The Keys to Effective Nasal Decolonization

Your surgical team can instruct patients to bathe with antimicrobial soap before surgery and apply skin prep around the surgical site before incisions are made and that still might not be enough to prevent surgical site infections (SSIs) from occuring. Clinical evidence shows that 80% of Staphylococcus aureus (S. aureus) that causes SSIs can be traced to the patient’s nose. “It’s a problematic pathogen for patients undergoing surgery and it makes sense to protect them as much as possible by eliminating the reservoir in their nares,” says Karen Hoffman, RN, MS, CIC, FSHEA, FAPIC, clinical instructor in the Division of Infectious Diseases at the University of North Carolina’s School of Medicine in Chapel Hill.

S. aureus is the most common cause of adult post-op infections, and specifically the most common pathogen causing orthopedic (38.6%) and cardiac (27%) SSIs, according to a study published in the journal Frontiers in Health Services. Stacey Hockett Sherlock, MAA, a qualitative analyst at VA Iowa City Health Care System and co-author of the study, says patients who are nasally colonized with S. aureus are more than twice as likely as non-colonized patients to develop an infection.

Patients scheduled for joint replacements or cardiac surgery at the VA health system used to be screened for S. aureus during pre-op clinic visits. Carriers were prescribed 2% nasal mupirocin ointment to self-apply for five days and required to bathe with chlorhexidine gluconate (CHG) soap for five days before surgery. During surgery, carriers received cefazolin and vancomycin as part of antibiotic prophylaxis. Non-carriers washed with CHG soap the night before and morning of surgery.

Some of the facilities within the VA health system didn’t have the resources available to screen and treat carriers, however, making universal decolonization on the day of surgery a more effective way to ensure colonized patients are treated. Ms. Sherlock was part of an effort to implement pre-op nasal decolonization at three sites within the VA health system and has firsthand knowledge of several keys to the rollout’s success.

• Make it easy. Nasal decolonization with mupirocin — which requires coordinating screenings, writing scripts for the antibiotic ointment and relying on patients to apply it — is inconsistently adopted and adherence is variable, according to Ms. Sherlock. Having providers apply povidone-iodine or an alcohol-based antiseptic on the day of surgery is a more practical approach and more likely to be implemented.

The approach of screening and treating also has the potential to miss carriers, according to Ms. Hoffman, who points out that 30% of the population is carrying S. aureus at any given time. “Studies have shown 65% of carriers were missed during screenings because the culture wasn’t collected or it wasn’t collected correctly,” she explains. “Attempting to target high-risk patient populations is a hit-or-miss strategy.”

Patients prefer a single treatment of intranasal povidone-iodine because it has fewer side effects and a more pleasant feeling than mupirocin, according to Ms. Sherlock. “Anything you can do to streamline the nasal decolonization process makes it more likely to be successfully implemented,” she explains.

Day-of-surgery nasal decolonization’s efficacy has been proven during joint replacements and cardiothoracic surgery, procedures that put patients at high risk of infection, but Ms. Hoffman believes universal decolonization is a worthwhile practice and can improve outcomes across a host of specialties. “To be effective, nasal decolonization should have a high rate of compliance,” says Ms. Hoffman. “That means it’s easy for staff to implement and patients don’t mind having it done.”

Attempting to target high-risk patient populations is a hit-or-miss strategy.
— Karen Hoffman, RN, MS, CIC, FSHEA, FAPIC

Alcohol-based products can be applied to the nares quickly and easily on the day of surgery by staff or the patients themselves, according to Ms. Hoffman. “These products have a citrus smell and don’t cause skin irritation,” she says. “Patients report that they are pleasant to use.”

Mupirocin, povidone-iodine and alcohol-based antiseptics all eliminate the nasal reservoir of S. aureus, according to Ms. Hoffman. “But which one will result in the best application compliance?” she asks. “That’s the one that will be most effective.”

• Recruit nurse champions. Each of the Iowa VA sites identified a key staff member to head the nasal decolonization project and found frontline nurses to be ideally suited for the role. “Nurses know what surgeons and patients want, and they understand the daily workflow,” says Ms. Sherlock. “They also tend to have a big-picture understanding of how the facility operates and what it would take to roll out the program successfully.”

Identify a motivated nurse who is looking to take on a quality improvement project, suggests Ms. Sherlock. “Nasal decolonization demands a lot of work, but it’s targeted in scope,” she says. “You can implement it, measure outcomes and track the progress fairly easily.”

Acknowledgment that the nurse is leading the program helps to avoid pushback about their role in the new initiative, although they might need support from their direct supervisor. The nurse also needs the freedom, resources and time to take on the added responsibility. “It should be incorporated into their everyday responsibilities, not added to what they already do,” says Ms. Sherlock. “Nasal decolonization might seem like a simple bundle to add to an infection prevention program, but it requires a lot of work to do it correctly.”

Also find early adopters among the staff and get their leaders on board, suggests Ms. Sherlock. “Build teams that will work together to implement the project,” she says. “It takes more than one motivated team member to get it done.”