By Matt Phillion
The Association of periOperative Registered Nurses (AORN) recently updated its guidelines for antisepsis and nasal decolonization. These updates lend weight to long-held practices and offer guidance toward safer pre-surgical and preoperative care. But what impact will they have on your organization?
“Ultimately, what these guidelines and changes represent is the incorporation of a very comprehensive bundle of care in the pre-procedural setting,” says Holly Montejano, MS, CIC, CPHQ, clinical science liaison with PDI Healthcare, and an epidemiologist and hospital infection prevention practitioner. “Incorporation of nasal decolonization makes it comprehensive.”
The AORN guidelines discuss both skin and nasal decolonization and skin prep as well as antibiotic prophylaxis and hair removal (among other topics), but the changes to decolonization guidelines are what jump out to Montejano.
“There really hadn’t been a component within the guidelines addressing nasal decolonization,” says Montejano. “That’s a big addition to these skin antisepsis guidelines.”
In terms of whether the changes will impact the workload for organizations and practitioners, a lot of facilities in the preoperative arena had already started incorporating nasal decolonization, she notes. Professional guidelines are out in the field for certain subsets of patients to receive nasal decolonization.
“Now we have AORN making a recommendation for incorporating nasal decolonization into best practice guidelines,” adding an influential weight to the practices, says Montejano.
The concept was on professionals’ radar even before the pandemic, she says.
“At the facility I came from where I was an infection preventionist, we were doing nasal decolonization for at least 10 years—they were doing it prior to when I started there for certain high-risk surgery types,” says Montejano. “Now we’re seeing it become the norm.”
Facilities had relied on research prior to official guidelines, which makes the update to AORN’s response impactful. The AORN adds their voice to the World Health Organization, the Institute for Healthcare Improvement, and the Society of Thoracic Surgeons, as well as the CDC and the Society for Healthcare Epidemiology of America.
Montejano highlights a standout component of the AORN guidelines: the mention of povidone iodine, an antiseptic, on the list of recommendations.
Antiseptic and antibiotic prep
What does povidone iodine mean for facilities? Including an antiseptic in the guidelines, not just antibiotics, is a key change for practitioners and for patients.
Patients are often prescribed mupirocin—a topical antibacterial—prior to surgery. While effective, muciprocin presents a distinct challenge. “In order to receive a full therapy, it’s five days twice a day, and meant to address a certain subset of organisms—staph and strep species,” in particular methicillin-resistant Staphylococcus aureus (MRSA), Montejano says.
The guidelines seek to reduce surgical site infections, which occur due to a multitude of organisms, and while mupirocin is effective at its primary use, it offers limited therapeutic coverage versus a broad-spectrum antiseptic. “This can make compliance difficult,” says Montejano. “The patient has to be given the prescription and stick to that regimen prior to the procedure.”
By contrast, an antiseptic, like 10% povidone iodine, can be applied once before surgery and offer a 99.9% reduction of Staphylococcus aureus, says Montejano. “It covers a whole lot of other Gram-positive and Gram-negative organisms,” she says. “It’s one and done.”
This eliminates one of the biggest challenges to mupirocin: unplanned surgeries.
“A lot of surgeries are elective and scheduled, but a lot are not,” says Montejano. “Particularly cardiac or neural patients. You don’t know when you’re going to have a heart attack or a stroke.” Those patients are at risk of falling out of compliance with a nasal decolonization protocol without the use of an antiseptic as preoperative treatment.
Of course, there’s one more challenge that a one-and-done treatment helps alleviate: patients not complying with the regimen.
“Patients are the most difficult variable to control,” says Montejano. Thus there’s an advantage to “[taking] surgical site infection prevention and intervention out of the patient’s hands and into that of a healthcare provider to ensure compliance.”
Why does decolonization matter?
The objective of decolonization is to decrease the bacterial load of the body and nose, and the AORN documentation references compelling stats in terms of how the body’s own flora can cause infection. According to the guidelines, 30% of healthy adults have staph on their skin or nose, and 80% of surgical infections can be attributed to the patient’s own flora.
