A Ten-state Cluster-randomized Controlled Trial of the Institute for Health Improvement's Project JOINTS
Condition: Disorder of Hip Region
Study type: Interventional

Summary: 
      In 2011, IHI designed a new campaign to accelerate uptake of evidence-based practices that
      had been shown to prevent surgical site infections (SSI) associated with hip and knee
      arthroplasty. Project JOINTS (Joining Organizations IN Tackling SSIs was a multi-faceted,
      disciplined initiative that used the Rapid Spread Network (defined above), methods and tools
      developed during previous IHI campaigns to influence orthopedic practices and hospitals
      performing hip and knee arthroplasty. Rather than launch nationally as other campaigns have
      done, Project JOINTS was introduced in a cluster-randomized fashion to enable a rigorous,
      independent evaluation of its effectiveness in promoting uptake of new evidence-based
      practices.
    

Detailed description: 
      For Project JOINTS, the evaluation team designed a state-level cluster randomized trial
      involving five pairs of states selected and matched on characteristics described below. One
      state from each pair received the 6-month Project JOINTS campaign, while the other state
      served as a control. To measure changes in the relevant evidence-based practices, RAND
      conducted a survey of orthopedic surgical staff in all ten states before and after Project
      JOINTS. The project was reviewed and approved by the RAND Institutional Review Board.

      Intervention: Project JOINTS built on the notion of synergistic use of evidence-based
      practices.14 IHI designed and encouraged implementation of a five-component "enhanced" SSI
      prevention bundle included three relatively new evidence-based practices and two
      well-established Surgical Care Improvement Program (SCIP) practices. The three evidence-based
      practices not consistently implemented by hospitals prior to 2010 were:

        1. Screen patients for nasal Staphylococcus aureus (SA) carriage and decolonize SA carriers
           with five days of intranasal mupirocin and CHG bathing (minimum 3 consecutive days of
           daily use) in the days immediately preceding surgery;

        2. Instruct patients, regardless of SA carriage, to bathe or shower with chlorhexidine
           gluconate (CHG) for at least three days before surgery;

        3. Use an alcohol-containing antiseptic agent for preoperative skin preparation. The
           campaign recruited state organizations from the RSN developed during the 100,000 Lives
           and 5 Million Lives Campaigns. The state organizations reached out to hospitals in their
           states inviting them to participate in the campaign, disseminating information about the
           campaign and its evidence-based practices, and assisting IHI in publicizing activities
           described below and in a prior publication.

      IHI developed a logic model summarizing how campaign activities were designed to achieve
      specified goals and this was discussed and refined in collaboration with the evaluation team
      in order to inform evaluation measures. IHI developed intervention materials (including a
      "How-to Guide," evidence reviews, a summary of the "business case" for the interventions to
      prevent SSIs, and tip sheets for surgeons and other providers, and patients and families),
      created and maintained a project website and email listserv, and offered a range of learning
      opportunities (including webinar calls, faculty-led office hours, and town hall meetings).
      Hospital and practice staff who participated in Project JOINTS (typically quality or safety
      improvement leaders and staff with oversight of infection prevention) received access to a
      password-protected IHI website maintained by IHI.

      In addition to SSI prevention in hip and knee arthroplasty, the Project JOINTs "How To Guide"
      also addressed important elements of the "Model for Improvement," developed by Associates in
      Process Improvement and later adapted by IHI for use in its campaigns. These elements
      included: (1) the development of a QI plan (including explicit aims and a measurement
      framework); (2) small-scale tests of change- ("PDSA cycles") to refine implementation
      approaches through iterative learning; and (3) reliance on multi-disciplinary implementation
      teams. To enhance credibility with clinicians, IHI collaborated with relevant professional
      organizations, recruiting faculty from the American Academy of Orthopedic Surgeons (AAOS) and
      the American Association of Hip and Knee Surgeons (AAHKS) and obtaining endorsement from the
      AAHKS.
    

Intervention name(s): Quality Improvement Campaign
Intervention type(s): Other
Intervention description(s): "How To Guide" addressed development of a QI plan; small-scale tests of change- ("PDSA cycles") to refine implementation approaches through iterative learning; and reliance on multi-disciplinary implementation teams. IHI recruited relevant professional organizations to identify faculty.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Health Services Research
Keywords: campaign; surgical site infection; orthopedic surgery; quality improvement; infection control