A Ten-state Cluster-randomized Controlled Trial of the Institute for Health Improvement's Project JOINTS
A Ten-state Cluster-randomized Controlled Trial of the Institute for Health Improvement's Project JOINTS
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.
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.
Inclusion Criteria:

 -  Surgeons, nurses, and other staff involved in direct care of patients undergoing hip
 or knee arthroplasty.

 -  Staff had to be affiliated with one of 20 hospitals selected at random from among all
 hospitals in each of 10 states that performed a minimum of 100 hip or knee
 arthroplasties for Medicare beneficiaries.

 Exclusion Criteria:

 -  Per diem staff