Nasal Antisepsis Done Right

Infection Prevention

By: Dan O'Connor

Published: 1/14/2020

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If you want to start a nasal decolonization program, you must first choose a nasal sanitizer: either pre-moistened, ready-to-use povidone-iodine swabsticks that look like Q-tips or a single-use ampule shaped like a tube of lip balm that combines ethanol with emollients. Next, you must decide whether you’ll swab the nostrils of all your patients an hour or so before surgery, or just decolonize the nares of those patients getting any type of implant: mesh, biological or hardware.

Regardless of the product and patients you choose, by joining the growing number of surgical facilities that have found nasal decolonization to be a simple and inexpensive way to deactivate the germs that are present in every person’s nasal passages, you’ll help stop the spread of nasal MRSA without contributing to antibiotic resistance, which is nothing to sneeze at. Research shows that one-third of the general population is colonized with nasal Staphylococcus aureus, and that 80% of surgical site infections are caused by bacteria that originates in the nose.

“Nasal decolonization is a simple, low-cost way to help reduce infection risk, and patients seem to understand and not mind at all,” says Teresa M. Salley, RN, MS, MSN, perioperative manager at Sycamore Hospital in Miamisburg, Ohio.

We reached out to OR managers who’ve made nasal antisepsis a part of their SSI prevention bundle for pointers on doing so successfully. Here’s what they had to say.

1. Should you decolonize all patients? Some experts believe you should swab all patients with a skin incision; others say it’s better to reserve nasal antisepsis for select patients undergoing procedures with higher risks of infection.

One facility swabs a list of patients provided by infection prevention, including all spine, joint replacement, transplant and bowel patients. Another only decolonizes those patients who screen positive for MRSA or MSSA. “Anyone receiving an implant,” is the criteria for Maureen May, RN, BSN, director of surgical services at Ascension St. Vincent Carmel and Fishers in Indiana. Nasal swabbing is reserved for joint, heart and spine patients at Advocate Good Shepherd Hospital in Barrington, Ill., says perioperative educator Sharon Dillon, BSN, MPA, CNOR. Houston Methodist Hospital in Baytown, Texas, will begin using nasal sanitizing swabs on joint replacement patients in response to a recent spate of MRSA infections, says clinical resource nurse Kathleen Vandenbout, BSN, RN, BC, CAPA.

Others say you should make nasal swabbing a universal procedure. “It’s easier if you do all patients,” says a facility leader. “Make it a universal procedure so that all patients receive swabs.”

BEFORE YOU GO Patients can apply nasal sanitizing swabs just before they're called back to the OR.   |  Kate Johnston/Saint Francis Hospital

2. How do you ensure that your busy pre-op nurses take the time to perform nasal decolonization? It only takes a minute or so to perform nasal decolonization, but you want to make sure your pre-op nurses don’t cut corners. One idea: Set out the swabs the night before, placing cups and swabs at each bedside. Another: Make it a routine part of the pre-op process, done immediately after the IV is started.

You can do random patient audits. You can also make it part of the medical record, an order on the nursing order set. “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.

You might ask your nursing assistants to perform the swab. Provide surgeons with evidence-based research and educate your staff on the who, what, where, when and, most importantly, why. Have your vendor onsite for several days to provide in-services to surgeons and staff.

“Follow up with the staff after implementation to discover if any work-arounds were put in place and if they’re applying it correctly,” says Ms. Culbertson. “Have conversations and directly observe.”

3. Nose to toes. For convenience and compliance, some suggest buying $7 kits that contain CHG wipes and nasal swabs, thereby bundling nasal antiseptics with patient skin decolonization.

4. Explain it to patients. Patients might be puzzled when you stick a wet substance up their noses. Instruct your nurses to explain that many bacteria live in the nose and pre-op nasal decolonization will decrease the patient’s risk of surgical site infection. Others suggest pre-admission testing nurses introduce the concept or hand patients a brochure in pre-op class.

“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.”

“Tell them they could be asymptomatic, but it could create a surgical site infection regardless,” says Ms. May.

Finally, this: Think of it as hand sanitizer for your nose. OSM

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