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The Association of periOperative Registered Nurses (AORN) recently updated its guide-

lines 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 guide-

lines and changes represent is the

incorporation of a very comprehen-

sive bundle of care in the pre-proce-

dural setting,” says Holly Monteja-

no, MS, CIC, CPHQ, clinical science

liaison with PDI Healthcare, and

an epidemiologist and hospital in-

fection prevention practitioner. “In-

corporation of nasal decolonization

makes it comprehensive.”

The AORN guidelines discuss

both skin and nasal decoloniza-

tion and skin prep as well as anti-

biotic prophylaxis and hair remov-

al (among other topics), but the

changes to decolonization guidelines

are what jump out to Montejano.

“There really hadn’t been a com-

ponent within the guidelines address-

ing nasal decolonization,” says Mon-

tejano. “That’s a big addition to these

skin antisepsis guidelines.”

In terms of whether the changes

will impact the workload for organi-

zations and practitioners, a lot of fa-

cilities in the preoperative arena had

already started incorporating nasal

decolonization, she notes. Profession-

al guidelines are out in the field for

certain subsets of patients to receive

nasal decolonization.

“Now we have AORN making a rec-

ommendation for incorporating nasal

decolonization into best practice guide-

lines,” adding an influential weight to

the practices, says Montejano.

The concept was on profession-

als’ 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 be-

come 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 anti-

septic, on the list of recommendations.

““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. Now we’re seeing it become the norm. ”

— Holly Montejano, MS, CIC, CPHQ, clinical science liaison with PDI Healthcare

AORN Updates Skin Antisepsis Guidelines:

What This Means for Organizations

By Matt Phillion

PSQH.COM | OCTOBER 2021 3SPONSORED MATERIAL PSQH.COM | OCTOBER 2021 2SPONSORED MATERIAL

Antiseptic and antibiotic prepWhat does povidone iodine mean for facil-

ities? Including an antiseptic in the guide-

lines, not just antibiotics, is a key change for

practitioners and for patients.

Patients are often prescribed mupiro-

cin—a topical antibacterial—prior to sur-

gery. 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 multi-

tude of organisms, and while mupirocin is

effective at its primary use, it offers limited

therapeutic coverage versus a broad-spec-

trum 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% po-

vidone 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 chal-

lenges to mupirocin: unplanned surgeries.

“A lot of surgeries are elective and

scheduled, but a lot are not,” says Monte-

jano. “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 na-

sal 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 allevi-

ate: 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 pa-

tient’s hands and into that of a healthcare

provider to ensure compliance.”

Why does decolonization matter?The objective of decolonization is to de-

crease the bacterial load of the body and

nose, and the AORN documentation ref-

erences 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 de-

fense, 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 de-

colonization in the operation bundle.

“We walk around with organisms on us

every day. These organisms can be patho-

genic when our immune defenses are com-

promised, 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 in-

tervention, 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 pack-

ages,” 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 im-

portance of training the trainer, to support them in

building a sustainable safety culture.

Leadership may need education as well. Any im-

provement 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 con-

sumers 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 con-

versation,” says Montejano. “ ‘Why did the nurse just

put this swab up my nose?’ This should be a conver-

sation between the worker and the patient so they

understand why.”

A broad-spectrum, pre-saturated, fast-acting an-

tiseptic 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 decolo-

nization 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.”

Tracking resultsNo 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. Mon-

tejano 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 expan-

sion of resources in order to effectively track resis-

tance to antibiotics.”

Implementation optionsAORN reviews both vertical and horizontal decoloniza-

tion approaches, and an antiseptic can fit into either

approach or into a blend of the two. Embedding an an-

tiseptic in a screen-and-treat program offers a vertical

option, while for a horizontal approach, an

organization might implement a uniform stan-

dard of care in the perioperative setting where

all patients get the same treatment.

“Variations lead to infection, which is what

was drilled into me as an infection prevention-

ist,” 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 ap-

proach. You can use it in either strategy.”

The AORN document is impressively com-

prehensive in its guidance and background,

Montejano says.

“It’s nice to see these guidelines in-

corporated—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 matthew.phillion@gmail.com.

International Infection Prevention Week

“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.”

Sponsored By:

International Infection Prevention Week

Healthcare professionals are continually under pressure to improve quality and safety, and performance improvement continues to present a major challenge for healthcare organizations. This is especially true for hand hygiene improvement efforts, and achieving and sustaining high compliance rates have been met with little success for many facilities.1

Tracking hand hygiene rates and providing feedback are essential elements of a

multimodal strategy to improve hand hygiene.2

Considering the inherent challenges with direct observation,1 some healthcare facilities are transitioning to automated hand hygiene monitoring technology to gather hand hygiene data. These systems quickly and efficiently provide substantially more quantitative data than direct observations without observer bias or a Hawthorne effect.3,4 However, data alone is insufficient in improving hand hygiene performance.

