Project JOINTS Exemplar Hospital Application
Ministry Saint Michael’s Hospital- Stevens Point, Wisconsin
Number of licensed beds: 181
Non-Teaching
Rural
Exemplar Contact Name: Joanne Madigan, Clinical Quality Specialist Surgical Services
Email: joanne.madigan@ministryhealth.org
Phone: 715-356-5682
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?
Based on an Infection Control Department recommendation prior to 2004, Ministry Saint Michael’s Hospital,
through its Department of Surgery, implemented the use of an alcohol-based prep for the majority of all surgical
cases. Exceptions are for patient allergy, mucous membrane or facial preps, or in a few cases surgeon preference.
However, all joint replacement patients are prepped with either chloroprep or duraprep

How did you roll out this practice? Did you test it with one patient, a few, or all to start?
Suggested use of this skin prep solution was rolled out to all surgical cases at the same time and then individual
providers (non-ortho) opted out for some/all of their cases.

What lessons have you learned as you've implemented this practice? What tips do you have to share?
Initial practice change regarding required dry time was met with some resistance. Education and re-education
has occurred as needed and observations for compliance have not suggested continued problems. We have not
experienced any of the skin irritation/burn problems reported by others.
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
NOTE: Please attach available data in any format you currently have in the email included with this application.
Data period: FY11 – October 2010-September 2011 = 100%
Skin antisepsis with alcohol-based agent = 386
Total elective THA, TKA = 386