Sparrow Hospital - Lansing, MI

flashypumpkincenterSoftware and s/w Development

Dec 14, 2013 (3 years and 6 months ago)

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Project JOINTS Exemplar Hospital Application

Sparrow Hospital
-

Lansing, Michigan

Number of beds: 587

Teaching

Urban and Rurual

Exemplar Hospital Contact Name: Becky Palmaan

Phone:
517
-
364
-
0621

Email:
Becky.Palmaan@sparrow.org


Enhanced Surgical Site Infections Prevention Bund
le element
: Bathing or showering with chlorhexidine gluconate (CHG)
soap for at least three days before surgery

In a few se
ntences, describe
in what ways your hospital has been suc
cessful 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?


See Attached
Documents





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


See
Attached Documents. We initially began with 2 surgeons utilizing the showering protocol for all of their TJR
patients
. We are in the process of standardizing this for all TJR patients currently and rolling it out to all of our
surgeons to adopt.





What l
essons have you learned as you've implemented this practice? What tips do you have to share?


This is a process that we are continually reviewing and supporting our surgeons’ offices in order to make this a
standardized protocol for all TJR patients. We
encourage those starting out the program to make it as easy as
possible for the surgeon’s office to utilize and explain to patients. Patient education in our pre
-
operative joint
class has been a key component along with carrying through the entire hospita
l stay.


Measurement



Measurement p
rovides 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 c
ompliance with process measures
, in this case
:


Percentage of patients undergoing elective hip or knee replacement surger
y 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


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


TJRs
completed from 2011 to date = 1309

Showering Protocol Completed = 335

Percentage = 25%