karen dekay, msn, rn, cnor, cic
TRANSCRIPT
Karen deKay, MSN, RN, CNOR, CICPerioperative Practice SpecialistAORN
Deva Rea, MPH, BSN, RN, CICClinical Science LiaisonPDI
Objectives
Recognize the impact of decolonization on reducing skin flora and surgical site infections
Navigate risk-based decisions for developing preoperative decolonization programs using the updated AORN guideline for preoperative patient skin antisepsis
Patient Story – Rosie Bartel
Advocate 3.3 Billion Dollars
1 Million Inpatient
Days
3% Mortality
Rate
75% Attributable
to SSI
Colonization
(https://www.cdc.gov/nhsn/pdfs/pscmanual/9pscssicurrent.pdf)
DefinitionsColonization: Asymptomatic carriage of organisms (such as S aureus) on skin, in body fluids, or tissues that are not causing a clinically adverse effect for the individual
Decolonization: Practice of treating patients with known S aureus colonization with antimicrobial and/or antiseptic agents to suppress or eradicate S aureus colonization
Methicillin-susceptible S aureus (MSSA): strain of S aureus that does respond to methicillin but remains resistant to other beta-lactam antibiotics and cephalosporins
Methicillin-resistant S aureus (MRSA): strain of S aureus that is resistant to all types of beta-lactam antibiotics, as well as cephalosporins
Colonization can lead to infection….
https://www.cdc.gov/infectioncontrol/training/strive.html#anchor_MRSA
S aureus Colonization Sites
Most often colonizes nares
30% with both skin and intranasal colonization
75% with nasal carriage are colonized
at 1 or more extra-nasal sites
(Mermel LA et al. J Clin Microbiol 2011; 49:1119)
a. 1b. 3c. 5d. 10
How many times per day does the average person touch their nose?
Polling Question #1
How many times per day does the average person touch their nose?
a. 1b. 3c. 5d. 10
(Kwok et al.,2015)
a. 20%b. 30%c. 50%d. 80%
What is the percentage of S aureus SSIs that can be attributed to the patient’s own bacteria?
Polling Question #2
S aureus and SSIs
Endogenous Leading pathogen
2- to 9-fold increase
80% to patient’s own bacteria
(Pal et al., 2019; Sakr et al, 2018)
(Weiner-Lastinger et al., ICHE 2020)
Causative SSI Pathogens per CDC NHSN(2015-2017)
a. Methicillin-resistant Staphylococcus aureus (MRSA)b. Methicillin-susceptible Staphylococcus aureus (MSSA)c. MRSA and MSSAd. Vancomycin-resistant Enterococci (VRE)
Which specific organism(s) should be targeted for surgical patient decolonization?
Polling Question #3
a. Methicillin-resistant Staphylococcus aureus(MRSA)
b. Methicillin-susceptible Staphylococcus aureus (MSSA)
c. MRSA and MSSAd. Vancomycin-resistant Enterococci (VRE)
Which specific organisms should be targeted for surgical patient decolonization?
MRSA and MSSA
MRSA ~1-3%
MSSA ~30%
Screening for both is necessary• Mediastinitis study
• Cardiothoracic and orthopedic study
(San Juan R., et al, 2007; Septimus & Schweizer, 2016; Van Rijen M.M.L., et al, 2013)
AORN Guideline for Preoperative Patient Skin Antisepsis
E-release: May 2021
Book Publication: 2022
Team Decision• Suggested Members• Risk-based• Resources• Proceed (yes/no)
Interdisciplinary TeamInfection
Preventionists
Epidemiologists
Pharmacists
Perioperative RNs Surgeons
Microbiology lab
personnel
Other stakeholders
Local Epidemiology & Procedures
Prevalence in
CommunityS aureus SSIs
Antibiotic Susceptibility
Profile
High Risk Procedures
• CABG and Valve Replacement
• Cardiac Assist Devices• Total Joint Replacement• Spinal Fusion• Trauma Patients with
Device Implantation
https://www.cdc.gov/mrsa/community/photos/photo-mrsa-9.html
https://text.apic.org/toc/microbiology-and-risk-factors-for-transmission/antimicrobials-and-resistance
https://www.cdc.gov/mrsa/community/photos/photo-mrsa-1.html
a. Asthmab. Cerebral vascular accident (CVA)c. Middle aged. Obesity
Which of the following is NOT a patient risk factor for colonization with S aureus?
