May 19, 2021

Learn the answers before rolling out a nares-cleansing protocol.

BY THE BOOK One way to ensure your nasal decolonization protocol is always followed: Perform random audits or make it part of the medical record.

Ask any surgical leader who has successfully implemented a nasal decolonization program at their facility and they'll all tell you the same thing: In order for the process to work, it must be convenient for patients and staff alike. To make your protocol as efficient as possible, here are three questions to ask before embarking on your own decolonization mission.

• Should we decolonize all patients? You'll likely find different answers depending on whom you ask. For instance, some experts feel decolonization should apply to all patients, with a universal protocol for all individuals undergoing surgery. Others, such as Maureen May, RN, BSN, director of surgical services at Ascension St. Vincent Carmel and Fishers in Indiana, limit decolonization to "anyone receiving an implant." Establish your facility's criteria from the get-go.
• How do we find time to do it? It takes only about a minute to decolonize the nares, but we all know how precious minutes can be in high-volume facilities. To ensure the protocol is always followed, perform random audits or make it part of the medical record. "Nasal decolonization is in the nursing documentation and is part of our SSI surveillance program," says Jeri Culbertson, RN, BSN, CIC, director of infection control and sterile processing at Black Hills Surgical Hospital in Rapid City, S.D.
• How do we explain the process to our patients? The last thing you want to do is confuse or worse, frighten, alreadyanxious patients by sticking a wet substance up their nose preoperatively. Instead, thoroughly explain the decolonization process to every individual whose nares will be decolonized, making sure the message is fully understood. "Discuss that germs live in the nose and people rub their nose unconsciously many times throughout the day," says Ms. Culbertson. "This treatment will lessen the risk of transferring germs from their nose to their surgical incision."

Ultimately, the more effort you put into planning your decolonization program, the more smoothly it'll run for your staff and patients in practice. The benefits are well worth it in the long run. Teresa M. Salley, RN, MS, MSN, perioperative manager at Sycamore Hospital in Miamisburg, Ohio, sums it up perfectly: "Nasal decolonization is a simple, low-cost way to help reduce infection risk."

Use peer-reviewed research to guide your decision on which proven method to incorporate into daily practice.

QUICK CLEAN Nasal decolonization can be an expensive, quick process that brings high value to infection prevention efforts.

Preventing surgical site infections (SSIs) is a multifaceted proposition that involves patient screening, skin prepping, antibiotic prophylaxis and nasal decolonization. Unfortunately, the latter doesn't always receive the attention it deserves, and that can be a potentially disastrous mistake to make.

"The simple administration of nasal decolonization before surgery is an extremely inexpensive preventative intervention," says Edward Septimus, MD, an infectious disease specialist and professor of internal medicine at Texas A&M College of Medicine in Houston. "If the patient is colonized with S. aureus, the nares are far and away the most common site."

When it comes to choosing a nasal decolonization method, there's some debate over which option is most reliable and effective. Dr. Septimus advises surgical leaders to let the data guide them. In addition to the research, however, also factor in the vital aspects of convenience and ease of use.

For instance, high-volume facilities may not have the time to add a time-consuming protocol like mupirocin, which requires screening patients at least a week in advance of surgery and monitoring at-home patient application compliance, into their workflow. If that's the case, applying povidone-iodine (PI) on the day of surgery may be a better choice. "You simply administer PI in the pre-op area before surgery with two applications in each nostril twice," says Dr. Septimus. "It's a much simpler regimen that's especially attractive to outpatient surgery centers."

Regardless of which protocol you ultimately choose, it's important to look at nasal decolonization as a single but critical component of a comprehensive SSI prevention protocol. Dr. Septimus was involved in a published study that included 20 hospitals performing total joints or open-heart surgeries and found one common thread regarding infections. "Facilities that complied fully with a robust, evidence-based SSI prevention protocol — screening, decolonization and administering the appropriate surgical antibiotics for prophylaxis — had lower infection rates than those that were partially compliant," he says. "It's about doing the small things consistently well."

Nasal decolonization is one of those small things that can make a big difference in terms of patient safety.