Good metrics and quality data drive strategy and direction and are fundamental driving forces in organizations. However, there is an aspect of data that is often overlooked. Quality metrics are outcomes data; they are lagging indicators and are a result of the processes that were in place prior to measurement. Hand hygiene events, opportunities, and compliance rates are outcomes data. They are lagging indicators downstream from the systems or processes that were in place prior to measurement. This is where facilities often veer off track, because hand hygiene is not improved by solely measuring and tracking the lagging indicators.

Valuable time and resources are invested in identifying root causes or reasons for noncompliance and developing targeted countermeasures for hand hygiene improvement. These countermeasures are leading indicators and can help predict outcomes. If the countermeasures have been correctly defined and implemented, then the outcome measures should improve. However, in order to determine whether the countermeasures are effective, they need to be measured and tracked relative to the outcomes. But for most facilities, little if any time is dedicated to tracking and measuring the leading indicators that are designed to influence the outcomes.

CREATING A CULTURE OF IMPROVEMENT FOR HAND HYGIENEBy: Lori Moore, MPH, BSN, RN, CPPS; Clinical Educator, Healthcare; GOJO Industries

When hand hygiene does not improve, the tendency is to focus improvement efforts on the behavior of healthcare workers, providing more training, more education and encouraging them to do better. However, focusing only on the hand hygiene behavior of healthcare workers is like treating the symptom without addressing the cause. The study of Human Factors Engineering has shown that telling people to do better next time is not a solution; this approach, often referred to as the “name, blame, and train mentality,” creates a poor environment and misdirects resources.5 Mark Graban states that it is unfair to ask employees to perform better than the system’s design will allow and further adds that it is the responsibility of leadership to provide a system in which people can be successful.6 Improving performance requires examining hand hygiene as a systems or process problem rather than strictly a people problem.

When it comes to patient safety and performance improvement, healthcare facilities are always on the road between what is and what can be. Atul Gawande states that “while the gap may be wide, better is possible” and further adds that in order to make a difference one should become a scientist and count things because “when you count something interesting, you will learn something interesting.”7 Quality and safety professionals spend a lot of time counting events and opportunities and calculating hand hygiene compliance rates, and there is much that can be learned from this outcomes data. But alone it is insufficient to improve hand hygiene. A culture of improvement must assume that the problem is caused by the system, and everyone, regardless of title or position, plays a role in the identification of problems and solutions to redesign the system. Action-based leading indicators upstream from the hand hygiene behavior must be developed, implemented, measured, and tracked (counted) relative to outcomes and adjusted as necessary.

References:1. Boyce JM. Hand hygiene, an update. Infect Dis Clin N Am. 2021;35:553-573. 2. Boyce JM, Pittet D, and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Guideline for hand hygiene in health-care settings. MMWR Morb Mortal Wkly Rep 2002;51(RR-16):1-45.3. McLaws ML, Kwok YLA. Hand hygiene compliance rates: fact or fiction? Am J Infect Control. 2018;46:876-880.4. Srigley JA, Furness CD, Baker GR, Gardam M. Quantification of the Hawthorne effect in hand hygiene compliance monitoring using an electronic monitoring system: a retrospective cohort study. BMJ Qual Saf. 2014;23:974-980.5. National Patient Safety Foundation. Patient Safety Curriculum. Introduction to Human Factors Engineering and Simulation. Boston, MA. 2016.6. Graban M. Measures of success: react less, lead better, improve more. Constancy, Inc.; 2019.7. Gawande A. Better: a surgeon’s notes on performance. Picador; 2007.* 52 week GHX Data ending Dec 2017; 2017 HPIS Data; Hall & Partners, September 2017 Brand Survey.©2021 GOJO Industries, Inc. All rights reserved. | 32536 (9/2021)

• PURELL SMARTLINK™ Activity Monitoring System – Collects group-level data 24/7. Room sensors automatically count soap and sanitizer events and opportunities.

• PURELLSM Clinician-Based Support – Our experts can help build customized hand hygiene programs, provide unbiased assessments, and offer improvement plans.

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32536-PSQH-2pgSpread-16x10.5.indd 132536-PSQH-2pgSpread-16x10.5.indd 1 10/4/21 1:13 PM10/4/21 1:13 PM

SECONDARY INFECTIONS:

Addressing the COVID-19 fallout

As COVID-19 has stressed healthcare systems worldwide, a pre-existing healthcare worker shortage coupled with caregiver burnout has only become more visible. The healthcare workforce has had to triage not only their incoming patients, but also their daily responsibilities, prioritizing only the most essential elements of the job.

Well before COVID-19 appeared, Infection Prevention and Control teams battled tirelessly to control and prevent Antimicrobial Resistant Organisms (AROs) transmission in our communities and healthcare organizations. The work to reduce Healthcare Acquired Infections (HAIs) with fiscal restraints, limited resources and an overburdened workforce has always been challenging, but the pandemic has further stretched limited and overworked staff leading to a cascade of negative secondary impacts that could be mitigated with improved infection surveillance capabilities.