Polling Question #4
Some Patient Risk Factors (Table 1)
Indwelling medical device
Living in congregant
setting
Advance age
(adults over age
65)
History of CVA Obesity
(BMI >30)• Asthma• End stage liver
disease• Cardiac• Diabetes• Immuno-
compromised
Underlying diseases such as:
(Campbell KA et al., 2015; Herwaldt et al., 2004; Siegal et al, 2006)
Develop Program• Strategy• Protocol• Timing
1.2,1.3,1.3.1,1.3.2, 1.4.1
Decolonization Strategies
Universal• General
population
Targeted• Select
population
Blended• Combines
strategies
(Septimus & Schweizer, 2016)
Characteristic Universal Targeted
Implementation Easier as everyone receives Challenging for screening, reporting of results, receiving product
Sensitivity 100% (Staphylococcus aureus carriers will not be missed)
Some patients may not be screened, the test procedure may not have 100% sensitivity, and non-nasal S aureus carriers may be missed
Product volume Approximately 5 times that in the targeted strategy
For detected S aureus carriers only
Screening No screening All patients
Cost Allocation of product Screening, reporting, allocation of product
(Septimus & Schweizer, 2016)
Decolonization Protocols • Mupirocin• Intranasal• Intranasal + Skin Agent
Antibiotic (Table 3)
• Povidone-iodine; Alcohol-based• Intranasal• Intranasal + Skin Agent
Antiseptic (Table 4)
Table 5: Health Agency & Professional Society RecommendationsEntity Nasal Protocol Skin Protocol
American College of Surgeons and Surgical Infection Society, 2016
Nasal mupirocin 2% No recommendation
American Hospital Association, 2013 Nasal mupirocin or nasal povidone iodine at least 3 days prior to surgery
Chlorhexidine gluconate (CHG)
American Society of Health-System Pharmacists, 2013
Nasal mupirocin 2% No recommendation
Centers for Disease Control and Prevention, 2019
Intranasal anti-staphylococcal antibiotic/antiseptic (eg, mupirocin or iodophor)
CHG
National Association of Orthopaedic Nurses, 2013
Nasal mupirocin 2% bid until time of procedure
No recommendation
National Institute for Health and Care Excellence, 2019
Nasal mupirocin 2% CHG
Society for Healthcare Epidemiology of America/Infectious Diseases Society of America, 2014
Anti-staphylococcal agent No recommendation
World Health Organization, 2016 Nasal mupirocin 2% with or without skin decolonization
If used, CHG
Timing Ideally before procedure• Screen/results• Product obtainment• ? Continue postoperatively
Urgent/emergent procedures
(Saraswat et al., 2017; Kohler et al., 2015)
Implement
Procure• Reliable• Easy• Continuous
Educate • Patient &
HCW• Procedure• Benefit
Monitor• Adherence • CHG• Mupirocin
1.4.2, 1.4.3, 1.4.4, 1.5,1.5.1
Weigh Factors
Epidemiology
Surgical Population
Weigh FactorsNumber of
applications
Patient compliance
Persistence
Cost
Screening for resistance
# of robust studies
# studies in your surgical population
Epidemiology
Surgical Population
Thank you!
References• Campbell KA, Cunningham C, Hasan S, Hutzler L, Bosco JA,3rd. Risk factors for developing staphylococcus aureus nasal
colonization in spine and arthroplasty surgery. Bull Hosp Jt Dis (2013). 2015;73(4):276-281 • Centers for Disease Control. National Healthcare Safety Network (NHSN). Surgical site infection event. In Procedure-
associated Module. January 2021: CDC 9-1 – 9-2.• Herwaldt L, Cullen J, French P, et al. Preoperative risk factors for nasal carriage of staphylococcus aureus. Infect Control
Hosp Epidemiol. 2004;25(6):481-484.• Kohler P, Sommerstein R, Schonrath F, et al. Effect of perioperative mupirocin and antiseptic body wash on infection rate
and causative pathogens in patients undergoing cardiac surgery. Am J Infect Control. 2015;43(7):e33-8• Kwok YO, Gralton J, McLaws, ML. Face touching: A frequent habit that has implications for hand hygiene.
AJIC.2015;43:112-114.• Mermel, L. A., Cartony, J. M., Covington, P., Maxey, G., & Morse, D. (2011). Methicillin-resistant Staphylococcus aureus
colonization at different body sites: a prospective, quantitative analysis. Journal of clinical microbiology, 49(3), 1119–1121. • Olmsted, R. Methicillin-resistant Staphylococcus aureus (MRSA) Bacteremia.
https://www.cdc.gov/infectioncontrol/training/strive.html#anchor_MRSA• Pal S, Sayana A, Joshi A, Juyal D. Staphylococcus aureus: A predominant cause of surgical site infections in a rural
healthcare setup of Uttarakhand. J Family Med Prim Care. 2019;8(11):3600-3606.
