Standardize Nasal Decolonization and Cut SSIs

Teamwide collaboration and compliance is critical to ensure antimicrobials are applied consistently and correctly every time.

With the surge in joint replacements and other orthopedic surgeries moving to ambulatory care, ASCs also face a higher risk for surgical site infections (SSIs).

That’s why every ASC team member must be educated, vigilant and consistent in facilitating and confirming that patients “come to surgery clean,” according to Peter Graves, BSN, RN, CNOR, a perioperative nurse consultant focused on infection prevention strategies for many years. Unfortunately, the nares don’t always get the attention they deserve in the cleanliness equation.

The ‘whys’ of non-compliance

While preoperative skin bathing with chlorhexidine has become a standard practice as part of an SSI prevention bundle, nasal decolonization — despite being a practice backed by strong evidence — is less understood and practiced than it should be.

Clinical evidence shows that 80% of S. aureus that causes SSIs can be traced to the patient’s nose, so it makes sense to eliminate reservoirs in the nares with applications of a facility-approved topical agent such as mupirocin nasal ointment, povidone-iodine or an alcohol-based antiseptic.

Historically, the challenge with nasal decolonization is the changing practices on whom to decolonize. Of course, a universal decolonization protocol would eliminate this issue, but if that’s not feasible, it’s crucial to decolonize certain patient groups. Fortunately, we’re moving in the right direction here.

“Less than a decade ago the standard practice was to survey specific patient populations and decolonize if tests came back positive,” says Kendra Gleffe, BSN, RN, CPAN, CAPA, surgical nurse navigator at UCHealth Yampa Valley Medical Center in Steamboat Springs, Colo.

ALARMING NUMBERS Because clinical evidence shows that 80% of S. aureus that causes SSIs can be traced to the patient’s nose, there’s a compelling case to be made for a universal decolonization protocol.

Today at her facility, nasal decolonization is recommended for patients with a prior history of methicillin-resistant S. aureus (MRSA) infection, patients undergoing joint replacement or spinal fusion and as part of ERAS (Enhanced Recovery After Surgery) pathways for multiple surgical specialties. Specifically, since 2014, all joint replacement and spine patients at UCHealth Yampa Valley receive nasal decolonization with povidone-iodine on the day of surgery, regardless of colonization status, Ms. Gleffe says. The protocol is also an ERAS infection prevention measure and is built into the ERAS order sets for colon resection, robotic hysterectomy, and knee, hip and shoulder arthroplasty.

In the event a patient allergy to povidone-iodine is identified during the pre-anesthesia phone call, the situation is discussed with the infection prevention nurse to weigh risks and benefits of mupirocin or alcohol-based decolonization versus using nothing, especially if the MRSA polymerase chain reaction (PCR) surveillance was negative, Ms. Gleffe explains. “This is done on a case-by-case basis,” she says.

Standardization as a starting point

Ms. Gleffe and Mr. Graves both agree that nasal decolonization has been an evolving process, and that approaches to education and collaboration must also evolve to share the evidence and make the practice easier for all.

From their different vantage points — from the front lines and from a high-level perspective, respectively — each shares advice for helping any ASC team improve nasal decolonization compliance to reduce SSIs, not only for patients, but also for staff who ensure it takes place and chart it accordingly.

• Create a nasal decolonization policy. “A policy establishes a practice guideline and expectation that nasal decolonization is to be used consistently with each patient,” says Mr. Graves. “It also establishes a quality assurance process when nasal decolonization is documented in the electronic medical record.” Like any good policy, he says a nasal decolonization practice must be shaped through interdisciplinary collaboration to ensure teamwide buy-in, including the physicians who play a major role in driving compliance. Mr. Graves suggests that any ASC policy and procedure for nasal decolonization should consider the following:

1. When nasal decolonization begins (at home or in the surgery center) and for how long
2. Which nasal decolonization product is to be used
3. Which to use when a patient presents with an allergy to the chosen product and having an alternative antimicrobial product available to substitute
4. Patient education about correct nasal decolonization technique
5. An assessment for patient compliance with the policy upon admission if decolonization takes place prior to surgery

“Nurses are very capable champions who are willing to implement nasal decolonization practices for their patients, but leaders also need to make this important step a standardized practice based on their policy,” Mr. Graves says. 

PRODUCT TYPES

3 Core Nasal Decolonization Agents

GUIDANCE NEEDED Regardless of the nasal decolonization product your OR staff uses, a clearly worded policy on when and how to apply the product is needed.

• Mupirocin. This commonly used prescription antibiotic topical ointment provides nasal decolonization against methicillin-susceptible S. aureus (MSSA) and MRSA. It is applied to the nostrils (nares). Instances of mupirocin resistance has been reported.

