Hospital Name: Ministry Saint Michael’s Hospital, Stevens Point, WI

Exemplar Hospital Contact Name: Joanne Madigan,

Number of licensed beds: 181 Teaching or Non-Teaching? Non-teaching Setting: Rural

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 bathing or showering with CHG soap for at least three days before surgery? What were the changes in existing processes your organization had to make in order for this to become part of the routine?

We had already been using the Sage wipes with our total joint population the evening before and the morning of surgery, so after participation in the Project JOINTS call series, we determined that best practice would be to expand the patient skin prep to 2 days of CHG showers beginning 3 days prior to surgery, followed by the Sage wipes the night before surgery and the final wipe completed on admission by the hospital staff.

·  How did you roll out this practice? Did you test it with one patient, a few, or all to start?

We implemented the expanded skin prep through our Joint Replacement Services Coordinator. She provided the education and supplies at the time of the preop joint education visit. The initial participation was with patients of the Ministry Medical Group orthopedic surgeons (patients of an independent provider group were not in this initial implementation, but will begin compliance with all of the SSI Bundle Elements 12/1/12).

·  What lessons have you learned as you've implemented this practice? What tips do you have to share?

Providing the patients with education and rationale has been very well received. Our providers are getting more frequent questions about what they and our hospital are doing to protect them from infections. Providers have been very happy to have the SSI Prevention Program elements information to share with the patients. Having the facility commit to provision of the supplies helps to ensure patient compliance.

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 elective hip or knee replacement surgery who have bathed or showered with chlorhexidine soap or wipes during the three days prior to surgery.

Numerator Definition: Number of patients undergoing hip or knee replacement surgery who have bathed or showered with chlorhexidine soap or wipes for at least the three days prior to surgery

Denominator Definition: Number of patients undergoing elective hip or knee replacement surgery

For MMG providers: Data period September 2012-November 2012 51/51 = 100%

NOTE: Please attach available data in any format you currently have in the email included with this application.

Implemented program end August 2012 – 100% of patients in MMG practice have completed – have also included Total Shoulders in this initiative. This data is for the MMG providers only.

Surgical Site Infection Prevention Program
Sept-Nov 2012 Volumes / Cultured / MRSA + / MSSA + / Mupirocin
Ordered / Patients
completing
5 day RX / 2 d CHG
Shower / Eve. Prior
CHG / DOS CHG
on Adm
MMG / 51 / 51 / 1 / 7 / 8 / 6 / 51 / 51 / 51
%
Compliance / 100% / 75% / 100% / 100% / 100%

*SSI Prevention Project elements participation with an affiliated independent ortho group just beginning end of November