for hip and knee
arthroplasty cases.
Ensure the alcohol-based skin prep is applied correctly,
following manufacturer’s instructions.
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Assessing Progress Over Time –
Recommended Process Measure
Percentage of patients undergoing hip or knee
replacement surgery with skin antisepsis at the
surgical site using an alcohol-containing
preoperative skin antisepsis agent.
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FAQs – Alcohol-based skin prep
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Which is more effective – a CHG-alcohol product or an
iodine-based alcohol product?
There is currently no specific evidence that CHG-alcohol
or iodophor-alcohol is more effective.
Are there concerns about sensitivity reactions to
alcohol-based skin prep?
It’s important to ensure manufacturers’ instructions for use
understood and followed to minimize the likelihood of
reactions. Reports of sensitivity issues are rare and most
often related to inappropriate application and/or drying
time.
FAQs – Alcohol-based skin prep
Some of our surgeon’s have reported that surgical
drapes don’t stick well after using alcohol-based skin
preps. How can this be addressed?
This concern is addressed in the CMS “Use of Alcoholbased Skin Preparations”:
“It’s important to make sure that the alcohol-based
skin prep solution is completely dry prior to
draping. This may take a few minutes or more,
depending on the amount and location of the
solution. The prepped area should be inspected to
confirm it is dry prior to draping”
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FAQs – Alcohol-based skin prep
Are there safety/fire concerns with using alcohol in
the surgical suite?
The Centers for Medicare & Medicaid Services (CMS)
addresses risk reduction techniques to permit safe use of
alcohol-based skin preparations in inpatient or outpatient
anesthetizing locations in their “Use of Alcohol-based Skin
Preparations in Anesthetizing Locations”.
http://www.cms.hhs.gov/SurveyCertificationGenInfo/downl
oads/SCLetter07-11.pdf
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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