• Povidone-iodine. This topically applied antiseptic agent for skin disinfection has been used for almost 70 years. Povidone-iodine products manufactured specifically for S. aureus decolonization of the nares are widely available.

• Alcohol-based. Nasal decolonization can also be completed by swabbing patient nostrils with an alcohol-based agent that is specifically manufactured for the task, as well as for postoperative use. This product is widely available and is used in a variety of clinical settings.

—Carina Stanton

The surveillance policy at Ms. Gleffe’s facility has also evolved drastically throughout the years and varies between surgeons even today. For example, some surgeons screen all patients preoperatively, including one high-volume joint replacement surgeon who prescribes mupirocin nasal decolonization in pre-op and intravenous vancomycin perioperatively for all patients who test positive for MRSA. These patients then remain on isolation precautions throughout their hospitalization.

To support nasal decolonization compliance, Ms. Gleffe’s hospital tracks whether this nasal antisepsis step was completed through charting in the electronic health record and the data dashboard. “If nasal decolonization wasn’t charted, we can conduct an audit to see if charting was missed or if nasal decolonization wasn’t completed,” she says.

• Educate on the evidence. When teams understand the evidence-based rationale behind nasal decolonization, it gives them the understanding to make sure nasal decolonization takes place and to be able to answer patient questions. “This discussion should start by sharing the latest data on nasal decolonization efficacy in reducing SSIs, not just for MRSA but for any S. aureus colonization that can cause infection,” Mr. Graves says. He also suggests educating staff on the alternative products and research to increase their awareness of decolonization trends. 

At UCHealth Yampa Valley Medical Center, staff are educated on nasal decolonization when they are oriented to the preoperative phase of care, Ms. Gleffe says. This education covers correct application by first watching a peer apply the povidone-iodine and then demonstrating the application on a patient. Correct application includes a minimum of six rotations lasting at least 15 seconds each and fully covering the external nares. She says there are also several product-based training videos available to staff.

• Make it easy for patients. Any standardized patient education should help patients understand why they need nasal decolonization and what the surgery center is doing to prevent the risk for surgical site infections, says Mr. Graves, who cautions, “you may not need to reinvent the wheel — manufacturers often have online education materials available that can help with patient education.”

It can also be beneficial to discuss nasal decolonization and preoperative skin bathing in the same conversation with patients, he adds. “The ultimate goal is to get the patient to arrive with clean skin, and that includes their nose and their hands,” he says.

The upside is obviously reducing nasal staph aureus colonization, but patient dissatisfaction is a relevant risk.
Peter Graves, BSN, RN, CNOR

Patients in Ms. Gleffe’s hospital are educated about nasal decolonization at the bedside on the day of surgery prior to application of the povidone-iodine nasal decolonization as part of an emphasis on the importance of infection prevention that is communicated to patients throughout the preoperative process. “I ask the patient to blow and clear out their nostrils and explain that because our noses are warm, moist filters, bacteria tend to congregate in our nares,” she says. “Then I explain how povidone-iodine decreases the risk of SSI by preventing the spread of bacteria present in the nose to the rest of the body during the perioperative period.”

Ms. Gleffe also explains to the patient how nasal decolonization feels. “I tell them it’s cold and slimy but doesn’t hurt,” she says. “I also reassure the patient that after application they can dab at any iodine that is dripping out of their nose, but I stress they can’t blow their nose or purposely try to expel it.”

• Take a team approach to product selection. “Like any decision, choosing a nasal decolonization product requires weighing your pros and cons of each product,” Mr. Graves says. “The upside is obviously reducing nasal staph aureus colonization, but patient dissatisfaction is a relevant risk.”

That’s why he suggests team members understand the practical side of what it feels like to experience nasal decolonization. For example, a bariatric surgeon during a lecture on reducing SSIs in his patients tried each nasal decolonization product himself to help gauge patient acceptance. “This is certainly a novel approach, and may not be appropriate for every surgery center,” Mr. Graves acknowledges. Ultimately, the goal is adoption. “You want to make sure patients will use the antimicrobial product as prescribed to effectively target any staph aureus in their nose,” he says.

To this end, Mr. Graves says a multidisciplinary product selection team within an ASC should evaluate and assess each product for ease of use and patient acceptance. Once products are selected, he advises making sure to loop in materials management staff so there is adequate supply of the chosen antimicrobial(s).

Moving toward widespread adoption

As ERAS protocols are implemented for more procedures at UCHealth Yampa Valley Medical Center, Ms. Gleffe sees awareness around nasal decolonization practice continuing to increase. Mr. Graves projects more widespread compliance with nasal decolonization in ASCs and other perioperative settings as it continues to increase in practice. However, he stresses the important role ASC leaders play in standardizing nasal decolonization compliance through policy, education and reinforcement the evidence-based practice guidance that supports this important action to prevent SSIs. OSM