A Retrospective Chart Review of a Nasal Decolonization Program to
Decrease Surgical Site Infections at a Comniunity Based Medical Center
By
EarlVLaih
(MBA,BSN,ADN)
MBA,Western Governors University, 2016
BSN,Chamberlain College of Nursing, 2009
ADN,Kansas Wesleyan University, 1997

A DNP Research Project Submitted to Clarion and Edinboro Universities
In Partial Fulfillment ofthe Requirements for the Dc ctor of Nursing Practice Degree
May 2021

5.12.21

Date

immittee Chain

5/14/2021

A

gI
Date

(j OD^jnittee Member
*

Committee Member

5/17/21
Date

Dean, College of Educationj, Health and Human Services
Clarion University

I

A Retrospective Chart Review of a Nasal Decolonization Program to Decrease Surgical Site
Infections at a Community Based Medical Center

Abstract
Background: Surgical site infections (SSI’s) are a major concern for patients, providers, and
healthcare organizations worldwide. SSI’s remain the costliest and most common of all hospitalacquired infections (HAI’s) (Septimus, 2019). It is estimated that SSI’s occur in 2 percent to 5
percent of all patients undergoing surgery, translating to 160,000 to 300,000 people annually at a
cost of $3.5 to $10 billion (Ban et al., 2017). An SSI substantially increases morbidity and
mortality as patients are twice as likely to die, are 60% more likely to be admitted to the
intensive care unit (ICU), and the readmission rate is five times higher than patients who do not
have a hospital-acquired SSI (Darouiche, 2019).

Research Question: Did the intervention of preoperative nasal decolonization using the Profend
Nasal Decolonization Kit, 10% povidone-iodine (PVP-I), reduce surgical site infections in
patients undergoing an orthopedic surgery with implantation, to include total joint arthroplasty
(TJA) and an orthopedic fracture repair, in a 12-month period preintervention compared to a 12month period post-intervention?

Objective: The objective of this DNP project was to evaluate the effectiveness of using a 10%
PVP-I Nasal Decolonization Kits in the prevention of SSI’s in patients undergoing an orthopedic
surgery for a TJA or fracture repair at the medical center.

Running head: RETROSPECTIVE CHART REVIEW OF NASAL

Methods: This DNP project used a retrospective data review from data points previously
collected as part of standard work performed in the EMR. All patient information was blinded
when the information was displayed. A standard report from the EMR was run to collect all
data.

Results: The preintervention group was composed of 431 patients and the postintervention
group contained 365 patients. The preintervention group had eight postoperative infections for
an infection rate of 1.86%. The postintervention group had an infection rate of 0.27%. This
resulted in a p-value of 0.0367 using a two proportions z-score, showing a statistical
improvement in SSI’s.

Conclusion: The facility successfully implemented a nasal decolonization program with 10%
PVP-I that decreased the number of infections, had a higher compliance rate for PVP-I nasal
swab over the national average for mupirocin, and showed potential cost savings for the medical
center.

Keywords: Nasal decolonization, povidone-iodine decolonization, surgical
site infections, SSI reduction.

Running head: RETROSPECTIVE CHART REVIEW OF NASAL

Dedication
I dedicate this doctorate project to my wife, Danielle, and my 5 children: Grace, William, Ellie,
Nick and Vaughn. Paise YHVH for His grace and mercy forever.

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Running head: RETROSPECTIVE CHART REVIEW OF NASAL

Acknowledgement
I thank Dr. Colleen R. Bessetti-Barrett, my project adviser, for the guidance she gave me
throughout the course of the project. I also wish to acknowledge Alejandra Sanchez
(Perioperative Senior Systems Analyst), Dr. Pamela Amodia (Infection Prevention Nurse
Manager), Ignacio Franko- Avila (Senior Quality Specialist) and Shelly Bressoud (Perioperative
Services Manager) for their support and assistance through this journey I have been on for the
past 2 years.

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Running head: RETROSPECTIVE CHART REVIEW OF NASAL

Table of Contents
Title Page

I

Abstract

II

Dedication

IV

Acknowledgment

V

Table of Contents

VI

List of Tables

IX

List of Graphs

IX

Chapter 1
Introduction

1

Clinical problem

3

Purpose

6

Significance in nursing

7

Project objectives

9

Chapter 2
Literature review

10
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Running head: RETROSPECTIVE CHART REVIEW OF NASAL

Summary of literature

10

Related research

11

Review of findings

12

Gaps in literature

16

Chapter 3
Methods

18

Project design

18

Sample

20

Methods

21

Instruments

22

Data analysis

23

Chapter 4
Results

25

Secondary findings

26

Chapter 5
Project summary

29
VII

Running head: RETROSPECTIVE CHART REVIEW OF NASAL

Limitations

30

Future research

30

Dissemination method

32

Impact of the program

32

Conclusion

34

References

35

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Running head: RETROSPECTIVE CHART REVIEW OF NASAL

List of tables
Table 1: Demographics

25

Table 2: Patient SSI data

26

Table 3: Z- score

26

Table 4: Decolonization percentage

28

Table 5: Financial impact

34
List of graphs

Graph A: Total patents decolonized prior to surgery

27

Graph B: Patient check in location prior to surgery

28

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Running head: RETROSPECTIVE CHART REVIEW OF NASAL

A Retrospective Chart Review of a Nasal Decolonization Program to Decrease Surgical Site
Infections at a Community Based Medical Center
Chapter 1
Introduction
Surgical site infections (SSI’s) are a major concern for patients, providers, and healthcare
organizations worldwide. That is one reason why The Joint Commission (TJC), the Centers for
Disease Control (CDC), American College of Surgeons (ACS), Association of Operating Room
Nurses (AORN), and other organizations continue to make SSI’s a major focal point for
continued process improvement. SSI’s remain the costliest and most common of all hospitalacquired infections (HAI’s) (Septimus, 2019).
The CDC defines an SSI as occurring within 30 days of surgery, except for surgeries with
implants, and classifies SSI’s in three categories (Surgical Site Infection, n.d.). The CDC
definition for SSI’s is used by the ACS and other organizations for reporting and tracking
SSI’s. The 3 SSI classifications are:


Superficial- A surgical site infection that occurs in the area of the skin where the incision
is made.



Deep- A surgical site infection that occurs beneath the incision area around the muscle
and the surrounding muscle tissue.



Organ space- A surgical site infection that can be in any area of the body other than the
skin, muscle, or surrounding tissue that was involved in the surgery. This can include an
organ or the body space between the organs.

