Infection prevention’s new rallying cry: Just a little swab will do you.
Yes, we’re hearing more and more about how nasal swabsticks magically decolonize the nares of pathogens and reduce MRSA SSI rates.
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The VA Portland Health Care System has quite a success story to share. A couple years ago, a nurse of 19 years embarked on an ambitious evidence-based project for her clinical nursing leader master’s thesis: lower MRSA infections through nasal decolonization before surgery. Melissa S. Schmidt, MSN, RN, CNL, CPAN, CAPA, PACU, had her work cut out for her. In 2016, the VA reported 13 MRSA-related SSIs, more than 1 a month. Ms. Schmidt set a modest goal to reduce infections by 10%. She underestimated herself.
She didn’t know a whole lot about Methicillin resistant Staphylococcal aureus (MRSA) and nasal decolonization. She learned fast that:
- 80% of wound infections are traced to the patients’ own nasal flora;
- most patients who develop MRSA infection will have been colonized before infection;
- 30% of people are colonized with Staphylococcus aureus, the leading cause of surgical site infections (SSI), when they reach the OR; and
- you can reduce MRSA SSIs through nasal decolonization.
Treat all or screen and treat?
Despite the VA’s best efforts to reduce infections, SSI rates among veterans had been on the rise, Ms. Schmidt discovered. A few things struck her when she examined the VA’s old protocol. One to 4 weeks before surgery, cardiac and orthopedic patients were screened for MRSA colonization via nasal swab. Patients who were MRSA-positive were treated with mupirocin ointment to the nares and chlorhexidine showers. At least that was the plan.
But physicians and patients alike struggled to comply with the mupirocin protocol. Patients weren’t always screened more than 7 days before surgery, some surgeons operated on patients with positive screens who hadn’t yet been decolonized and patients didn’t always follow instructions — not surprising when you consider that they had to self-administer mupirocin twice a day for 5 days and shower with chlorhexidine for 5 days.
“Would you rather self-administer nasal mupirocin twice a day for 5 days or have a nurse administer [povidone iodine] within 2 hours of surgery?” asks Ms. Schmidt, now the clinical nurse leader at the Portland VA. “The outcomes are about the same. That’s why no one’s using the mupirocin protocol.”
Research supports Ms. Schmidt’s views of the antibiotic-based antiseptic. One study found that a single treatment of nasal PI yields superior results to 7 to 10 mupirocin treatments over 5 days. Another found that PI is less expensive than nasal mupirocin, with comparable SSI outcomes.
Keep it simple
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Ms. Schmidt knew she had to design a decolonization protocol that was both easy to administer and effective. So she scaled back from her initial plan to treat all pre-op patients with chlorhexidine washcloths, oral chlorhexidine rinse and intranasal PI the evening before and the day of surgery.
The modified protocol simply calls for a nurse to swab the nares of every patient with povidone iodine 2 hours before surgery. Since they started doing that about a year ago, they’ve had 0 SSIs. Bonus: It only takes 2 minutes — there are 4 swabs per bottle, each used to windshield-wipe the vault and point of each nostril in 30-second sequences — for a pre-op nurse (or the patient) to swab and the PI costs $14 per patient. Most times the nurse handles the swabbing. If, for example, the patient is ticklish in his nose, he’ll swab himself under a nurse’s supervision.
Not only do they treat every patient for MRSA. With the exception of ophthalmic and GI procedures, and patients who are allergic to povidone-iodine, they also screen every surgical patient ahead of time for MRSA. This way, there’s ample time to get the 10% or so of patients who are carriers the right antibiotic. Patients who bypass the pre-op holding area are treated with PI in the OR by the circulating RN. So why screen and treat every patient with PI? Because, as Ms. Schmidt explains, PI is effective against all gram-positive cocci in addition to MRSA.
A word of caution: Ms. Schmidt says you can expect some early pushback from nurses who don’t see the value in adding 2 minutes to patient check-ins. Keep them engaged by updating them quarterly about the outcomes of their interventions. “People do things that have value,” she says. “Communicate that value. We’re preventing SSIs.”
To ensure a smooth liftoff, ask your vendor to send a trainer on site for the first few days, says Ms. Schmidt, who was happy to also receive templates for education. Finally, VA nurses don’t swab themselves. “Research has not shown that decolonizing staff makes a difference, so we don’t,” she says.
