Modified Protocol Decreases Surgical Site Infections after Total Knee Arthroplasty.

We investigate the effectiveness of a comprehensive aseptic protocol in reducing surgical site infection (SSI) after knee arthroplasty in a single medical center with a high prevalence of MRSA. A database of all patients in a single center undergoing primary knee arthroplasty between 2005 and 2011 was reviewed for SSI using Centers for Disease Control criteria and AAOS guidelines. All patients were treated with an aseptic protocol consisting of the following: preoperative 2% mupirocin nasal ointment and 0.4% chlorhexidine surgical site wipes, modified instrument care, perioperative prophylactic vancomycin and cefazolin, and surgical site skin preparation with chlorhexidine, alcohol, and iodophor. We compare our protocol total knee arthroplasty SSI rate to our institutional historical control (2001-2004) and to contemporary literature. Among 1,224 patients, 70% were ASA class >2 and 64% had a body mass index (BMI) > 30 kg/m(2). We found an overall 0.49% infection rate, significantly lower than that of our institutional historical control (0.49 vs. 2.24%, p < 0.001; odds ratio [OR], 0.21; number needed to treat [NNT], 145) and seven recently published reports (p < 0.001-0.042; OR, 0.07-0.42). Compared with these reports, significantly more of our patients were ASA class > 2, BMI > 30 kg/m(2), immunosuppressed, or had rheumatoid arthritis. Our aseptic protocol decreases SSI in a high-risk population undergoing knee arthroplasty in a medical center and community with a high prevalence of MRSA.

Back to basics: Four years of sustained improvement in implementation of contact precautions at a university hospital.

BACKGROUND: The use of contact precautions is an essential component of an effective multidrug-resistant organism (MDRO) control plan. Despite reliance on a passive automated reminder system to alert clinicians of the need for contact precautions, poor adherence was recognized at the study medical center. DEVELOPING THE INTERVENTION: A performance improvement project incorporating brief weekly surveillance rounds on each inpatient unit was developed to maximize compliance with implementation of contact precautions and to evaluate risk factors for failure to institute precautions. In the weekly rounds, infection preventionists determined the point prevalence of the appropriate implementation of contact precautions for MDRO (that is, whether or not patients with electronic flags had been appropriately placed on contact precautions). This project was evaluated during a 22-week rollout period followed by a four-year follow-up period. The experience and data derived from the rollout period were intended to shape the long-term plan to sustain high levels of compliance with contact-precaution initiation. RESULTS: During the first week of surveillance, only 70% of eligible patients were isolated, but by week 16 90% were isolated appropriately. Because surveillance rounding was successful in improving institution of contact precautions during the rollout period, this practice was continued. During the following four years (follow-up period), > or = 90% success at implementing isolation precautions was demonstrated during 74% of the weeks. CONCLUSIONS: This experience with surveillance demonstrated an effective, practical, and sustainable method of improving implementation of contact precautions for patients with MDRO.