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Running head: RETROSPECTIVE CHART REVIEW OF NASAL

The Joint Commission is a voluntary accreditation organization for acute care medical
centers and healthcare organizations. They conduct triannual surveys of hospitals and assess
them on a list of established standards and criteria. One of these standards, IC.01.03.01, states an
organization must conduct surveillance of its risk procedures and target resources to reduce the
risk for procedures that are classified as high-risk (Surgical Site Infections (SSI) - Surveillance
and Resources, n.d.). This standard prompts organizations to continually monitor SSI’s, and
look for ways to prevent harm for patients undergoing invasive procedures in their
facilities. Proactive risk assessment, retrospective chart reviews, and deep dives into fallouts are
some ways in which an organization conducts surveillance. Out of the surveillance, programs to
optimize care preoperatively, intraoperatively, and postoperatively are developed and practice
changes are implemented to reduce risk. SSI bundles are common practice changes designed to
reduce the risk of an SSI and improve patient outcomes that are based on scientific underpinning,
expert opinion, and best practices from leading organizations. Common SSI Bundle elements
include:


Smoking cessation prior to surgery.



Maintaining normothermia through the perioperative setting to include pre-, intra-, and
postoperative phases of care.



Hair removal preoperatively outside of the surgical suite.



Antibiotic dosing preoperatively with redosing intraoperatively as indicated.



Appropriate surgical skin prep supported by literature as opposed to personal preference.



Surgical hand scrub with the correct product, for the correct time.

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Running head: RETROSPECTIVE CHART REVIEW OF NASAL

In addition to SSI bundles, other recommendations and practice changes have been made
to include things such as SCIP Core Measures and ERAS protocols. SCIP is the Surgical Care
Improvement Project. Born in 2005 out of the Surgical Infection Prevention (SIP) project from
2002 driven by a joint effort between the Centers for Medicare and Medicaid Services (CMS)
and the CDC with the primary goal of reducing SSI’s by 25% by 2010 (Drake, 2011). While SIP
primarily focused on antibiotic stewardship, SCIP expanded on antibiotics to include
reconditions specific to surgery service lines such as colorectal surgery, cardiac, and
gynecology. SCIP also outlined recommendations to address venous thromboembolism and
preoperative hair removal. Though SCIP has had a lot of mixed reviews and implementing
standard protocols to reduce SSI’s, it did not achieve the stated goal of a reduction of SSI’s by
25% by 2010 (Rosenberger et al., 2011). SCIP did establish a set of standard core measures that
have been built on since its initial implementation.
The ERAS program is the Enhanced Recovery After Surgery. Starting in Europe around
the same time as SCIP, ERAS was also a program to reduce SSI’s. ERAS added expanded
interventions when it came to the United States, building on its European origins. ERAS is
made up of various elements in 3 stages of the surgical process to include the pre-, intra-, and
postoperative phase of care in the surgical setting. The 3 stages are:


Preoperatively:
o Preoperative patient education and counseling.
o Meeting with the surgeon or intake nurse.
o Use of multimodal analgesia.
o A carbohydrate drink two hours before surgery.



Intraoperatively:

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Running head: RETROSPECTIVE CHART REVIEW OF NASAL

o Goal-oriented fluid management.
o Judicious use of opioid pain relievers.
o Minimally invasive surgery, when possible.


Postoperatively:
o Early ambulation postoperatively.
o Early oral nutrition postoperatively.
o Early removal of all lines, tubes, and drains,
o Early transitioning to oral pain medications.

ERAS initially targeted orthopedic total joints, orthopedic fractures, and hysterectomies
as their primary service lines. Since the launch, and due to the success, ERAS has been
expanded to most surgical services lines in some way, shape, or form. The carbohydrate drink to
keep the gut working, multimodal analgesia to reduce opioid usage, early postoperative nutrition
to get the gut working postoperatively, and early ambulation are key pillars of ERAS that can be
seen across service lines.

Clinical Problem
Despite the efforts over the years, SSI continues to be a priority for improved outcomes
and patient care in the surgical population. It is estimated that SSI’s occur in 2 percent to 5
percent of all patients undergoing surgery, translating to 160,000 to 300,000 people annually at a
cost of $3.5 to $10 billion (Ban et al., 2017). An SSI substantially increases morbidity and
mortality as patients are twice as likely to die, are 60% more likely to be admitted to the

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Running head: RETROSPECTIVE CHART REVIEW OF NASAL

intensive care unit (ICU), and the readmission rate is five times higher than patients who do not
have a hospital acquired SSI (Darouiche, 2019).
In addition to the financial cost, the human burden of an SSI can be extraordinary. The
average SSI increases the length of stay (LOS) by 9.7 days, causing prolonged hospitalization as
well as separation from family and loved ones (Ban et al., 2017). Pain, anxiety, and loss of
function can have a lasting impact on the patient and those close to them. Healthcare providers
involved in the care of a patient impacted by an SSI may experience “second victims”
trauma. A “second victim” in healthcare is a member of the care team that is having difficulty
managing emotional distress related to the poor outcome of the patient (Tartaglia & Matos,
2020).
Methicillin-sensitive Staphylococcus aureus (MSSA) and methicillin-resistant
staphylococcus aureus (MRSA) infections are the most common pathogens causing an
SSI (Septimus, 2019). Nasal decolonization prior to surgery has shown to be an effective
intervention to reducing MSSA and MRSA SSI’s (Zhu et al., 2020). As nasal decolonization is
not part of SCIP, ERAS or many SSI bundles, this is an area of opportunity for focused targeted
improvement.
Nasal mupirocin is the most commonly used antibacterial agent used for preoperative
nasal decolonization (Sporer et al., 2016). The use of nasal mupirocin has shown to decrease the
risk for an SSI in patients who were colonized for Staphylococcus aureus in their nares prior to
surgery. Mupirocin is a cream prescribed and dispensed from a tube. It is applied to both nares,
three times a day for five days by the patient at home, prior to surgery. Though mupirocin is the
most widely used antibacterial for nasal decolonization, due to the application
regimen compliance by the patient can is low. Up to 75% of all patients fail to follow

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Running head: RETROSPECTIVE CHART REVIEW OF NASAL

the mupirocin application regimen, thus decreasing the effectiveness of the regimen (Tsang et al.,
2018). This was attributed to the uncomfortableness of applying the nasal swab three times a
day for five days, and the mess caused by applying the cream to the cotton tip applicator that is
then placed in both nares.
Three years prior to this project, this medical center participated in a mupirocin nasal
decolonization trial with other medical centers in the health system. As referenced in Tsang, et
al, patient compliance was poor and no reduction in SSI’s was realized from this work. Given
the effectiveness of nasal decolonization, more exploration was done by the medical center
where it was discovered povidone-iodine (PVP-I) is another antibacterial used in nasal
decolonization.
A literature review was performed, and key stakeholders were consulted. After
reviewing the literature and discussing with appropriate parties, the medical center decided to use
the Profend Nasal Decolonization Kit. The kit consists of four applicators applied, two to each
naris, containing 10% PVP-I. PVP-I is applied in the preoperative area by the registered nurse
prior to the patient being transported to the operating room (OR) for surgery.

