Preoperative Nasal Decolonization: Impact on Surgical Site Infections in Patients Undergoing Total Joint Arthroplasty

Preoperative Nasal Decolonization: Impact on Surgical Site Infection in Patients Undergoing Total Joint Arthroplasty Surgical site infections (SSIs) are costly to a patients' quality of life and a hospital's finances and reputation (Torres et al., 2016). Hospital-acquired infections (HAIs) contribute to an increased length of stay, patient dissatisfaction, and increased mortality. SSIs contribute to a 3% mortality rate, with 75% of these deaths directly attributed to the SSI (CDC, 2020). SSIs are the most expensive of all HAIs that reportedly costs $10,000 to $25,000 per infection and over $90,000 if the infection involves a resistant organism or a joint implant (Torres et al., 2016). Romero-Palacios et al. (2019) state that surgical site infections following total joint replacement cost the United States (U.S) $1.62 billion annually. Preventing HAIs is critical to prevent financial strain for the hospitals since the Centers for Medicare and Medicaid Services (CMS, 2020) has stopped reimbursing hospital-acquired events, such as SSIs. Methicillin-resistant Staphylococcus aureus (MRSA), and methicillin-sensitive Staphylococcus aureus (MSSA) has been attributed to SSIs following total joint arthroplasty (Pelfort et al., 2019; Peng et al., 2018). A considerable portion of the population harbors different S. aureus forms, including 20%-36% with MSSA and 6% with MRSA (Peng et al., 2018; Septimus, 2016). Decolonization is an evidence-based intervention in reducing HAIs. Eliminating colonized bacteria with nasal decolonization has been shown in preventing S. aureus infections and using povidone-iodine statistically reduces SSIs (Urias et al., 2018). The guidelines for targeted decolonization require all patients to be tested for MRSA and then recommends treatment of those who test positive; while universal decolonization is treatment for all patients regardless of MRSA status. Both methods have been shown to decrease infections (Hayden et al., 2016). The purpose of this DNP project is to implement a universal preoperative NASAL DECOLONIZATION 7 nasal decolonizing procedure with povidone-iodine for adult patients undergoing elective total joint arthroplasty procedures to reduce surgical site infections (SSIs) caused by MRSA, and MSSA. Problem The Centers for Disease Control [CDC] (2020) defines SSI as an infection occurring within 30 days and 90 days of total joint replacements. Diagnosis of infection includes the presence of purulent drainage or organisms from sterile cultures and demonstration of pain, tenderness, localized swelling, redness, and heat and are categorized as superficial, deep incisional, or organ/space infections (CDC, 2020). According to the CDC, in 2014, approximately 14 million surgical procedures resulted in over 110,000 (0.78%) surgical site infections in the U.S. According to the Agency for Healthcare Research and Quality (AHRQ), more than 450,000 total hips replacements and 790,000 total knee replacements are performed annually in the U.S. (American Academy of Orthopedic Surgeons, 2020), with an infection rate of 2% to 4% (Franklin, 2020). In California, during 2018-2019, there were 211,417 total joint procedures performed, which resulted in 963 infections (0.46%) (U.S. Department of Health, 2020). S. aureus is one of the most common organisms that causes SSIs, which can lead to increased patient mortality, length of hospitalization, and healthcare costs (Hayden et al., 2016; Septimus & Schweizer, 2016, Zhu et al., 2020). S. aureus is the most common organism in total joint replacement infections (Pelfort et al., 2019; Peng et al., 2018). The anterior nares are a significant source for colonization, and the majority of S. aureus infections are from the patient's nasal flora (Hayden et al., 2016; Pelfort et al., 2019; Peng et al., 2018; Septimus & Schweizer