References cont…• Sakr A, Brégeon F, Mège JL, Rolain JM, Blin O. Staphylococcus aureus Nasal Colonization: An Update on Mechanisms,
Epidemiology, Risk Factors, and Subsequent Infections. Front Microbiol. 2018;9:2419.• San Juan, R., Chaves, F., Gude M.J.L., et al. Staphylococcus aureus poststernotomy mediastinitis: Description of two
distinct acquisition pathways with different potential preventative approaches. J Thorac Cardiovasc Surg 2007;134:670-676.• Saraswat, M. K., Magruder, J. T., Crawford, T. C., et al. Preoperative Staphylococcus aureus screening and targeted
decolonization in cardiac surgery. Ann Thorac Surg. 2017;104:1349-1356• Septimus EJ, Schweizer ML. 2016. Decolonization in prevention of health care-associated infections. Clin Microbiol Rev
29:201–222.• Siegal, JD, Rhinehart E, Jackson, M & Chiarello, L. Management of Multidrug-resistant organisms in healthcare settings,
2006. Last updated February 15, 2017. https://www.cdc.gov/infectioncontrol/guidelines/mdro/• Van Rijen M.M.L., Bode,L.G., Baak D.A., et al. Reduced costs for Staphylococcus aureus carriers treated prophylactically
with mupirocin and chlorhexidine in cardiothoracic and orthopedic surgery. PLOS one 2013;7:e42065• Weiner-Lastinger LM, Abner S, Edwards JR, et al. Antimicrobial-resistant pathogens associated with adult healthcare-
associated infections: Summary of data reported to the National Healthcare Safety Network, 2015-2017. Infect Control Hosp Epidemiol. 2020 Jan;41(1):1-18.
Using Profend® Nasal Decolonization Kit Putting Guidelines into Practice
Deva Rea MPH, BSN, RN, CICMarc-Oliver Wright MT(ASCP), MS, CIC, FAPIC
Objectives• Identify how Profend® Nasal Decolonization Kit fits into the
new guidelines• Define elements for successful product implementation• Highlight customer success story using Profend® Nasal
Decolonization Kit
First Polling QuestionAre you currently decolonizing the nose pre-operatively?1. Yes, for all procedures2. Yes, but only for high-risk procedures3. No, not performing nasal decolonization4. I don’t know
Second Polling QuestionWhat type of nasal decolonization practice is being deployed at your facility?1. Targeted decolonization2. Universal decolonization3. Blended – depends on the situation (procedure, MD, etc.)4. None5. I don’t know
Decolonization Strategies• Profend® swabsticks work for all decolonization strategies:
• Universal: • Broad spectrum activity against S. aureus, MRSA, and other bacteria1
• May remove the need to screen pre-operatively for MSSA• No evidence of bacterial resistance• Can be used in emergent procedures
• Targeted: • Reduces 99.7% of S. aureus at 10 minutes, 1 hour and 99.9%
at 12 hours for patients testing (+) for MSSA/MRSA2
1. PDI in vitro Study PDI-0113-KT12. PDI in vivo Study PDI-0113-CTEV01
Procurement• Profend® Nasal Decolonization Kit
is readily available through your medical supply distributor
• Product packaging:• 4 swabs in 1 patient kit• 12 patient kits in 1 box (shelf unit) • 4 shelf units/case
Timing and Protocol• No additional resources needed• Treatment via standing physician order or nurse driven protocol as
part of the SSI prevention bundle• No prescription required; no prescription cost to the patient
• Application is simple and efficient and easily fits within the pre-operative workflow
• Application 1 hour pre-procedure; 10-minute pre-procedure for emergent cases
• In vivo data shows a 99.9% reduction of S. aureus at 12 hours3 post application providing coverage during the highest risk period
3. PDI in vivo Study PDI-0113-CTEV01
Implementation and Application• Quick, 60 second total treatment time – Up to 2.5x faster
application than other PVP-Iodine swabs4
• 4 swabsticks/patient (2 each nostril); 15 sec. for each application• Neat, dry-handle design minimizes mess
• Pre-saturated swabs need no preparation – just snap and swab• Slim, compact design for patient comfort
• Assured treatment compliance as product is applied by clinician 1 hour prior to surgery
• 96.6% of patients surveyed are comfortable with nasal application of PVP-Iodine5
4. Instructions for use5. Maslow J, Hutzler L, Cuff G, Rosenberg A, Phillips M, Bosco J. Patient experience with mupirocin or povidone-iodine nasal decolonization. Orthopedics. 2014;37(6):e576–e581.
