WK 8 ASSIGN DATA

Walden University

College of Nursing

This is to certify that the doctoral study by

Ashley Simons

has been found to be complete and satisfactory in all respects, and that any and all revisions required by the review committee have been made.

Review Committee Dr. Barbara Niedz, Committee Chairperson, Nursing Faculty

Dr. Allison Terry, Committee Member, Nursing Faculty

Chief Academic Officer and Provost Sue Subocz, Ph.D.

Walden University 2023

Executive Summary: Quality Improvement Initiative

Reducing Orthopedic Surgical Site Infections Through Nasal Decolonization

by

Ashley Y. Simons

MS, Walden University, 2016

BS, South University, 2014

ADN, Midlands Technical College, 2007

Executive Summary Submitted in Partial Fulfillment

of the Requirements for the Degree of

Doctor of Nursing Practice

Walden University

February 2024

1

Summary

According to the National Healthcare Safety Network, a unit of the Centers for

Disease Control and Prevention, surgical site infections (SSIs) can occur after a

surgically invasive procedure. The Network estimated that implementing evidence-based

research could prevent roughly half of SSIs. Historically, patients with SSIs have an

elevated morbidity and mortality rate. Data on the organization's patient safety dashboard

highlighted an uptick in SSI and methicillin-resistant Staphylococcus aureus (MRSA)

bloodstream infection rates among patients who underwent surgically invasive joint

procedures, an important practice problem. The purpose of this Doctor of Nursing

Practice (DNP) project was to evaluate the impact of the 3-month quality improvement

(QI) initiative on the SSI and MRSA rates for surgical joint procedures at the site. The QI

implementation included a standardized nasal decolonization process of preoperative

povidone-iodine (PI).

Prior to the QI initiative, there were four SSIs with two MRSA infections in a 3-

month period. After the QI project, the dashboard reported only a single SSI during the

plotted time frame of the QI product standardization and zero MRSA infections in the 3

months following the new process. The one reported SSI infection resulted in

approximately $50,000 in accrued costs following the initial surgery. The 11 preoperative

nurses surveyed prior to and after the 3-month trial QI process expressed satisfaction and

increased compliance in using the new process.

2

Background

SSI/MRSA infections are a clinical and economic burden. According to (Hou et

al., 2023) one occurrence of a surgical site and MRSA infection can be devastating for

individual patients in terms of discomfort, pain, longer lengths of stay, and hospital

readmissions. The organization had identified SSI/MRSA infections as costly and was

pursuing a zero-based outcome to eliminate any incidence of SSI/MRSA infections at the

site. Hospital leaders championed a QI effort by citing a surgical preparation study

(Figuerola-Tejerina et al., 2017) that included the application of 10% PI nasal swabs

preoperatively to the nares to reduce the SSI and MRSA infection risk of those who

undergo surgical invasive joint procedures. According to Figuerola-Tejerina et al. (2017),

wound infections account for over 2 million nosocomial infections in hospitalized

patients.

During the fiscal year (FY) 2022, the organization reported 16 out of 485 patients

to have experienced a SSI after undergoing a surgically invasive procedure. In the 3-

month retrospective data for October, November, and December, six SSI/MRSA

infections were reported among those who underwent surgically invasive joint

procedures. According to Bhattacharya (2016), Staphylococcus aureus plays a

predominant role in the etiology of SSIs. The average cost of one SSI within the

organization during FY 2022 ranged from $25,00 to $90,000.

Before the 3-month QI initiative, leaders at the site had not identified standard

practice processes. The current PI swabs were large compared to the human nasal

3

anatomy. The amount of product varied with each swab, and there was no standard time

application to the nares. It was a messy process that was uncomfortable for the patient.

Wagner et al. (2020) conducted a randomized control trial study within the

Raleigh Duke Hospital perioperative area that included populations of patients who

underwent total hip arthroplasty (THA), total knee arthroplasty (TKA), and spinal fusion

(SF). Following the 3-month preoperative implementation of the PI nasal swabs, the

reported data revealed zero SSIs out of the 47 THA and 79 TKA surgical cases and only

one identified SSI among the 320 SF surgical cases. Wagner et al.'s findings are

consistent with those of other researchers. Hammond et al. (2022) and Goldman et al.

(2019) found that including PI nasal decolonization preoperatively incorporated with

additional care bundles such as chlorhexidine gluconate bathing decreased the rates of

SSI/MRSA bacteremia rates among patients undergoing surgically invasive procedures.

