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Our protocol is easy to implement, cost-effective and widely accepted by patients.
When patients arrive at our hospital's same day surgery unit, we give them a package of 2% chlorhexidine wipes and ask them to rub down the surgical site. Then, about an hour before their procedure, a pre-op nurse snaps open an ampule containing an alcohol-based sanitizer and instructs them to swab the inside of each nostril. Staphylococcus aureus pathogens that lurk in the nares are killed in a matter of minutes.
The application is simple to perform, which belies its importance. Research has shown that one-third of the general population is colonized with nasal S. aureus and 80% of surgical site infections are caused by bacteria that originates in the nose.
Treating patients with the sanitizer is inexpensive — about $3 per patient. We crunched the numbers and predicted we'd need to spend $18,000 for a year's worth of product. Compare that to upwards of $30,000 for treating a single SSI and the cost-benefit is abundantly clear.
CLINICAL TRIAL
Don't Do Away With Mupirocin Just Yet
NO ONE NOSE Head-to-head comparisons of all nasal decolonization methods will help identify the best option.
Fears of an increase in mupirocin-resistant MRSA have called into question the antibiotic's effectiveness as a nasal decolonization technique for combatting SSIs. But a recent study suggests the alternative alcohol-based antiseptic method requires further research before it becomes the go-to approach (osmag.net/wCk9RB).
"Because we use alcohol for hand hygiene and have not seen resistance develop to it, why not use the same thing for nasal decolonization? It's a fantastic idea," says Anubhav Kanwar, MD, one of the study's authors and leader of the Infectious Diseases, Tropical Medicine and Traveler's Health Clinic at Tri-State Memorial Hospital in Clarkston, Wash.
Dr. Kanwar and his team of researchers evaluated the effectiveness of a one-time application of an alcohol-based nasal antiseptic in MRSA-colonized patients, who received either a single dose or the manufacturer-recommended triple dose over 3 minutes. Researchers swabbed the anterior nares and vestibule prior to application, and then again 10 minutes, 2 hours, and 6 hours after application to test MRSA levels. They found that both the single and triple dose applications reduced MRSA concentrations at 10 minutes and 2 hours, with the triple dose statistically significant. But at 6 hours after both single and triple doses were applied, the concentration of MRSA in the nose returned to the pre-application baseline.
"Additional studies are needed to determine if repeated applications and more alcohol doses are needed to get rid of MRSA," says Dr. Kanwar. "Even though you're able to stop [MRSA] transiently [with alcohol], if it's coming right back, you're not achieving the desired outcome."
He says alcohol-based nasal antisepsis provides instant treatment, but patients are still at risk of developing SSIs when the sanitizing effects wear off in 2 to 6 hours. Mupirocin's action, on the other hand, is prolonged. "What we want is a permanent reduction in the MRSA colony count in the nose," he explains. "We're not at that point yet with alcohol."
Dr. Kanwar adds that resistance to mupirocin is a concern, but it's not a major concern, at least not yet. He says povidone-iodine nasal treatment has exciting possibilities, but it's too early to conclude that it will replace mupirocin.
The bottom line, he says: "We need to see more data from head-to-head comparisons of all the options before we decide if one is better than the others."
— Joe Paone
Before adding the nasal swab to our pre-op routine, we explored other nasal decolonization methods, most notably topical antibiotics. Screening patients for S. aureus colonization weeks before surgery and treating carriers with mupirocin is an effective way to decolonize patients before they enter your ORs, but this approach comes with inherent drawbacks. Patients must apply mupirocin over 5 consecutive days, making compliance a significant challenge. It's also costly, requires a prescription and raises concerns of potential antibiotic resistance (see "Don't Do Away With Mupirocin Just Yet").
More than 60% of our patients simply weren't complying with the at-home mupirocin decolonization protocol. Some found the application unpleasant or didn't comprehend its importance. Others were too busy and forgot, didn't have the time or didn't perform the regimen fully. Put all of those mitigating factors together and the big picture wasn't good: Patients' non-compliance put them at increased risk of surgical site infection.
If you want something done right
Pamela Bevelhymer, RN, BSN, CNOR BY A NOSE An alcohol-based antiseptic is a patient-friendly way to inhibit the growth of nasal Staphylococcus aureus.
We eventually stopped asking patients to treat their nares at home, deciding instead to do it ourselves on the day of surgery when we could make sure it's done, and done right.
We chose alcohol-based swabs, but we also considered povidone-iodine swabs. With this method, you administer alternating 30-second swabs of each nostril for a total of 4 applications. It's an effective antiseptic method, but the swabs are somewhat messy to apply and cost $26 per patient. Addition-ally, some patients are allergic to povidone-iodine.
When we decided to move forward with the alcohol-based antiseptic, we developed a clinical practice guideline and implemented it after our infection control practitioner approved it. It's standard practice for our pre-op nurses to treat every patient — barring a surgeon's specific recommendations or other contraindication, such as nasal and other head and neck surgeries (the alcohol contained in the product increases surgical fire risk) — with the sanitizer.
Proof is in the numbers
The program went live in January 2017, and the results have been overwhelmingly positive. We've found that our patients are very accepting of the process; often, they comment that they appreciate the efforts we make to reduce their infection risks. But the fact is, it's had a real impact on our SSI rate. Our already-low levels of SSIs have regressed year after year. Our baseline infection rate baseline for all cases was 0.8% in 2015, 0.7% in 2016, 0.55% in 2017 and 0.2% in 2018. So far this year, it's 0.17%.
Clearly, effective pre-op nasal decolonization can reduce SSI rates. Just as clearly, there are significant barriers to patient compliance. For us, finding a simple and cost-effective method of administration has helped us clear those barriers and has been a positive addition to our continuing efforts to prevent avoidable infections. OSM
If you want something done right
BY A NOSE An alcohol-based antiseptic is a patient-friendly way to inhibit the growth of nasal Staphylococcus aureus.
| Pamela Bevelhymer, RN, BSN, CNOR
We eventually stopped asking patients to treat their nares at home, deciding instead to do it ourselves on the day of surgery when we could make sure it's done, and done right.
We chose alcohol-based swabs, but we also considered povidone-iodine swabs. With this method, you administer alternating 30-second swabs of each nostril for a total of 4 applications. It's an effective antiseptic method, but the swabs are somewhat messy to apply and cost $26 per patient. Addition-ally, some patients are allergic to povidone-iodine.
When we decided to move forward with the alcohol-based antiseptic, we developed a clinical practice guideline and implemented it after our infection control practitioner approved it. It's standard practice for our pre-op nurses to treat every patient — barring a surgeon's specific recommendations or other contraindication, such as nasal and other head and neck surgeries (the alcohol contained in the product increases surgical fire risk) — with the sanitizer.
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