It's important to decolonize patients prior to a procedure to reduce SSI risk.

Credit: PDI Healthcare
DEVA REA is a Clinical Science Liaison for PDI Healthcare. She received a Bachelor of Science in Microbiology and Molecular Biology and Bachelor of Science in Nursing at the University of Central Florida and a Master of Public Health in tropical/communicable diseases and Graduate Certificate in Infection Control at the University of South Florida, Tampa. She is board Certified in Infection Control (CBIC).

As ambulatory surgical procedures continue to grow in volume, OR teams need to focus on infection prevention strategies that encompass all types of surgery performed in ASCs and Hospital Outpatient Departments (HOPDs). Nasal decolonization is an important strategy that deserves attention. Deva Rea, MPH, BSN, BS, RN, CIC, Clinical Science Liaison, PDI, answers some critical questions about nasal decolonization and why it is so significant.

Why is it important to decolonize patients prior to a procedure? And why is nasal decolonization so significant?
Outpatient procedures on patients who do not require an overnight stay are increasingly being performed in ambulatory surgical centers (ASCs). ASCs are expected to perform 68% of orthopedic, 30% of spine and 33% of cardiology procedures by the mid-2020s.¹ As more procedures continue to transition to the ambulatory arena, there is a need to monitor and prevent surgical site infections (SSIs). Decolonization is one core infection prevention strategy to prevent SSIs.

Our skin is colonized with more microorganisms than actual human cells (∼3 × 101,3 human cells vs. ~3.8 × 101,3 microorganisms).² Typically we live in harmony with these skin microbes, but when the integrity of the skin is disrupted, via a surgical incision, there is a risk of developing a healthcare associated infection (HAI) such as a SSI. Colonization is most common in body sites such as the nose, skin, and gastrointestinal tract.³ And the body sites of colonization are usually specific to the type of bacteria. Staphylococcus aureus most commonly colonizes the skin and mucosal membranes of the nose.⁴

It is important to reduce the amount of organisms, or microbial burden, on the skin prior to any incision with nasal and skin decolonization. If decolonization is not done, there is a greater possibility that the organisms on the skin will be able to invade deeper layers of the skin and soft tissues. Topical antiseptics prevent bacterial carriage and infection. Skin decolonization is typically performed with a chlorhexidine gluconate (CHG) based solution. Nasal decolonization is typically performed with an antiseptic or antibiotic. Forgoing nasal decolonization is a huge breakdown in appropriate decolonization because the nose is highly colonized with many microorganisms. Without nasal decolonization, a patient has a reservoir of nasal microbes available for possible recolonization of their skin, and thus an increased SSI risk.

Why is Staphylococcus aureus so important in the prevention of SSIs? br /> Staphylococcus aureus is the leading SSI pathogen.⁵ Specifically, it is the leading pathogen for SSIs in high risk cardiac, orthopedic, spinal and abdominal procedures, which are continually transitioning to the ambulatory setting.⁵ Up to 30% of the human population is asymptomatically and permanently colonized with nasal S. aureus.⁴ And 80% of the SSIs caused by S. aureus match the same strain that was in the patient's nose.⁴ A patient colonized with S. aureus has a 2 to 9 times greater risk of SSI.⁴ Nasal colonization with S. aureus is the most important determinant of subsequent S. aureus infections.

What is the benefit of using an antiseptic such as povidone iodine (PVP) for nasal decolonization?
PVP is an antiseptic with broad spectrum activity against bacteria, fungi, and some viruses. It is administered the same day as the procedure and is efficient. PVP typically has efficacy against S. aureus for up to 12 hours. There is also no known resistance to PVP. Many studies have shown PVP nasal decolonization to be very effective in reducing SSIs when combined with skin decolonization.^6,7

PVP nasal decolonization is also effective in reducing other pathogens, including multi-drug resistant organisms (MDROs) such as MRSA and VRE.8 Finally, the Centers for Disease Control and Prevention (CDC) have developed core strategies that tackle HAIs, such as SSI. In the CDC's "Strategies to Prevent Hospital-onset Staphylococcus aureus Bloodstream Infections in Acute Care Facilities," they recommend skin decolonization with chlorhexidine gluconate (CHG) and nasal decolonization with an antibiotic or an iodophor (povidone iodine) antiseptic for prevention of device associated infections as well as SSIs.⁹ These strategies will be useful not only for acute care, but also for ambulatory surgical settings as these facilities continue to increase their surgical volume.