The

initial population identified were all patients undergoing orthopedic surgery with implantation.
This included total joint arthroplasty (TJA) or a fracture repairs with hardware, followed by
spine surgery. The rest of the surgical population followed within weeks of the initial orthopedic
rollout.

Purpose
The purpose of this project was to evaluate the effectiveness of using a 10% PVP-I Nasal
Decolonization Kits in the prevention of MSSA, MRSA, and other infections for patients

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Running head: RETROSPECTIVE CHART REVIEW OF NASAL

undergoing orthopedic surgery for a TJA or fracture repair at the medical center and patients
with active MRSA or a history of MRSA.

Significance in Nursing
Nurses within the facility are responsible for educating, advocating, and partnering in the
prevention of SSI’s. The American Association of Colleges of Nurses (AACN) (2006) states the
role of the DNP graduate nurse is to be initially involved in a practice that includes
interdisciplinary collaboration, quality improvement, patient safety, and the knowledge of
organizational and community systems. The AACN list eight DNP Essentials that the graduate
nurse is to master prior to graduation. The DNP Essentials include:


Scientific underpinning of practice.



Organizational and System leadership for quality improvement and system thinking.



Clinical scholarship and analytical methods for evidence-based practice.



Information systems/ technology and patient care technology for the improvement and
transformation of health care.



Health care policy for advocacy in health care.



Interprofessional collaboration for improving patient and population health outcomes.



Clinical prevention and population health for improving the nation’s health.



Advanced nursing practice.

This DNP project used several of the 2006 AACN Essentials to guide the development of
the project. DNP Essential I states that a DNP will be able to critically appraise literature to
identify best practices and translate those findings into clinical practice. Prior to the start, a

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Running head: RETROSPECTIVE CHART REVIEW OF NASAL

literature search was performed to identify guidelines and best practices related to the prevention
of SSI’s and nasal decolonization. Review and assessment of the guidelines allowed for
comparison of past and current practices at this community based medical center compared to
best practices and current guidelines outlined by experts and governing bodies in the literature.
The basis for this project is nasal decolonization to decrease harm events for patients
undergoing surgery. After the literature review was complete and a process was determined, the
information was presented to the Regional Infection Prevention (IP) group for the health system.
the Regional IP committee came back with a recommendation not to proceed with the use of
PVP-I nasal decolonization. Despite the recommendation, nursing worked with local IP,
surgeons from the facility, anesthesia providers, and pharmacy to review the data. DNP
Essential II (AACN, 2006) relates to the critical need for nursing leaders to use organizational
and system leadership to improve care. Gaining local consensus, the project was able to move
forward.
DNP Essential III outlines the DNP graduate will engage to provide scholarly practice
and the application of new discoveries in a complex practice (AACN, 2006). Mupirocin was a
known intervention to the medical center for SSI’s and had drawbacks that were deemed not
sustainable to continue in practice. Searching the literature for viable alternatives produced the
discovery of a single application of 10% PVP-I intervention. Upon analyzing the literature and
presenting it to key stakeholders such as surgeons, anesthesia, and pharmacy, the project moved
forward.
Information systems in the form of the electronic medical record (EMR) were utilized for
effectively and reliably. This is encompassed in DNP Essential IV (AACN, 2006). The EMR

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Running head: RETROSPECTIVE CHART REVIEW OF NASAL

allows for information to be extracted in a systematic way and in a format ready for use in
analyzing the data to determine outcomes.
DNP Essential VI (AACN, 2006) interprofessional collaboration to improve patient and
population health. A team of professionals that included nursing surgeons, anesthesia and
pharmacy worked in an interprofessional manner to deliver care to the patient population for this
study. By keeping the patient at the center of the care, healthcare professionals were able to
overcome initial objections to change and deliver care designed to reduce risk and improve
outcomes.
The DNP nurse overseeing care in perioperative services is in a unique position to see all
aspects of care through the department. Where other disciplines are focused on their phase of
care, the DNP nurse in this case is tasked with coordinating multiple phases of nursing care as
well as communicating and collaborating with the interprofessional team. These skills, coupled
with the knowledge gained during this DNP program make up the foundation of DNP Essential
VIII (AACN, 2006).

Project Objectives.


Identify the patient population pre- and post-intervention at a community-based medical
center.



Identify areas for quality improvement in SSI rates for the pre- and post-intervention
groups.



Identify the impact of the intervention, both human and financial cost.

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Running head: RETROSPECTIVE CHART REVIEW OF NASAL

Chapter 2

Review of Literature.

Summary of Literature.
Surgical Site Infections are a worldwide health concern. SSI’s are nondiscriminatory as
they impact any age or gender, and are seen in all racial and ethnic populations. SSI’s are a
healthcare-associated infection that contributes to a longer length of hospital stay, higher
mortality, increased readmissions, and increased cost associated with care (Copanitsanou,
2020). MSSA and MRSA are two of the most common organisms causing SSI’s (George et al.,
2016).
Nasal decolonization for MSSA and MRSA has shown to decrease infection rates (Huang
et al., 2019). Pelfort et al. (2019) show SSI’s involving MRSA and MSSA present a major
adverse event in a total joining arthroplasty (TJA). Carriers of MSSA and MRSA are two to nine
times more likely to develop a Staphylococcus aureus (S. aureus) SSI than patients that are not
colonized (Elshafie et al., 2018). This is for all surgical outcomes. The purpose of targeted
intervention for MSSA and MRSA are these organisms are generally considered to be a
modifiable risk factor for SSI’s (Zhu et al., 2020). A modifiable risk factor means preoperative
nursing interventions can have an impact to positively change patient outcomes.
S. aureus is the leading cause of SSI’s nationwide (Rezapoor et al., 2017). Patients who
are colonized with MRSA are at high risk for infections after discharge from surgery (Huang et
al., 2019). Although the prevalence of MSSA and MRSA in the nares varies by population, the
general population's mean carriage rate is estimated to be at 37.2% (Kent et al., 2019). This

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Running head: RETROSPECTIVE CHART REVIEW OF NASAL

makes MSSA and MRSA a significant risk factor for patients undergoing surgery. Identification
of the risk factors that contribute to a greater risk of MSSA and MRSA colonization may allow
the reduction of SSI’s and improve patient outcomes (Kent et al., 2019).
Did the intervention of universal preoperative nasal decolonization using a Nasal
Decolonization (10% povidone-iodine solution) Kit reduce MSSA and MRSA infections in
patients undergoing surgery in a 12-month period preintervention compared to a 12-month
period post-intervention?