The VA hasn’t reported a MRSA SSI since the implementation of the intervention. “On any given day, you can walk into the pre-op holding area and hear the staff explaining and performing the intervention,” says Ms. Schmidt. “I feel very accomplished that chart reviews reveals high compliance, and the intervention has been adopted by the staff as normal practice.”
Alcohol based
Alcohol-based antiseptic treatments have a strong following. Among alcohol’s benefits: it doesn’t contribute to bacterial resistance, its effect is immediate and long-lasting, and, like iodine, it can be applied immediately before surgery.
Then there’s ease of use. Alcohol-based products dry quickly and are easy to apply, whereas povidone-iodine is a tubed ointment that can be difficult for patients to apply, notes Sue Barnes, RN, CIC, FAPIC, an infection prevention consultant. “The iodine product similarly is not pleasant to use. It stings, and it doesn’t smell good,” she says.
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Indeed, Ms. Schmidt says some patients complain of the “bromide” odor that subsides after a few minutes. “I’ve done it to myself,” she says, “and it smells like a swimming pool.”
Mupirocin has a fan in Sharon Orrange, MD, associate professor of clinical medicine at the Keck USC School of Medicine in Los Angeles, Calif. Dr. Orrange practices internal medicine and performs pre-op clearances for patients. She shares research to back her facility’s decision to use mupirocin, including one published in the Journal of Arthroplasty in 2013, which found that mupirocin twice a day and daily chlorhexidine showers for 5 days before surgery eradicated MRSA in colonized total joint patients. The other study, released by the Society for Healthcare Epidemiology of America (SHEA) in 2012, found that treating all total joint patients with mupirocin and screening them first and then treating only those who are positive to be equally more beneficial and equally more cost effective than a no-treatment strategy.
Researchers concluded that the treat-all and screen-and-treat strategies have similar average cost-effectiveness ratios, with only trivial differences. A treat-all strategy is simpler to implement and avoids missing potential carriers because of false-negative test results. However, facilities with a high prevalence of mupirocin-resistant strains may prefer a screen-and-treat strategy, concluded the study, led by Xan F. Courville, MD, from the department of orthopaedics at Dartmouth Hitchcock Medical Center in Lebanon, N.H.
Last spring, when Mackenzie McCoy, RN, was in nursing school at the Mayo Clinic in Rochester, Minn., she explored nasal decolonization as a student working at the Mountain View Regional Hospital (MVRH) in Casper, Wyo. She shared her experience in an honors thesis paper. At the time, MVRH was using povidone-iodine antisepsis. The swabs came presaturated and required application 1 hour before surgery; application required rotating the swab in the nostril for 30 seconds on each side and then repeating the process. According to Ms. McCoy, the patients reported no discomfort with the application. The nares tolerated the solution well, she notes, and the cost for an application was $3.60.
Ms. McCoy also evaluated the use of alcohol-based nasal antisepsis in her thesis paper. Because MVRH doesn’t use the product, she and some nurses used the products on themselves. They agreed that it was easy to use, less messy than the povidone-iodine swabs and that it had a pleasant scent. One application cost $1.31 when they purchase 250 applicators, she says.
Marshall Medical Center, a 113-bed acute care hospital in Placerville, Calif., uses alcohol-based antiseptic on everyone who gets an incision, not just those who test positive through screening, says Nina Deatherage, RN, BSN, CIC, the infection control lead. “It took a while to get the surgeons to approve that we will be doing this to their patients as part of the pre-op bundle,” she says.
They administer the alcohol-based antiseptic 3 times to patients within the hour before surgery, says Ms. Deatherage. “It’s like painting a wall,” she says. “Three rolls and you know you have covered every spot.”
Ms. Deatherage adds that she was sold on the antiseptic’s pleasant smell. And, she should know, having tested it out on her own nasal cavity. “My work partner and I used it twice a day for a week on ourselves,” she says. “The smell was nice, and we had no ill effects whatsoever. I hear patients say “Oh, this is pleasant!’”
Sure, sticking a swab up a patient’s nose is more challenging than having them pump a bottle of hand antiseptic, but it is worth the effort. In fact, according to Ms. Barnes, further studies are considering the worth of continuing nasal decolonization postoperatively, when the patient leaves the facility, and the potential benefits of having an entire surgical team undergo the process before surgery. OSM
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