Ghaddara et al. (2020) and Zhu et al. (2020) demonstrated that a single application of PI

preoperatively decreases nasal MRSA up to 6 hr after application, suggesting a single

dose is effective for short-term use.

As Hou et al.'s (2023) and Strobel et al.'s (2021) studies demonstrated, procedures

associated with an SSI result in a substantial financial burden to the health care system.

Costly additional care following an SSI can include additional treatments, additional

surgeries, and costly intravenous antibiotic therapy that can all accompany an increased

hospital length of stay.

The literature provides adequate support for the use of the PI swabs specifically

developed to appropriately fit the nares in an adult patient. I conducted this DNP project

4

based on the presumption that providers could implement the standardized preoperative

nasal decolonization protocol in a sufficient manner. The ability of the nurses to adhere to

the implemented protocol and administer the ordered nasal decolonization swabs

preoperatively was described as attainable.

Project Development

I implemented the project in collaboration with key stakeholders. A quality

review was conducted and shared via the organizational report, which showed an uptick

in the SSI/MRSA infection rate during FY 2022. Further data from the site's infection

prevention and patient safety manager's dashboard highlighted subcategories of the

surgical procedures resulting in SSI/MRSA infections, such as hips, knees, shoulders, and

spines.

SSIs were monitored at the site for up to 90 days following a surgical procedure

and reported quarterly. SSIs can vary from superficial to deep, causing various severe

complications. According to the National Healthcare Safety Network (2023) guidelines,

surgical joint procedures such as hip prosthesis and knee prosthesis allow for 90-day

surveillance for deep and organ space SSI confirmation.

All reported confirmed SSIs were updated on the site’s dashboard by the infection

preventionist, whose role was specific to surgical services. In this DNP project, I

evaluated the impact of the QI initiative on three measures: (a) the SSI and MRSA

infection rates of those who underwent a surgically invasive joint procedure, (b) the

impact on the cost of care, and (c) nurses’ satisfaction with the QI provisional tool versus

5

the previous unstandardized process. The method for obtaining data on reported

SSI/MRSA infection rates was the same for both before and after the QI implementation.

Results

I collected data on SSI and MRSA infections prior to the 3-month QI initiative

study. In the retrospective analysis, data collected from FY 2022 included the number of

surgical joint procedure cases by month and the reported SSI/MRSA surgical joint cases

reported for October, November, and December. During FY 2022, retro-analysis reported

two joint SSIs and one MRSA infection during October, two joint SSIs and one MRSA

infection during November, and no SSI or MRSA infections during December in 316

cases. The resulting rate per 1,000 cases was 18.99. Table 1 includes the number of

surgical joint cases and SSI/MRA infections and total cases.

Table 1

Fiscal Year 2022 Surgical Joint Procedures

Month No. of cases SSI and MRSA infection rates (no.) SSI MRSA

October 105 2 1 November 117 2 1 December 94 0 0 Total 316 4 2

Note. Data were collected from the project organization's patient safety dashboard. SSI =

surgical site infection; MRSA = methicillin-resistant Staphylococcus aureus.

The findings following the 3-month QI initiative standardization preoperative

process included data from February, March, and April of FY 2023. Results yielded one

reported hip SSI during April 2023, with no additional reported SSI/MRSA for the

6

remaining surveyed months during the QI initiative. There were 293 cases resulting in an

8.82 rate per 1,000 surgeries, less than half the rate before the trial. Table 2 includes the

number of surgical joint cases and the reported SSI/MRA infection rates obtained from

the site's infection rates dashboard.

Table 2

Fiscal Year 2023 Surgical Joint Procedures

Month No. of cases SSI and MRSA infection rates (no.) SSI MRSA

February 83 0 0 March 116 0 0 April 94 1 0 Total 293 1 0

Note. Data was collected from the project organization's patient safety dashboard. SSI =

surgical site infection; MRSA = methicillin-resistant Staphylococcus aureus.

The site's chief financial officer provided financial cost data. The executive

identified surgical site/MRSA infections as an organizational weakness and supported a

strategic QI initiative to decrease the accompanying cost. Surgical site/MRSA infections

can be detrimental and costly to the patient and the organization. At the time of writing,

the average cost of the PI swabs used before the QI standardized was significantly

cheaper than those of the customized nasal PI swabs implemented during the QI

standardization initiative. The average cost of the customized swabs was about $4 per

single-use box, whereas the large all-purpose PI swabs were about $4 for a pack of a

count of 50, totaling around 0.08 cents for each single-use PI swab. However, the

possible accrued cost for one surgical site/MRSA infection far outweighs the cost of the

7

$4 PI nasal swab pack that is prophylactically applied. The possible accrued cost from

one surgical site/MRSA infection can cost the organization around $90,000. During the

3-month QI initiative, the organization significantly decreased the SSI/MRSA rates at the

site, saving up to $450,000 or more in associated costs. SSI/MRSA infections can result

in a substantial burden to the health care system with a projected increased length of stay

and additional accrued expenses; as such, health care leaders should adopt evidence-

based interventions to ease the financial burden (Hou et al., 2023).