Education• Education is provided to the
healthcare workers via onsite/virtual vendor training, online training module, video and written Profend® IFU
• Patient brochures are also available including QR code for video IFU
Third Polling QuestionWhat is the total treatment time for Profend® swabsticks application?1. 120 secs (2 minutes): 30 sec. each for 4 swabsticks2. 60 secs (1 minute): 15 sec. each for 4 swabsticks3. 60 secs (1 minute): 30 sec. each for 2 swabsticks4. I don’t remember!
Elements of Successful Implementation• Product readily available• Nurses/healthcare workers trained on new product• Patients informed and accepting of protocol• Process fits nicely into workflow• Process easy to monitor for compliance• Positive patient outcomes
Nasal PVP-I implementation for preventing surgical site infections: Perspectives of surgical nursesPurpose: “To evaluate the implementation feasibility, fidelity and acceptability of intranasal PI (Povidone-Iodine) solution application by surgical nurses using the Integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) conceptual framework.”6
6. Hammond EN, Brys N, Kates A, Musuuza JS, Haleem A, Bentz ML, et al. (2020) Nasal povidone-iodine implementation for preventing surgical site infections: Perspectives of surgical nurses. PLoS ONE 15(11): e0242217. https://doi.org/10.1371/journal.pone.0242217
Nasal PVP-I implementation for preventing surgical site infections: Perspectives of surgical nursesMethod: Qualitative study6
• 2 facilities used different methods for implementation of PVP-I pre-surgical
• ASC (facility A) and Acute Care OR (facility B)• Used conceptual framework to develop interview questions
and analyzed the data using deductive content analysis• Evaluated nurses’ experience/perceptions on preoperative
intranasal decolonization product implementation6. Hammond EN, Brys N, Kates A, Musuuza JS, Haleem A, Bentz ML, et al. (2020) Nasal povidone-iodine implementation for preventing surgical site infections: Perspectives of surgical nurses. PLoS ONE 15(11): e0242217. https://doi.org/10.1371/journal.pone.0242217
Results – Takeaways • Role of an implementation facilitator is critical to the success of
product adoption• Ensure facility notifies staff of new product implementation and
include why• Ensure sufficient information given pre-implementation stage to
nurses to develop competence in explaining to patients • Video training worked well (facility B) to convey product use, and
allowed for a resource to reference• Protocol should be formal and written for indefinite reference• Use a variety of educational tools
6. Hammond EN, Brys N, Kates A, Musuuza JS, Haleem A, Bentz ML, et al. (2020) Nasal povidone-iodine implementation for preventing surgical site infections: Perspectives of surgical nurses. PLoS ONE 15(11): e0242217. https://doi.org/10.1371/journal.pone.0242217
What Is the Impact of Prophylactic Nasal Decolonization in Prevention of SSI? Wagner et.al., Duke RaleighAbstracts / American Journal of Infection Control 48 (2020) S15−S58
Abstract:• Using principles of total quality management
(TQM) to implement a new broad spectrum antiseptic nasal swab product,
• An interdisciplinary team initiated nasal decolonization in elective total hip, total knee, and spinal fusion surgical patients.
Conclusions:• Found preoperative nasal povidone iodine
decolonization to be a safe, efficient, and cost-effective strategy in reducing SSIs in elective orthopedic surgeries. Patients and organizations may benefit from incorporating this strategy into preoperative SSI prevention protocols.
Results:• Zero SSIs for the 47 THAs and 79 TKA surgeries performed,
and only 1 SSI for the 320 SF surgeries completed • Collective SSI rate (0.002) decreased 60% from 3 months
prior and is 3 times lower than the SSI rate of the 797 other surgeries (0.006) performed during the 3-month nasal decolonization period
• No adverse safety events pertaining to nasal decolonization have been reported
• Due to the success of the nasal decolonization initiative, other surgeons outside of the pilot populations have requested the povidone iodine nasal swab administration for their patients preoperatively
Last Polling Question- it’s a tough oneWhat year was PVP-I first synthesized by the Toxicology Labs of Philadelphia?1. 19422. 19553. 19904. 2020
In summaryProfend® Nasal Decolonization Kit
Thank you!
Audience Q&A
53
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