Related Research.

Meaningful Limits.
A search for literature was conducted for SSI interventions to include randomized
controlled studies (RCS), Meta-analysis reviews, and systematic reviews. The literature was
searched for MSSA and MRSA nasal decolonization processes and effectiveness. These limits
were used to identify studies related to the clinical question on hand.

Identification.
PubMed was utilized for the literature search. The initial search had a date limit of 2016
to the present and resulted in 254 articles returned for review. This was the only source utilized
for publications at this time.

Screening.

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Running head: RETROSPECTIVE CHART REVIEW OF NASAL

The initial 254 articles were all screened as related to the clinical question. Titles and
keywords in the articles were reviewed to look at the relationship to the clinical question. The
following exclusion criteria were used to reduce the sample size:


Intervention that did not include nasal decolonization.



Multiple interventions that included nasal decolonization.



Too specific of a population or age group.
Forty-six articles were left for review after this screening for exclusion criteria.

Eligibility.
Eligibility was assessed for the 46 articles remaining. Out of the articles reviewed, 19
were deemed applicable to the clinical question. Reasons for exclusion included the following:


The full-text article was not available.



An article in English was not available.



The sample size was too small.



It was a repeat study.



The setting was not applicable.



The study was not pertinent to the clinical question.

Review of findings.
Decreasing SSI’s through nasal decolonization remains controversially related to mixed
outcomes in published literature (Rohrer et al., 2020). Mupirocin is the most common choice for
intervention for nasal decolonization. Combined with chlorhexidine (CHG) skin wipes, 2%
topical mupirocin is the most widely used topical antibacterial agent used for nasal

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Running head: RETROSPECTIVE CHART REVIEW OF NASAL

decolonization (Septimus, 2019). Mupirocin instructions for use, or application, include three
times daily applications at home for 5-days by the patient prior to the day of surgery using a 2%
mupirocin ointment (Tsang et al., 2018).
George, Leasure, and Horstmanshof (2016) concluded that nasal decolonization using
mupirocin in conjunction with chlorhexidine skin cleansing effectively reduced MSSA and
MRSA SSI’s. This conclusion was reached meta-analysis of the literature for this
intervention. Sources were identified by searching electronic databases to include Medline,
Embase, EBSCO, CINHAL, EMB reviews, and Google Scholar. A summary of the data
concluded SSI’s are among the most common hospital-acquired infections (HAI’s) and
demonstrated that eradication of nasal decolonization was associated with a reduction of the
introduction of S. aureus bacteremia, along with the conclusion that nasal decolonization reduced
MSSA and MRSA SSI’s (George et al., 2016).
Sporer et al. (2016) examined 9,690 patients undergoing a total joint arthroplasty (TJA)
and realized an initial SSI rate of 1.11% reduced to 0.34% post-intervention using MSSA
screening with mupirocin nasal decolonization. This review was conducted at a single medical
center site from 2009 to 2014. The savings for this reduction at this one facility was estimated at
$231,741 for this single medical center.
MSSA, MRSA, and Methicillin-resistant Staphylococcus epidermidis (MRSE) nasal
carriage is listed as the only independent risk factors for patients undergoing orthopedic
surgery (Elshafie et al., 2018). The use of a mupirocin protocol preoperatively reduced the
identified SSI’s from 8 SSI’s to 1 in the study group of 1108 patients at a single surgery
site. This is credited with a shorter length of stay, higher postoperative patient function, and
increased patient satisfaction post-surgery (Elshafie et al., 2018).

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Running head: RETROSPECTIVE CHART REVIEW OF NASAL

While many studies show promising outcomes for the use of mupirocin, with some
studies showing internasal mupirocin has decreased 85% of MSSA and MRSA colonization after
treatment, other literature is not as clear (Stambough et al., 2017). Four studies that used
mupirocin for nasal decolonization in cardiothoracic surgery showed no statistical difference
before and after the intervention (Tang et al., 2020). Also, other reviews have shown MRSA
strands that are resistant to mupirocin (Humphreys et al., 2016). This leads to a knowledge gap,
as more research is needed to determine efficacy. Despite this, mupirocin is the most studied and
considered the most effective agent for eradicating S. Aureus colonization in the
nares (Septimus, 2019).
This project reviews the use of a 10% povidone-iodine solution for Kaiser Fresno
Medical Center. PVP-I is a complex polyvinylpyrrolidone and tri-iodine ions used as an
antiseptic for skin, wounds, and mucous membranes (Septimus, 2019). While providing an
affordable intervention, PVP-I is also an effective and readily available antiseptic option for
nasal decolonization (Eggers, 2019). PVP-I has shown to have a broad antibacterial spectrum
and is active against many viruses and antibacterial-resistant strains, including MRSA (Elshafie
et al., 2018).
Eggers (2019) points out PVP-I has high potency for virucidal activity with MRSA along
with MSSA, hepatitis A, influenza, Middle- East Respiratory Syndrome (MERS), and Sudden
Acute Respiratory Syndrome (SARS). This has led it be used for nasal decolonization for MSSA
and MRSA, as it has not shown the cross-resistance that has been documented in other nasal
decolonization agents. PVP-I is well tolerated by most patients, particularly when applied to the
skin and nares, and is rarely associates with allergic contact dermatitis or other reactions to the
medication (Eggers, 2019).

