b. Povidone Iodine 5% Swabsticks, Single Pack (4 packs) c. Clean gloves

Transcription

1 Program Agenda SUBJECT: Universal Decolonization Protocols for Pre-operative Orthopedic Patients EFFECTIVE DATE: 5/2014 REVISED DATE: I. Policy: The largest fraction of hospital acquired infections (HAIs), such as MRSA, resides on the skin and the nose and could gain access to the bloodstream, lungs, and bladder by way of devices and incisions that breach normal host defenses. Therefore, universal decolonization protocols that are evidence-based for the reduction of MRSA and device-related infections are to be performed on adult orthopedic patients undergoing total joint replacements in addition to hospital policies and procedures for the prevention of HAIs. Universal decolonization at JHMC is the routine use of Chlorhexidine (CHG) bath and the application of Povidone Iodine 5% nasal application preoperatively on orthopedic patients prior to surgery for joint replacement. Povidone Iodine 5% Nasal Application will be done one (1) hour but not greater than six (6) hours prior to surgery. Nasal screening or pretesting is not required prior to Povidone Iodine nasal application unless ordered by the physician. II. Responsibility: A. JHMC Outpatient providers are responsible for prescribing CHG bath/shower prescription and patient education. The patient should have CHG Bath or shower prior to coming to the hospital on the scheduled date of surgery. B. Povidone Iodine 5% application will be done for outpatients in either the Same Day Unit or Pre-Surgical Holding area whichever the patient location is prior to surgery and documenting in the patient s EHR. C. For in-patients, the nursing personnel assigned to the patient in the nursing unit is responsible for providing CHG bath and Povidone Iodine nasal application immediately prior to being transferred to the Operating Room (OR) and documenting in the patient s EHR. III. Procedures: A. Povidone Iodine 5% Nasal Application: 1. Supplies: a. Tissue paper

2 b. Povidone Iodine 5% Swabsticks, Single Pack (4 packs) c. Clean gloves Policy & Procedure At least one (1) hour but not more than six (6) hours prior to orthopedic surgical procedure, perform Povidone Iodine 5% Nasal application as follows: 1. Perform hand hygiene. Bring tissue paper and four (4) packs of Povidone Iodine 5% Single Pack Swabsticks at the patient bedside. 2. Introduce self and explain procedure to patient. 3. Don a pair of clean gloves. Clean patient s nostrils with a tissue if needed. 4. Open a Povidone Iodine Swabstick and insert comfortably into the patient s nostril and rotate it for 15 seconds covering all surfaces. Move the swabstick in to the inside tip of the nostril and rotate it for another 15 seconds. Discard in appropriate trash receptacle. 5. Open the second pack of Povidone Iodine swabstick; insert the swabstick into the other nostril comfortably. Rotate swabstick for 15 seconds covering all surfaces of nostril then, move the swabstick into the inside tip of the nostril and rotate it for another 15 seconds. Discard used swabstick into trash receptacle. 6. Repeat the procedure for each patient s nostril using a freshly opened Povidone Iodine Swabstick each time. (Each nostril should receive two swab applications.) 7. Document procedure done in EHR. B. Chlorhexidine Bath Equipment/Supplies: 1. 2% Chlorhexidine Gluconate (CHG) solution 2. Bath basin 3. Wash clothes and towels Exclusion Criteria (DO NOT USE): 1. Infants <2 months of age. 2. Patients with history of an allergic reaction to CHG. 3. Patients with severe skin disease or burn. 4. Patients with indwelling epidural catheter or lumbar drain. Note: Do not use CHG solution on the face, eyes, ears, mouth and internal genitalia. 2

3 Nursing personnel will bathe the patient daily with 2%% CHG solution, commencing within 24 hours post admission into the adult ICUs, RCU, Isolation and for preoperative patients prior to surgery. They will also use CHG to cleanse the patient when contaminated with bodily secretions/excretions. Nursing Actions and Special Considerations: 1. Explain procedure to patient, provide privacy. 2. Assemble all equipment and supplies needed for the bath. Offer bedpan or urinal prior to giving bath. 3. Wear gloves. Change gloves as needed to keep your hands dry. 4. Place patient in an upright position as tolerated to assist with mouth care. 5. Remove gown and expose only areas as necessary by covering body parts with towel to prevent exposure and chilling. Lower head of bed unless contraindicated. 6. Wash face, neck and ears using regular soap. Rinse face and dry thoroughly. 7. Apply CHG solution to a wet wash cloth or directly on to wet skin. Use minimum amount of CHG to cover all skin areas EXCEPT face, eyes, ears, mouth and internal genital areas. Wash the upper body, paying attention to areas that fold (breast, axilla, and abdomen). Rinse thoroughly with warm water and gently pat dry. Failure to rinse thoroughly may cause skin dryness. Special considerations: Do not add CHG solution to water. Do not apply directly to dry skin. Do not apply to areas of skin breakdown. Do not apply to new surgical incision until wound healing has begun. Do not use regular soap, deodorant or powder after washing with CHG. CHG Solution is for external use only. 8. Cover upper body part with towel to prevent chilling while washing lower areas of the body. Wash genitalia with regular soap and water. If able, have patient wash and dry external genitals. Monitor for any presence of skin irritation and/or discharge. 9. Change basin water. 3

4 10. Turn patient on side. Wipe back and buttocks with wash cloth wet with water. Then, apply 2% CHG to the wet wash cloth, wash back and buttocks and dry thoroughly. Check for presence of skin irritations or pressure sores. The following lotions may be used after washing with CHG: Aveeno (PS#42305); Eucerin (PS#115806); Lubriderm (PS # 43377); Baza Protect (PS#147435) and Barrier Moisture Citric Acid (PS#147437). 11. Assist patient to put on hospital gown and comb hair. 12. Observe patient for any signs of reaction to the CHG solution and refer to MD. Documentation: 1. Complete daily care flowsheet, note condition of the skin and observation in the patient s EMR. 2. Notify MD/Nurse of abnormal findings or observation. IV. References: A. CDC, B. Hibiclens, Molnlycke Healthcare US Literature C. Phillips, M. et al. Preventing Surgical Site infections: An Open-Label, Randomized Trial of Nasal Mupirocin Ointment and Nasal Povidone Iodine Swab, NYU Langone Medical Center D. Podgorny, Kelly L. Project Director, and Division of Healthcare Quality Evaluation: Principle Investigator, Joint Commission s Implementation Guide for NPSG on Surgical Site Infections: The SSI Change Project, 2013 E. Universal ICU Decolonization: an Enhanced Protocol, The REDUCE MRSA Trial Working Group, Harvard Pilgrim Health Care, University of California Irvine Hospital Corporation of America, AHRQ Publication No EF September 2013, Prepared for the Agency for Healthcare Research and Quality Rockville, MD and Centers for Disease Control and Prevention Atlanta, GA. Downloaded 5/2014. F. National Collaborating Centre for Women s and Children s Health, National Institute for Health and Clinical Excellence, Surgical Site Infection, Prevention and Treatment of Surgical Site Infection, October, MidCity Place 71 High Holborn London WC1V 6NA, Downloaded 5/2014. G. APIC Guide 2010, Guide to the Elimination of Orthopedic Surgical Site Infections, APIC Headquarters,1275 K Street, NW Suite 1000, Washington, DC

5 Ortho.Preop.Decol.P&P 5/2014 TBL:JAH:tbl 5