Project JOINTS Exemplar Hospital Application
Williamette Valley Medical Center- McMinnville, Oregon
Number of beds: 88
Non-Teaching
Rural
Exemplar Hospital Contact Name: Natalie Reed
Natalie.Reed@capellahealth.com
503-435-6571
Enhanced Surgical Site Infections Prevention Bundle element: Staphylococcus aureus (SA) screening and use of
intranasal mupirocin and CHG bathing or showering to decolonize SA carriers
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 SA screening and use of intranasal
mupirocin and CHG bathing or showering to decolonize SA carriers? What were the changes in existing
processes your organization had to make in order for this to become part of the routine?
When we decided to open our total joint program in June of 2010, much discussion centered on the
need to improve and restructure our pre-operative process. This included adding MRSA screening and
decolonization, to this process. We completely re-did our pre-op processe so that it included a timeline
allowing for screening and decolonization of patients with MRSA. We screen all total hip and total knee
replacement patients for MRSA and now MSSA at their PAT visit and provide decolonization instruction,
mupirocin and extra hibiclens at the patient’s hospitalist appointment. ( see the attached algorithm) We
determined the best way to ensure compliance was for the hospital to provide the mupirocin and
hibiclens cleanser to patients, and not rely on patients filling a prescription or purchasing cleanser on
their own .
Revising our pre-operative process was a major change for our hospital and has worked very well, but it
took months of meeting and preparations to make the necessary changes and to educate staff to the
new system. It also meant the physicians had to agree to a new timeline for surgery, one that was
much longer than previously used. Prior to June 2010, patients could decide to have a total hip or total
knee replacement on Monday and have the surgery on Friday. Now we schedule these surgeries at least
four weeks out from when the determination for surgery is made.
We did not start screening for MSSA until joining Project Joints in May 2012. Our lab performs MRSA
screening on routine microbiology agar; colonies of staphylococcus aureus are tested for penicillinbinding protein 2s (PBP2a) production. To add the MSSA screening, our lab now reports incidence of
Staphylococus aureus and differentiates between those organisms that are MSSA or MRSA based on the
results of the PBP2a test. In essence, by adding MSSA to the screening, we changed how we report our
results, but did not have to add an additional test to the screening process.

How did you roll out this practice? Did you test it with one patient, a few, or all to start?
Because we believe screening and decolonization is so important, we started this process with all
patients when our program opened in June 2010. When we added MSSA screening in May, we started
with all patients as there was no reason not to.

What lessons have you learned as you've implemented this practice? What tips do you have to share?
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The pre-admit department and timing are critical to this process here at WVMC. Patients meet with
pre-admit nurses and are screened 3 weeks prior to surgery. Results from the nasal swab are sent
to both pre-admit and the orthopaedic surgeon’s office. The pre-admit department flags positive
results to be addressed at the hospitalist consult. The orthopaedic office, does not address the
results. We instituted this process to standardize the protocol and be better able to provide
patients with consistent teaching and information.
Patient education about SA and decolonization works best in person. Patients meet with a
hospitalist two weeks prior to surgery. Those that are SA positive are provided with mupirocin
ointment and extra hibiclens cleanser along with both verbal and written instructions in how to
decolonize. We did not want to take the chance that patients would not fill a prescription or not
purchase additional cleanser. We learned that the education needs to be very specific for patients
and their families/coach. Family members should also be educated to this process if possible.
Hospitalist must be in agreement with this process. Because we utilize hospitalists to address
positive results prior to surgery, it is critical that the hospitalist is educated about decolonization and
in agreement with these instructions.
Consistent messaging to patients is necessary. Pre-admit, office staff, joint care coordinator,
hospitalist staff, nursing and physicians must all place emphasis on the importance of SA screening
and decolonization for patients to understand why this is important.
We need to formally track number of patients we swab, number of patients that test positive and
number of patients that are compliant with decolonization for future quality improvement
processes.
Measurement
Measurement provides information on whether the changes made to implement the Enhanced Surgical Bundle are
resulting in improvement. In any improvement initiative, the ultimate goal is to improve an outcome measure (e.g.,
reduce SSIs); hospitals and surgical practices will accomplish this by first improving the processes that are key drivers.
Please provide for us any information you can regarding compliance with process measures, in this case:

Percentage of patients undergoing hip and knee replacement surgery who have had preoperative nasal swabs
to screen for Staphylococcus aureus carriage: Started screening for both MRSA/MSSA 05/07/12. Started data
collection regarding this screening beginning of Q2 2012.
33/33 100% MRSA screening 04/01/12 to 05/06/12
21/21 100% MRSA/MSSA screening 05/07/12 and later.
Numerator Definition: Number of patients undergoing hip or knee replacement surgery who have had a nasal swab
specimen processed to screen for Staphylococcus aureus carriage prior to surgery
Denominator Definition: Number of patients undergoing elective hip or knee replacement surgery

Percentage of patients undergoing hip and knee replacement surgery with nasal swabs positive for
Staphylococcus aureus who have received five days of intranasal mupirocin prior to surgery:
6/6 patients received instruction and mupirocin ointment
5/6 completed full 5 days of decolonization (one patient only did for 3 days)
Numerator Definition: Number of patients undergoing hip or knee replacement surgery with a nasal swab specimen
result indicating Staphylococcus aureus carriage who have received five days of intranasal mupirocin prior to surgery
Denominator Definition: Number of patients undergoing elective hip or knee replacement surgery with nasal swabs
positive for Staphylococcus aureus
NOTE: Please attach available data in any format you currently have in the email included with this application.