“These bacteria live on our bodies in an equilibrium until we disrupt our immune defense, and a surgical incision is what disrupts the integrity of the skin,” says Montejano.
Decolonization can improve this up to nine times, so it’s important to include decolonization in the operation bundle.
“We walk around with organisms on us every day. These organisms can be pathogenic when our immune defenses are compromised, and certainly colonization can increase our risk,” says Montejano.
The important component here, she notes, is selling nasal decolonization to those it directly impacts. Leaders need to explain any new intervention, implementation, or product use to frontline staff and educate them so they can understand how it keeps patients safe and free of infection during a high-risk period.
“There’s a lot of ways to educate; in my position with PDI, we provide comprehensive education packages,” says Montejano. The pandemic has brought virtual education to the forefront, so computer-based modules and learning systems are also becoming more common. Montejano also points out the importance of training the trainer, to support them in building a sustainable safety culture.
Leadership may need education as well. Any improvement comes with a cost, so “it’s a matter of understanding the proactive aspects of these types of interventions,” says Montejano. “They drive good patient outcomes. And really, patients are now consumers of healthcare—they’re educated, and they want to make sure facilities they go to are providing good, evidence-based care.” Nasal decolonization is part of that care, she says.
Different approaches to nasal decolonization have different impacts, and these differences can help influence both providers and patients in terms of pre-surgical prep. Antibiotic treatment can be more labor intensive for frontline workers to administer to patients than antiseptic treatment, so educating the healthcare workers administering the product as well as the patient receiving it bolsters compliance and sustainability of practice.
“This is as good a time as any to have that conversation,” says Montejano. “ ‘Why did the nurse just put this swab up my nose?’ This should be a conversation between the worker and the patient so they understand why.”
A broad-spectrum, pre-saturated, fast-acting antiseptic aids in ease of use as the healthcare worker need only open the dose and apply.
Using antiseptics for nasal decolonization also sidesteps the long-standing concern about building up antibiotic resistance.
“So much of the research that has been done in terms of surgical site infection prevention and decolonization has been done with mupirocin because of its frequent use,” says Montejano. “Two years after it was launched in the 1980s, there was already resistance reported. It’s very much on everyone’s radar.”
No discussion about changing tactics for preventing surgical site infections is complete without mentioning the need for tracking efficacy. The AORN guidelines do point out the need for surveillance of resistance, which Montejano says makes sense: “You want to be tracking its efficacy for its intended use.”
“In my own experience, certain facilities are tracking resistance trends, and that is an impetus to move from antibiotic to antiseptic [treatments],” says Montejano. “All facilities should be tracking their resistance patterns. They’re mainly doing it with oral and intravenous antibiotics, not so much with topicals.”
Because mupirocin is a topical treatment, some organizations may need new tracing methods. Montejano points out that resistance and other factors can vary between communities as well.
“We’re very much interconnected,” she says. “Evaluate available resources [and] plan for expansion of resources in order to effectively track resistance to antibiotics.”
“Variations lead to infection, which is what was drilled into me as an infection preventionist,” says Montejano. “As much as you can, standardize the care.”
Whether adopting universal or horizontal approaches, Montejano recommends taking the antiseptic piece of the new guidelines to offer broad-spectrum coverage that doesn’t have resistance concerns.
“It’s nice because an organization can now choose how,” she says. “An antiseptic fits into both types of strategies, whether you’re using a universal or more targeted approach. You can use it in either strategy.”
The AORN document is impressively comprehensive in its guidance and background, Montejano says.
“It’s nice to see these guidelines incorporated—it may be a changing of the guard in terms of the best chemistry,” she says. “At the end of the day, we’re talking about human lives. We need to be critical in assessing the literature out there to ensure interventions used in direct patient care are safe and effective.”
Matt Phillion is a freelance writer covering healthcare, cybersecurity, and more. He can be reached at firstname.lastname@example.org.