Before asking the project site's nursing staff to employ the QI standardized tool

(i.e., the PI customized nasal swabs containing 10% PI), I disseminated a survey to 11

preoperative nurses to determine satisfaction with the current larger all-purpose PI swabs.

The anonymous feedback from all 11 nurses mentioned dissatisfaction with the current

product. The preoperative nurses stated that the swabs were considerably larger than an

average adult's nares. The process was uncomfortable and messy for the patient, which

often caused an already uneasy patient to experience undue stress before their scheduled

surgery. Following the 3-month QI initiative, I disseminated an additional

postimplementation survey to include the same 11 preoperative nurses. All nurses

preferred the newly implemented product over the previous product. The findings

supported that the ease of use of the project and the mention of an effective, more tactile

usability product were essential to the satisfaction of the nurses and patients.

Decreasing the organization's surgical site/MRSA infection rates may positively

affect the patient by reducing pain and suffering and allowing them to return to their

previous quality of life. As referenced to (Smith, 2017) patients with positive outcomes

8

often become more trusting of the health care organization that provided their treatment

and may be more likely to return for repeated care. Solid research evidence suggests that

financially stable organizations report healthier patient experiences with decreased

readmission rates (Akinleye et al., 2019). Internal data regarding the organization's

financial stability also indicates a reduced risk of opposing patient quality and safety

outcomes for medical and surgical patients. Nurses' satisfaction with using the trial

customized PI nasal swabs was also evident in the data.

It was possible that a patient with a confirmed surgical site/MRSA infection might

have had surgery at an outside facility or a sister organization that did not include the

standardized preoperative preparation. The possibility of receiving a patient from an

outlying facility who developed an SSI could have skewed the reported data on infection

prevention. This could be considered a limitation of the project in summarizing the

SSI/MRSA data. Another limitation identified could be the need for compliance from the

surgeons and nursing staff to provide the newly implemented QI product as expected. If

providers failed to order the standard preoperative nasal decolonization preparation, they

might have missed an opportunity to prevent an SSI/MRSA occurrence.

Conclusions

Following the 3-month QI initiative, there was a significant decrease in

SSI/MRSA rates at the site. The impact on the organization may be significant by

standardizing a QI process to reduce SSI/MRSA infection rates during the preoperative

process on the day of surgery. Providers may also be able to reassure already nervous

patients that the site acknowledges the risk that accompanies surgical procedures and has

9

taken steps to decrease the risk at the site. A systematic review of quantitative data

suggests patients who experience better outcomes with minimal complications may be

more likely to sustain an active lifestyle, return to the site in the future for other services,

and refer others based on their positive experiences (Bombard, 2018).

At the time of writing, the organization encompassed four local hospitals within

the area. Throughout the campuses, no standard preoperative processes were applied to

patients undergoing a surgically invasive joint procedure on the day of surgery. By

standardizing the preoperative process throughout the sites, providers may be able to

offer patients the same standard of care regardless of location. Standardizing care could

benefit the organization by decreasing the impact of the cost of surgical site/MRSA

infections. Thus, recommendations on using the customized, nasal PI swabs across the

system will be offered to the senior leadership team at the system level.

Data collected from the survey of the 11 preoperative nurses support the QI

process change. The data include comments regarding the ease of use for nurses and

positive feedback relayed to nurses from patients at the time of application. By applying

evidenced based research, reducing SSI/MRSA rates may positively affect the

community by preventing harm to underserved and underfunded communities lacking

health care resources. By implementing a standardized organizational process for all

patients undergoing surgical invasive joint procedures, health care leaders may be able to

place equity and inclusion at the forefront of the care provided by staff. Such efforts may

foster positive social change.