Research suggests there are many potential benefits for keeping your staff's noses clean.

Compelling, peer-reviewed research exists to support standardized nasal decolonization of all surgical patients. But what about staff? After all, if decolonization is indeed a proven way to reduce infection-causing pathogens in the nares, shouldn't it apply to all individuals in the OR?

Some infection preventionists currently agree, with research exploring the effectiveness of a patients-and-staff decolonization regimen. "We're seeing the expansion of nasal antiseptics within the healthcare community, and it's certainly a trend that perioperative leaders will want to watch closely," says infection prevention consultant Sue Barnes, RN, BSN, CIC, FAPIC, who previously served as the national program leader for infection prevention and control at Kaiser Permanente.

It especially makes sense, she says, when you consider that masks aren't 100% effective at preventing infection. "If a healthcare provider is colonized with MRSA or S. aureus in their nose, it's possible for some of that bacteria to escape in respiratory aerosols, especially if the provider has a cold," she says. "This would increase risk of contamination of the sterile field or open incision during a surgical case." If that staffer's nares were decolonized, however, that would in theory decrease the risk of infection.

Ms. Barnes points to a growing body of data to support this proposition in practice. "There are studies now demonstrating that if your surgical team practices nasal sanitizing prior to the case, there's an additive surgical infection prevention effect," she says.

For instance, a study in the American Journal of Infection Control looked at the effectiveness of nasal decolonization in reducing bacterial carriage in healthcare providers at an urban hospital. For the study, all providers who tested positive for nasal S. aureus colonization were treated three times per day with a decolonization agent or with a placebo. S. aureus and total bacterial colonization levels were then measured prior to and at the end of a 10-hour work shift. Decolonization of staff was found effective at reducing both S. aureus and total bacterial carriage.

Reducing patient infections isn't the only reason to extend a standardized nasal decolonization protocol to the other side of the table. Ms. Barnes says there are a host of other potential benefits. "For instance, could nasal decolonization of healthcare workers reduce their risk of getting sick, and reduce absenteeism for an organization?" she says, adding that further research is warranted to find out.

The pandemic prevention aspect is just one of many reasons to consider treating the nares of every patient before surgery.

Ample evidence already exists on the benefits of adding a standardized nasal decolonization regimen to a multifaceted surgical site infection (SSI) prevention bundle, but there's another perk of swabbing the nares. It could help combat the spread of COVID-19.

As an enveloped virus, COVID-19 is highly susceptible to the proven nasal decolonization agents most commonly used by facilities, says Randy Loftus, MD, professor of anesthesiology at the University of Iowa in Iowa City. "The virus is inactivated with brief exposure to these agents," he says. "Timely use of these agents, based on our knowledge of the epidemiology of transmission of other infectious organisms like S. aureus, creates an evidence-based defense strategy against COVID-19."

With widespread vaccinations and declining COVID-infection rates, healthcare facilities are certainly in a better place than they were a year ago. However, we're still a long way from achieving herd immunity, so any steps providers can take to limit the spread should be taken.

Even without the COVID-19 aspect, plenty of providers believe nasal decolonization should be a standardized component of infection prevention protocols for all surgical patients, not just specific infection-prone procedures such as total joints. Dr. Loftus is among this group. "Nasal decolonization is currently applied to a subset of patients — primarily those undergoing joint replacements — but the evidence for SSI prevention suggests its use should be more widespread," he says. He hopes the pandemic will serve as a catalyst for a more universal approach to nasal decolonization.

"COVID-19 should serve as a wake-up call," says Dr. Loftus. "We need to pay attention to limiting transmission by universally applying evidence-based measures, including nasal decolonization. It's through that approach that we'll control the spread of bacteria and viruses, reduce infections and dramatically improve patient outcomes."