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Running head: RETROSPECTIVE CHART REVIEW OF NASAL

Rezapoor et al. (2017) noted a significant decrease in positive nares cultures 4 hours and
24 hours after swabbing with a 5% PVP-I solution and a 10% PVP-I solution. This protocol is to
swab each naris twice, two minutes apart in the preoperative area of the facility prior to entering
the operating room (OR) suite. The effectiveness of PVP-I has been criticized due to
inactivation by nasal secretions. This has been mitigated by PVP-I using film-forming excipients
that improve adhesion of the solution and protection from inactivation from the nasal secretions
by changing the pH levels or my interacting with the organic nasal compounds (Rezapoor et al.,
2017).
A surgical site infection, especially a deep or organ space, can have a devastating effect
on the patient, family, and providers. SSI’s in the United States increase hospital costs by $3$10 billion per year, add 7- 10 additional hospital days per patient and have a mortality rate of
3% that is directly attributed to the SSI (Rezapoor et al., 2017). The average cost of a
periprosthetic joint infection (PJI) was reported in one study as $25,692 for a total
hip arthroplasty (THA) and $31,753 for a total knee arthroplasty (TKA) (Kerbel et al.,
2018). Other studies note the cost of a revision for a total joint arthroplasty related to a PJI
between $23,000 and $25,000, or more, per incident (Sporer et al., 2016).
In addition to the financial impact on the healthcare system, a patient is ultimately
impacted. A postoperative SSI for a patient decreases mobility, increases pain, and increased
morbidity. The significant morbidity and the enormous cost associated with TJA SSI make
preventive measures to reduce infection rates of major importance (Pelfort et al., 2019).
Nasal decolonization can be a cost-effective means to treat and eliminate colonized
MSSA and MRSA prior to undergoing elective surgery in order to reduce the risk of a
postoperative SSI (Peng et al., 2018). As noted above, an SSI can significantly impact the cost

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Running head: RETROSPECTIVE CHART REVIEW OF NASAL

of care, length of stay, quality of life, quality of function, and morbidity and mortality for the
patient. The cost of decolonization can vary depending on product use but is noted between $5
and $18 per application (Stambough et al., 2017).
Universal nasal decolonization programs produce a similar reduction in SSI’s compared
to facilities using targeted screening programs (Tang et al., 2020 and Stambough et al.,
2017). Additionally, direct culture is the least sensitive method used for detecting MSSA and
MRSA and could provide a false negative for a colonized patient as well as an increased cost
(Tansarli et al., 2020).
PVP-I is applied using four swabs, two each naris, in the preoperative department before
the patient goes to the OR. This is considerably easier than the mupirocin regiment of three
times a day for 5-days at home before surgery. Profend is also an immediate intervention when a
5-day read time is not always available for surgery. This is especially important in orthopedic
trauma cases such as fractures. The ease of use and increased compliance, along with no known
cross resistance, made PVP-I the intervention of choice for this study. Universal nasal
decolonization was chosen for this study related to the increased cost and effort needed to culture
patients prior to surgery, and the reliability of the swabbing technique related to collecting a
specimen.

Gaps in literature.
Mupirocin is the intervention that has been studied the most with promising results for
TJA (Elshafie et al., 2018). With this, inconclusive results related have been noted with other
service lines within perioperative services (Stambough et al., 2017). This leads to the need for
further investigation. This medical center has used mupirocin and did not continue with the

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Running head: RETROSPECTIVE CHART REVIEW OF NASAL

intervention after the trial period related to poor patient compliance with the preoperative
application protocol and no significant impact on SSI’s.
PVP-I has shown to be effective at SSI reduction for MSSA and MRSA. This leads to
the question of whether an intervention with PVP-I can improve compliance to decrease SSI’s in
the surgical population.

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Running head: RETROSPECTIVE CHART REVIEW OF NASAL

Chapter 3
Methods.

Project Design.
This project took place in a perioperative services department at a community-based
medical center in central California in the heart of the San Joaquin valley. This department
performs about 10,000 cases annually, though the past year has experienced about a 20%
decrease in surgical volume related to Covid- 19 and the subsequent shutdowns of the operating
room (OR) related to inpatient surge volumes that impacted hospital capacity. This medical
center has:






169 licensed beds.
2,533 employees.
326 physicians.
46,721 emergency department visits in 2019.
1,596 newborn deliveries in 2019.

(Fresno, n.d.)

This medical center is an integrated health system comprised of three entities with
exclusive contracts with one another. The three entities include the health plan, network
hospitals, and the corresponding medical group. All patients undergoing surgical procedures are
members of the health plan, meaning all care is provided at the system hospital with a surgeon
from the system's medical group. Therefore, all information is tracked in a single electronic
medical record (EMR). Should a patient experience an emergency or some other situation after
surgery that would result in that patient seeking care outside of a system medical center, the
health plan is notified to pay the claim, and information from the outlying hospital will be
transmitted back to the system medical center for insertion into the EMR, ensuring the ability to
track all patients postoperatively for complications. The only exception to this process would be

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a patient seeking care at an outside facility and that patient does not submit the claim to the
health plan for coverage and reimbursement. This is important to note as all medical care is
captured in a single EMR, accessible for review in this project.
This DNP project will focus on a retrospective chart review for the collection of data
from the medical centers EMR. Data included the date of surgery, the type of surgery, age, sex,
and BMI. For patients that experience an SSI, the date of diagnosis for infection, type of
organism causing the SSI, and whether or not Profend was used preoperatively was
captured. Number of infections in the preintervention and postintervention group were examined
along with demographic variables for each patient. The data collection provided for a better
understanding of SSI’s for this medical center.
This medical center implemented a 10% PVP-I nasal decolonization program in July
2019 in an effort to reduce SSI’s. This DNP project is a program review to evaluate the
effectiveness of that intervention. The sample used for this review was all patients undergoing
an orthopedic procedure for a total joint arthroplasty or an orthopedic fracture in the operating
room of a community-based medical center. The time period will be the 12-month period
immediately prior to and the 12-moht period after the implementation of PVP-I nasal
decolonization. The preintervention group timeframe is July 1, 2018, to June 30, 2019. The
postintervention group timeframe is August 1, 2019, to July 31, 2020. Implementation of the
intervention was conducted in July 2020.
Implementation started with an introduction to the physician chiefs for each service line
by members of the SSI reduction committee to include the perioperative services director,
physician OR director (PORD), assistant physician in chief (APIC) for quality, and members of
the infection prevention team. Staff education for the preoperative RN’s and OR RN’s was

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Running head: RETROSPECTIVE CHART REVIEW OF NASAL

conducted in partnership with the vendor and included written material and hands-on application
of the nasal swab. PVP-I nasal decolonization orders were added to the anesthesia order set in
the EMR and were also an ad-hoc order that could be placed by any provider.
The rollout occurred over a 2-week period starting with orthopedic surgery at the medical
center, followed by neurosurgery, and then continued through all service lines. This was to
allow for 1:1 observation of RN’s performing the intervention and allow for workflows to be
finalized and barriers addressed. No major issues occurred in the July 2019 rollout of the nasal
decolonization process. The implementation was planned over a four-week period, but due to
ease of use by the nursing staff and buy in from providers, the timeframe was compressed and
completed within two weeks.

