Is Universal Nasal Decolonization the Standard of Care?

A shift is taking place in surgical facilities, and more providers understand the many benefits of a horizontal approach to keeping patients’ nares clean.

Ask Kimberly Candray, CIC, BS, MT(ASCP), why universal nasal decolonization should be a standard component of every facility’s SSI prevention bundle, and you’ll get a response that’s tough to argue with.

“The evidence is out there that facilities that use nasal decolonization have better SSI rates than those that don’t, and patients can look up that information and decide where they want to go,” says Ms. Candray, market director of infection prevention for Northwest Healthcare in Tucson, Ariz. “Why wouldn’t we as an institution want to do this? Why would we not want to do the absolute best and safest thing for our patients?”

Slow path forward

Ms. Candray’s question cuts to the heart of why nasal decolonization — a proven safeguard against SSIs — hasn’t quite garnered the adherence of other prevention tactics. After all, research shows that S. aureus is the most common cause of SSIs, and the nose is the most colonized area on the body. “Studies show that around 80% of what’s on your skin comes from your nose,” says Ms. Candray. “Many places are decolonizing the body but they’re neglecting to decolonize the nose at the same time.” Based on the data, she’s puzzled as to why more facilities don’t make the practice a standard part of their SSI bundles. “There’s so much evidence out there that points to a reduction in SSIs if you use nasal decolonization, but facilities have been very slow to adopt it — even in the hospital settings,” she says.

While there are barriers to adoption for some facilities to start a protocol — cost, time and patient satisfaction concerns among them — these obstacles pale in comparison to the benefits. Connie Steed, MSN, RN, CIC, FAPIC, a consultant specializing in infection prevention and control, is a strong proponent of a “horizontal” or universally applied nasal decolonization strategy because of the protection it affords patients. “Any procedure with an incision has a risk, and mitigating that risk is important,” says Ms. Steed, who has more than 40 years of experience in infection prevention and control in a variety of settings and recently retired from her role as corporate director of infection control for Prisma Health in Greenville, S.C. “A horizontal approach [such as universal nasal decolonization] standardizes care and reduces confusion for providers.” When all patients receive the same mitigation strategy, she adds, staff don’t need to stop and think about which protocol applies to which patient.

Fortunately for Ms. Candray, getting buy-in for decolonization from her facility has never been a major obstacle — even in an ASC setting — because of how policies at her hospital system are structured. “We have two ambulatory surgery centers that are attached to our system, and whatever we do in the hospital setting, we also do in the surgery centers,” she says.

In terms of the specific decolonization products [See Breaking Down the Available Options] her facility uses, Ms. Candray says Northwest Healthcare started with povidone-iodine in the outpatient setting, switched to an alcohol-based antiseptic and recently switched back to an iodine-based agent. In the hospital setting, patients are decolonized with mupirocin. The change from alcohol to povidone-iodine did bring some concerns because some patients complained — saying it burned their nose or left staining — but ultimately staff focused on driving home the importance of the process to get patients on board.

PRODUCT CATEGORIES

Breaking Down the Available Options

When it comes to selecting a nasal decolonization agent, providers generally have three main options. Infection preventionists, OR staff and patients may have some strong opinions about which products work best, but the product itself isn’t quite as important as the act of protection itself. As Kimberly Candray, CIC, BS, MT(ASCP), market director of infection prevention for Northwest Healthcare in Tucson, Ariz., puts it: “Regardless of what you use, it’s important to use something.”

• Mupirocin. This nasal ointment is the primary antibiotic for decolonization, and it’s a very effective option, but because it takes up to five days to be most effective against S. aureus, patients can be resistant and high use can lead to increased antibiotic resistance.

• Povidone-iodine. This agent that can be applied immediately before surgery, is resistant to S. aureus and has a growing body of literature supporting its effectiveness. One potential drawback, however, is that patients sometimes complain it stings or doesn’t smell very good.

• Alcohol-based antiseptics. Another easy-to-use option that can be applied right before surgery, alcohol-based antiseptics don’t cause irritation and are often referred to as pleasant by patients, but lack the research of the other two options.
—Jared Bilski

“We give them the education behind why we’re doing what we’re doing,” says Ms. Candray. “Without getting too into the weeds on the actual science behind nasal decolonization, we say to patients, ‘We want to prevent you from getting a surgical site infection, and this product will help.’” That extra clarification can go a long way toward putting already-anxious patients at ease prior to their procedures.

Bringing it home

KEEP IT SIMPLE Explaining why you are decolonizing nares without getting too deep into the science will help put the patient at ease before their procedure.

If you’re interested in bringing a universal nasal decolonization approach to your own facility, dig in and really take the time to find out what’s out there. “Do your research,” urges Ms. Candray. “Make sure that you review the products that will potentially work at your facility.” Once you’ve done your due diligence and reviewed the research — most vendors have clinical studies that can be analyzed and cross-referenced with other research — on a product’s efficacy, get potential vendor representatives heavily involved. “Reach out to the product reps and learn about their products,” says Ms. Candray. When you’re ready, bring the vendor in and evaluate them on their offerings, service and responsiveness. “The reps should come and train staff on multiple shifts to make sure everyone is using the product appropriately and following the instructions for use,” she says.

When vendor reps act like a true partner, it takes some of the burden off infection preventionists to tackle so much education and training. This can prove invaluable for centers where “infection preventionist” is just one of many hats a staff member wears.

Another way to make universal nasal decolonization a reality is to emphasize its critical role as part of total-body infection prevention strategy. “I’ve been doing total-body decolonization since before it was popular, and it works,” says Ms. Candray. It works so well that she sees universal decolonization becoming a standard in all settings soon. “As we see the reduction in surgical site infections, I think we’ll see a lot more compliance and a lot more buy-in for universal nasal decolonization,” says Ms. Candray.

Ms. Steed has also noticed a paradigm shift of sorts in how facilities treat patients’ nares — a movement away from an approach reserved for high-risk patients to one that favors horizontal strategies. “I’ve seen an expansion among hospitals that have seen targeted decolonization work and are looking to add it to additional populations,” she says. “It’s clearly a good risk mitigation that expands bundles for surgery.” OSM