Project JOINTS Exemplar Hospital Application
Bellin Hospital – Green Bay, Wisconsin
Number of licensed beds: 167
Non-Teaching
Urban
Exemplar Hospital Contact Name:
Email: cabess@bellin.org
Phone: 920-639-4411
We give permission to IHI to make public all the information on this Project JOINTS Exemplar Hospital application.
Enhanced Surgical Site Infections Prevention Bundle element: Use of an alcohol-containing antiseptic agent for
preoperative skin preparation
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?
Literature was presented at our Infection Prevention Committee meeting about the use of an alcohol-containing
antiseptic agent for preoperative skin preparation. The Infection Prevention Committee made the recommendation
to indorse an alcohol-containing antiseptic agent for preoperative skin preparation. Infection Preventionist then
brought the literature to the Orthopedic Surgeons and one by one we changed preference cards to incorporate the
use of a alcohol-containing skin antiseptic.

How did you roll out this practice? Did you test it with one patient, a few, or all to start?
o We started with one physician and moved implementation forward until all surgeons were using the
alcohol-containing antiseptic.
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What lessons have you learned as you've implemented this practice? What tips do you have to share?
o Be sure that you have the literature support to get the buy in from the surgeons. Be sure the staff know
how to use the product correctly and when issues occur address the potential causes before letting a
surgeon switch back to an old product. Be prepared for a learning curve.
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 or knee replacement surgery with skin antisepsis at the surgical site using an
alcohol-containing preoperative skin antisepsis agent.
Numerator Definition: Number of patients undergoing hip or knee replacement surgery with skin antisepsis at the
surgical site using an alcohol-containing preoperative skin antisepsis agent (e.g., chlorhexidine gluconate plus alcohol or
iodophor plus alcohol)
Denominator Definition: Number of patients undergoing elective hip or knee replacement surgery
We didn’t do measurement. We made the change to the preference cards and fortunately they all agreed to the
change. We don’t allow them to use anything else unless there is an allergy with a patient to the specific product we
are using.