Sample.
Data was collected from the EMR in a retrospective chart review for patients undergoing
an orthopedic procedure with implantation at the community-based medical center. Information
from the EMR was exported to a spreadsheet for review. An exhaustive census sample was used
to capture all patients. Being an integrated healthcare system, the postoperative follow-up was
captured for 100% of patients undergoing surgery.
The preintervention group from July 2018 to June 2019 included 431 unique
patients. The postintervention group from August 2019 to July 2020 included 365 patients. Data
was compiled by the facility infection prevention manager, the infection prevention analyst, and
the author. Patient names and medical record numbers were masked to ensure patient
confidentiality. The decrease in surgeries between the two groups was contributed to the facility

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Running head: RETROSPECTIVE CHART REVIEW OF NASAL

reduction of surgeries related to the Covid-19 pandemic and was not seen as significantly
significant to impact the outcome.

Methods.
This DNP project used a retrospective data review from data points previously collected
as part of standard work performed in the EMR. Informed consent from patients was not
required due to the nature of the review. The infection prevention department and the author
were the only individuals to see patient-identifying information. All patient information was
blinded when the information was displayed. A standard report from the EMR was run to collect
all patient data.
For reliability, SSI data from the report was cross-checked with SSI data reports
generated by the infection prevention department. Any discrepancy in data between the EMR
and infection prevention triggered a manual drill-down to verify the accuracy of data. The
findings of the drill-down was then shared between the three members of the data collection
team and consensus for the correct data recording was achieved. There were three discrepancies
recognized in the data pertaining to an SSI. On all three occurrences, the error was attributed to
a transcription error from the EMR to the infection prevention report, and the information from
the EMR was deemed correct.
The number of infections in each group was identified and reviewed. Observer bias or
the Hawthorne effect by the surgeons or the perioperative team was not considered a factor for
this review. The Hawthorne effect is when individuals, or a group of individuals, change normal
behavior when they are aware, they are being observed (Demetriou et al., 2019). The chart

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Running head: RETROSPECTIVE CHART REVIEW OF NASAL

review was conducted after the completion of the post-intervention group; therefore, no member
of the perioperative team was aware a review for this data would occur.

Instruments.
The primary data collection tool was an Excel spreadsheet. An internal report from the
EMR was run to extract most data into the Excel spreadsheet. Tableau software was used to
extract PVP-I use in the post-intervention group. Tableau is an interactive visual software used
by the medical center to extract reports and data not available on the EMR platform (Tableau,
n.d.).
The primary data for the review was the presence of an SSI within 30-days of the surgical
date. In addition to the presence of an infection, date of surgery, the type of surgery, age, sex,
BMI, date of diagnosis for infection, type of organism causing the SSI, and whether or not
Profend was used preoperatively were collected. Cultures were not performed on all
documented SSI’s. In those cases, “no culture” was noted on the collection tool.
Patient age, sex, surgical wound classification, ASA classification, SSI level of infection,
and date the infection is detected will also be collected. The CDC has standardized classification
definitions for wound classifications to correctly establish the cleanliness and condition of the
surgical site prior to surgery. These classifications are:





Class 1- clean wound. Wounds that are uninfected with no signs and symptoms of infection
and are closed postoperatively with primary closure.
Class 2- clean-contaminated wound. Controlled entry through the mouth, ears nose, or
urinary system are classified as a wound class 2. A puncture wound, either external by a nail,
knife, or gunshot wound, or internal by a broken bone protruding through the skin can also be
a Class 2 wound.
Class 3- contaminated wound. Contaminated wounds occur from a gross break in sterile
technique, or an internal leak from the gastrointestinal tract into the wound. The break in
sterile technique can be before or during surgery.

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Running head: RETROSPECTIVE CHART REVIEW OF NASAL



Class 4- dirty infected wound. These wounds are typically the result of trauma where the
infection is already present or contaminated contents, such as stool in the abdominal cavity,
are present at the time of surgery.
(Herman & Bordoni, 2020)
The ASA Classification, also known as the American Society of Anesthesiologists

Physical Status Classification System, is used to stratify risk factors related to anesthesia and has
been used for over 60 years (ASA Physical Status Classification System, 2020). The ASA
Classification categories are:







ASA 1- A normal healthy patients
ASA 2- A patient with mild systemic disease.
ASA 3- A patient with sever systemic disease.
ASA 4- A patient with sever systemic disease that is a constant threat to life.
ASA 5- A patient that is not expected to survive without the surgery.
ASA 6- A brain-dead patient for the purpose of organ donation.

Wound Class and ASA Class are important indicators for complications and risk
stratification in the comparison of outcomes in two groups.

Data analysis.
Upon completion of data collection, the information will be saved and uploaded into the
department's secure shared drive. Limited file access was given to the data. The author, the IP
manager, and the IP analyst are the only individuals with file access.
A two proportions z-score will be used to determine statistical significance of the data
set. The hypothesis for implementation of the nasal colonization was 10% PVP-I is the reduction
of risk for postoperative infections, SSI’s, at the medical center. In statistics, a hypothesis test
will determine quality under a given assumption (Hamasaki et al., 2021). The z-test will
determine whether the assumption has been violated or rejected. Calculating the p-value of the

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Running head: RETROSPECTIVE CHART REVIEW OF NASAL

data in a z-test determines the validity of the hypothesis. The lower the p-value, the stronger the
evidence to reject the null hypothesis. A p-value less than 0.05 indicates statistical significance.

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Running head: RETROSPECTIVE CHART REVIEW OF NASAL

Chapter 4

Results.
The purpose of this DNP project review was to review the impact PVP-I nasal
decolonization had on the reduction of SSI’s at a community-based medical center. The data for
the review was divided into two groups consisting of the preintervention, from July 1, 2018, to
June 30, 2019, and the postintervention group, from August 1, 2019, to July 31, 2020.
The preintervention group was composed of 431 patients. The postintervention group
contained 365 patients. The average age was 70.9 years and 71.3 years for the preintervention
and postintervention groups respectively. The breakdown was 62% female and 38% male for
both groups. The average wound classification was 1.1 for the preintervention group and 1.0 for
the postintervention group. The ASA classification for the two groups was the same at 2.5. The
two groups were very similar in makeup (See Table 1 below).