Current Challenges What we know

With the present pandemic, Infection Prevention and Control teams’ challenges have only intensified. According to the Cambridge University Press, significant increases in the national Standardized Infection Ratios for CLABSI, CAUTI, VAE and MRSA bacteremia were observed in 2020. This increase in HAIs during COVID-19 has highlighted the critical need to build resiliency into infection control programs, to ensure healthcare security and continuity of services while ensuring safer patient care and a safer environment for employees and contractors.

Staff shortages and staff burnout.

The potential for cross contaminations, breaches in protocol and breaches in care pathways increase substantially when staff members are overtaxed and rely on strained resources, requiring a focus on patients’ immediate care needs. Although this focus is necessary given the extreme pressure healthcare workers are under, infection surveillance processes can help to make reporting easier to mitigate and understand HAIs.

Environmental concerns.

If a health system does not have the resources to maintain a clean environment, the procedure and protocols can be followed perfectly and still result in negative health outcomes because of airborne, water or surface contaminants. Healthcare environments are complex and large numbers of patients, clients, staff and visitors can result in

contamination of environments, equipment and surfaces. Increased bed turnover and patient volumes result in bio burden and contaminant reservoirs, which lead to escalating contamination risks and associated costs. It is essential to have a monitoring process with timely and effective audit and feedback systems to ensure safer care.

Additionally, turnover has been high for staff who monitor and audit for infection compliance, resulting in a more junior workforce responsible for interpreting and managing frequently changing guidance from governing bodies.

Multi-drug resistant organisms.

Rising HAIs directly leads to increases in multi-drug resistant organisms. The increased use of empiric antibiotics to proactively treat secondary infection risks may contribute to evolutionary resistance increases, therefore making infections more difficult to treat in the future.

Delayed acute patient care.

Many people are aware of the increased infection risks in hospitals right now, causing them to delay seeking care, leading to sicker patients who are more susceptible to infection. These same patients have moved from an acute phase of illness to a chronic phase, adding to the complexity related to treatment and recovery.

However, delayed patient care is not limited solely to not seeking care when needed, but also includes “care gaps,” which commonly occur in outpatient settings. These care gaps can include missed diagnoses, medication errors in prescribing practice and decreased monitoring of patients, especially those with chronic conditions. These chronic conditions have the potential to become acute in presentation with delayed care.

Reporting A tool to meet surveillance mandates and improve patient safety

The temporary reprieve from governing bodies’ reporting requirements is unlikely to last long term and putting structures and technology in place to provide data feedback by surveillance will set your organization up to ensure the continuity of care and security of care delivery.

Additionally, the CDC plans to issue $2.1 billion in funding to U.S. health organizations to improve infection prevention and control and expand public health measures. Part of the funding is intended to strengthen states’ capacity to prevent, detect and contain infectious disease threats across healthcare settings and help provide data analysis about antibiotic use which will help to improve antibiotic prescribing.

Staff shortages and staff burnout.

Implementing systems allows for consistency in protocols and procedures and for a standardization of workflow, even with high turnover. With limited staff, it’s more important than ever to be able to save time through reduction of routine data aggregation and analysis to collaborate interdepartmentally more easily. Having consumable data reports and displays for shared distribution to care teams both at the macro (total care population) and micro (specific care services and patients) levels helps to keep everyone abreast of rising concerns and be proactive in addressing them.

Environmental concerns.

Quality assurance auditing of environmental services, cleaning and disinfection reports and collaborative monitoring of environmental reports like HVAC systems or climate humidity can help both cleaning teams and engineers to have real-time data available to them when they need it to highlight problem areas and address them before there is an event. This data can also help systems to focus limited resources in the most critical areas.

Multi-drug resistant organisms.

Managing MRDOs is a multifaceted problem that works best in a data-democratized facility, meaning a facility where all staff members have access to the data impacting their work. With the right data, IPAC teams and bed managers can ensure isolation and precautions are in place to limit spread, while also partnering with AMS teams and physicians to ensure good clinical guidelines exist for empiric therapy and perform timely prescription interventions.

Delayed acute patient care.

With such crushing urgency and demand on traditional healthcare systems, tracking, tracing, updating records and gaining insight from health systems and disparate data streams is not possible without specialized tools which notify providers of changes in data. This critical data is necessary to aid providers with the information they need to treat both the patients immediately in front of them and those whom are being cared for remotely. Patient status and dispositions may now be treated by hospitalists; however, the patient is likely to be outside the hospital environment for treatment and/or convalescing. In all cases, having access to clinical information in a centralized, consumable format is essential to a care provider so that they can bring context to the patient’s current presentation.

The global healthcare continuum is rapidly changing in complexity and urgency, requiring healthcare systems and their workforces to consistently adapt and innovate. Prioritizing a culture where departments collaborate together with access to relevant data and tools informs both immediate acute actions and longer-term strategic decisions which leads to safer patients, a safer workforce and ultimately, a safer organization.

Questions to ask your teams

Is your healthcare system prepared to handle the increase in HAIs following the COVID-19 pandemic to keep patients safer?

As you think toward the future, what gaps do you see? What technology will you need to address those gaps?

What resources will you need to ensure a safer workforce and improve staff retention?

How can you engage multiple departments for a more collaborative approach to achieve a safer organization?