10

References

Akinleye, D. D., McNutt, L.-A., Lazariu, V., & McLaughlin, C. C. (2019). Correlation

between hospital finances and quality and safety of patient care. PLOS ONE,

14(8), Article e0219124. https://doi.org/10.1371/journal.pone.0219124

Bombard, Y., Baker, G. R., Orlando, E., Fancott, C., Bhatia, P., Casalino, S., Onate, K.,

Denis, J.-L., & Pomey, M.-P. (2018). Engaging patients to improve quality of

care: A systematic review. Implementation Science, 13(1).

https://doi.org/10.1186/s13012-018-0784-z

Bhattacharya, S. (2016). Surgical site infection by methicillin-resistant Staphylococcus

aureus– On decline? Journal of Clinical and Diagnostic Research, 10(9), DC32–

DC36. https://doi.org/10.7860/jcdr/2016/21664.8587

Dellinger, E. P., Villaflor-Camagong, D., & Whimbey, E. (2021). Gradually increasing

surgical site infection prevention bundle with monitoring of potentially

preventable infections resulting in decreasing overall surgical site infection rate.

Surgical Infections, 22(10), 1072–1076. https://doi.org/10.1089/sur.2021.183

Figuerola-Tejerina, A., Bustamante, E., Tamayo, E., Mestres, C. A., & Bustamante-

Munguira, J. (2017). Ability to predict the development of surgical site infection

in cardiac surgery using the Australian Clinical Risk Index versus the National

Nosocomial Infections Surveillance-Derived Risk Index. European Journal of

Clinical Microbiology & Infectious Diseases, 36(6), 1041–1046.

https://doi.org/10.1007/s10096-016-2889-0

11

Ghaddara, H. A., Kumar, J. A., Cadnum, J. L., Ng-Wong, Y. K., & Donskey, C. J.

(2020). Efficacy of a povidone iodine preparation in reducing nasal methicillin-

resistant Staphylococcus aureus in colonized patients. American Journal of

Infection Control, 48(4), 456–459. https://doi.org/10.1016/j.ajic.2019.09.014

Hammond, E. N., Brys, N., Kates, A., Musuuza, J. S., Haleem, A., Bentz, M. L., &

Safdar, N. (2020). Nasal povidone-iodine implementation for preventing surgical

site infections: Perspectives of surgical nurses. PLOS ONE, 15(11), Article

e0242217. https://doi.org/10.1371/journal.pone.0242217

Hammond, E. N., Kates, A. E., Putman-Buehler, N., Watson, L., Godfrey, J. J., Brys, N.,

Deblois, C., Steinberger, A. J., Cox, M. S., Skarlupka, J. H., Haleem, A., Bentz,

M. L., Suen, G., & Safdar, N. (2022). A quality improvement study on the

relationship between intranasal povidone-iodine and anesthesia and the nasal

microbiota of surgery patients. PLOS ONE, 17(12), Article e0278699.

https://doi.org/10.1371/journal.pone.0278699

Hou, Y., Collinsworth, A., Hasa, F., & Griffin, L. (2023). Incidence and impact of

surgical site infections on length of stay and cost of care for patients undergoing

open procedures. Surgery Open Science, 11, 1–18.

https://doi.org/10.1016/j.sopen.2022.10.004

National Healthcare Safety Network. (2023, January). Outpatient procedure component

surgical site infection (OPC-SSI) surveillance. Centers for Disease Control and

Prevention. https://www.cdc.gov/nhsn/pdfs/opc/opc-ssi-protocol-current-508.pdf

12

Smith, C. (2017). First, do no harm: Institutional betrayal and trust in health care

organizations. Journal of Multidisciplinary Healthcare, Volume 10, 133–144.

https://doi.org/10.2147/jmdh.s125885

Strobel, R. M., Leonhardt, M., Förster, F., Neumann, K., Lobbes, L. A., Seifarth, C., Lee,

L. D., Schineis, C. H., Kamphues, C., Weixler, B., Kreis, M. E., & Lauscher, J. C.

(2021). The impact of surgical site infection—A cost analysis. Langenbeck's

Archives of Surgery, 407(2), 819–828. https://doi.org/10.1007/s00423-021-02346-

y

Wagner, M., Barnes, C., O’Farrell, E. J., McCauley, S., Walczak-Daege, T. L., &

Stringfield, C. (2020). What is the impact of prophylactic nasal decolonization in

prevention of SSI? American Journal of Infection Control, 48(8), Article S51.

https://doi.org/10.1016/j.ajic.2020.06.069

Zhu, X., Sun, X., Zeng, Y., Feng, W., Li, J., Zeng, J., & Zeng, Y. (2020). Can nasal

Staphylococcus aureus screening and decolonization prior to elective total joint

arthroplasty reduce surgical site and prosthesis-related infections? A systematic

review and meta-analysis. Journal of Orthopaedic Surgery and Research, 15,

Article 60. https://doi.org/10.1186/s13018-020-01601-0