Table 1:
Preintervention
Postintervention

Ave Age
70.9
71.3

Sex F/M

1
62%/38% 419
62%/38% 359

Wound Class
2
3
4 Ave
2
2
8 1.1
4
0
2 1.0

1
2
7

ASA
2
3
4 Ave
237 179 13 2.5
189 159 10 2.5

In a review of the raw data (Table 2) there were eight (8) post-operative infections in the
preintervention group and one (1) postoperative infection in the postintervention group. This
translates to a 1.86% infection rate in the preintervention group, compared to a 0.27% infection
rate in the postintervention group with a p-value of 0.0376 (Table 3). A p-value less than 0.05 is
significant and means the chance of a type 1 error is small.

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Running head: RETROSPECTIVE CHART REVIEW OF NASAL
Table 2:
Unique Identifier Procedure(s)
2018-066
2018-106
2018-127

HIP REPLACEMENT REVISION TOTAL
HIP FRACTURE- NAIL INSERTION
KNEE REPLACEMENT TOTAL BILATERAL

2018-166
2018-191

HIP REPLACEMENT REVISION TOTAL
KNEE REPLACEMENT TOTAL

2018-216
2018-266
2018-272

KNEE REPLACEMENT TOTAL
KNEE REPLACEMENT TOTAL
KNEE REPLACEMENT REVISION

2019-169

HIP FRACTURE- NAIL INSERTION

Procedure IDs Pat Age
121421
82.56
1215431
76.69
1214538
64.09
121421
63.74
1211672
77.88
1211672
72.15
1211672
73.48
1213898
69.19
1215431
95.4

Sex
F
F
F
M
M
F
F
F
F

Wound Class ASA Class SSI Level
1
3
1
2
1
3
1
2
1
2
1
3
1
2
1
3
2
3

Date
08/20/2018
09/30/2018
10/16/2018
11/16/2018
12/03/2018
12/27/2018
02/05/2019
02/13/2019
01/04/2020

Date of Event POD#
Pathogen
9/3/2018
15
p. mirabilis
10/28/2018
28
No Culture
11/9/2018
22
MRSA
12/12/2018
26
S. Aureus
12/22/2018
19
No Culture
1/25/2019
30
MRSA
2/20/2019
16
No Culture
3/9/2019
25 Pseudomonas
1/29/2020
26
No Culture

Table 3:

Z-score proportions test

Pre-Intervention Post- Intervention

Number of Events (InfectionsNumerator)
Number of Trials
(Denominator)
Number of non-events (TrialsEvents)
Proportion

8

1

431

365

423

364

1.86%

z- value
p-value

0.27%
2.1037
0.03572

Secondary findings.
Implementation occurred in July 2019 with data collection range for the intervention
group from August 1, 2019, to July 31, 2020. It was expected 80% of the patients undergoing
surgery would be decolonized with 10% PVP-I prior to surgery. In the review of the data, 55%
of patients were decolonized with PVP-I during the examination period. Out of this, there were
two distinct groups: patients that were sent to the preoperative area; patients that bypassed the
preoperative area (Graph A).

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Running head: RETROSPECTIVE CHART REVIEW OF NASAL

Graph A:

TOTAL PATEINTS DECOLONIZED
PRIOR TO SURGERY

166 patients,
45%

No
decolonization

PVP-I
decolonization

199 patients,
55%

The preoperative unit (PreOp) is open Monday through Friday from 0600 to 1700 each
day. All outpatients and patients coming from the medical-surgical floor to the OR are first
taken to the preoperative unit within perioperative services where an RN repairs them for
surgery. During hours where the PreOp is closed, or if the patient is coming to the OR from the
critical care unit (CCU) or the telemetry unit (Tele), then the patient goes direct to the OR. In
this workflow, the OR RN, rather than the PreOp RN, checks the patient in for surgery. As the
data shows, 323 of the 365 patients, or 88.5%, in the intervention group were check-in through
the PreOp, leaving 42 patients that went directly to the OR (See Graph B).

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Running head: RETROSPECTIVE CHART REVIEW OF NASAL

Graph B:

Patient check in before Surgery
42 patients, 11.5%

323 patients,
88.5%
Patients checked in to PreOp prior to surgery
Patients taken directly to the OR, bypassing PreOp

This created two subgroups in the intervention group; patients that went through PreOp
and Patients that did not go through PreOp. For patients that went through PreOp prior to
surgery, 192, or 494%, of the 323 patients were decolonized. Patients that did not go through
PreOp prior to surgery had a 16.7% decolonization rate, 7 out of 35 (See table 4).
Table 4:

PVP-I
No
decolonization decolonization

Percentage
decolonized

Total

PreOp
No PreOp

192
7

131
35

323
42

59.4%
16.7%

Total

199

166

365

54.5%

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Running head: RETROSPECTIVE CHART REVIEW OF NASAL

Chapter 5

Project summary.
This DNP project review was undertaken to assess the implementation and effectiveness
of 10% PVP-I in the reduction of SSI’s for patients undergoing orthopedic surgery with
Implantations, to include total joint arthroplasty and orthopedic fracture repair surgery. The
project initially focused on the impact of 10% PVP-I on MSSA and MRSA infections only. In
the literature review phase of the project, it was discovered PVP-I had broader coverage outside
of the staphylococcus aureus bacteria strains.
This program review did determine the implementation of PVP-I had a significant impact
on SSI’s for the population under review. The proportion of SSI’s in the preintervention group
was 1.86% compared to the postintervention rate of 0.27%. This resulted in a p-value of 0.03572
using a two-proportion z- score, showing a statistically significant change in SSI’s. This resulted
in seven (7) fewer SSI’s in the postintervention group. The facility also saw a decrease in the
overall SSI odds ratio from 1.17 in July of 2019 to 1.11 in July of 2020.
A secondary finding noted poor administration of PVP-I in patients undergoing surgery.
The facility goal was 80% of all patients undergoing surgery would receive nasal decolonization
with PVP-I prior to surgery. The data review showed only 54.5% of the patients overall
receiving PVP-I prior to surgery. For patients that bypassed the preoperative area of the facility
and went directly to the OR, the compliance rate was 16.7%.
The one patient diagnosed with an SSI in the postintervention group, patient 2019-168
(Table 2), had surgery on a Saturday afternoon, bypassing the preoperative unit, and did not have

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Running head: RETROSPECTIVE CHART REVIEW OF NASAL

documentation of nasal decolonization in the MAR prior to surgery. A review of the nursing
workflows to improve compliance may be beneficial in support of nasal decolonization.

Limitations.
Retrospective chart audits and studies offer a wealth of information. However, there are a
number of potential pitfalls and barriers to this type of review. All data were collected by the
author and allows for possible bias or misinformation. Though data was collected by the author,
it was reviewed by members of the medical center's infection prevention department, decreasing
the risk of bias or misinformation. All information gathered is part of a terminate medical record
that cannot be altered by the author, making verification of data easier.
Retrospective project designs can be prone to misclassification. In the process of
verifying automated data a number of discrepancies were noted by the author. This resulted in a
more in depth, manual review of the EMP to verify validity of data obtained. Other data analysts
were engaged in the verification process as well.
The data collected for this project focused on a single service line, orthopedic surgery
with implants, at a single sight community-based medical center, limiting the scope. Expanding
the review to all service lines and other facilities would broader the foundation of data and
provide further insight into effectiveness.

Future research.
Future research could include more service lines within surgical services and more
facilities other than a single-site medical center. This would broaden the number of interventions
to give a fuller picture of the impact and effectiveness of PVP-I in the reduction of SSI’s.

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Running head: RETROSPECTIVE CHART REVIEW OF NASAL

With the Covid-19 pandemic, the world has become more familiar with the Coronavirus
(CoV) family of viruses. There are currently seven documented coronaviruses in the human
population. They are:


Severe Acute Respiratory Syndrome (SARS or SARS-CoV)



Middle East Respiratory Syndrome (MERS or MERS-CoV)



SARS-CoV hCoV-HKU1



hCoV-OC43



hCoV-NL63



hCoV-229E



SARS- CoV-2 (Covid- 19)

(Zhu, et al., 2020)

Though four of the CoVs are non-life threatening and manifest in mild cold or flu type
symptoms, SARS, MERS and now Covid- 19 have shown to be deadly in the human population.
PVP-I has shown a high potency for virucidal activity against SARs and MERS (Eggers, 2019).
Given this information and the magnitude of the Covid- 19 pandemic, further research on the use
of PVP-I for the prevention and treatment of Covid- 19 would be beneficial.
HAI’s from colonized pathogens such as Staphylococcus aureus, enterococci, gramnegative organisms, and Clostridium difficile are associated with an increased risk of infection
(Septimus, 2019). Mupirocin is considered the gold standard for nasal decolonization despite low
compliance rates by patients and the increased concern regarding Mupirocin resistant organisms
(Humphreys et al., 2016). PVP-I has shown ease of use and is not susceptible to organism
resistance. Further investigation into the use for PVP-I nasal decolonization for the prevention
of HAI’s could provide a low-cost intervention to reduce harm events in the acute care setting.

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Running head: RETROSPECTIVE CHART REVIEW OF NASAL

In addition, SSI’s were diagnosed on postoperative day (POD) 15 to 30 in the
preintervention group, with the average POD to diagnoses being 22.6 days. The one SSI in the
postintervention group was POD 26. This could pose the question on whether the SSI’s were
caused by a pathogen introduced during surgery or was the SSI related to postoperative wound
care?

Dissemination method.
This is a single community-based medical center that is part of a system of 21 hospitals in
Northern California. Locally opportunity for discrimination includes staff in-services,
presentations for physicians at their service line specific meeting, and the facility’s SSI
workgroup. In addition, there is a monthly surgical quality and safety committee (SQS)
comprised of a multidisciplinary team are well as the operating room committee (ORC) which
has representation for surgeons, anesthesia, and the facilities perioperative services leadership
team. SQS also reports up to a Regional SQS oversight committee that provides oversight to
local medical centers. Regional peer groups for SSI, infection prevention and SQS are additional
forums for the dissemination of these results.

Impact of the program.
The summary will cover three areas to determine success and outcome of the nasal
decolonization program. These three areas are:


Success to the patient.



Successful implementation of a nasal decolonization program.



Successful impact to the facility.

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Running head: RETROSPECTIVE CHART REVIEW OF NASAL

The patient.
As previously noted, nasal decolonization with 10% PVP-I showed a significant decrease
from eight SSI’s in preintervention group, or an infection rate of 1.86%, compared to one SSI, or
an infection rate of 0.27%, in the postintervention group. This means seven few patients in the
12-month time frame of the postintervention group. This statistical difference did provide for
better outcomes and a positive impact for patients undergoing orthopedic surgery.
The program.
Program implementation was also successful, though this review did show gaps in
nursing practice that could be improved to provide better patient care. Compliance for the 5-day
mupirocin regimen is noted to be as low as 25% nationally (Tsang et al., 2018). Though the
compliance rate for PVP-I was lower than expected, at 54.5%, during the postintervention
period, this is a significant improvement over that of mupirocin or no intervention at all.
The facility.
Reducing SSI’s by seven cases in a 12-month period had a positive financial impact. The
cost per nasal decolonization project ranged between $5 and $18 per treatment. That calculates
to an annual cost of $6,570 for 356 patients in the 12-month postintervention group. The average
cost of an orthopedic SSI was listed at $23,000 to $25,000 per infection. Seven orthopedic
patients with a postoperative SSI would have a financial impact of approximately $161,000
(using the low average of $23,000 x 7 patients). A nasal decolonization program, in this case,
therefore, shows a potential savings of $154,430 over the course of the year (See Table 5).

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Running head: RETROSPECTIVE CHART REVIEW OF NASAL

Implementation of PVP-I did show decease in the facility SSI odds ratio, though this
decrease was not statistically significant. The odds ratio for the preintervention timeframe was
1.17 compared to the odds ratio of 1.11 for the postintervention time period.

Conclusion.
Though the facility did not see a significant change in their SSI odds ratio, the nasal
decolonization program was successfully implemented, the number of SSI’s were reduced and
there was a potential financial savings associated with the intervention. Though more study is
needed, this implementation has shown a positive impact on patient care and is another step in
reducing total patient harm.

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Running head: RETROSPECTIVE CHART REVIEW OF NASAL

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