Running head: INTEGRATIVE LITERATURE REVIEW 1

Integrative Literature Review

Kelley Schlosshan

Bon Secours Memorial College of Nursing

Nursing Research

NUR 4222

Christine Turner, PhD., RN Associate Professor

April 20, 2018

Honor Code: I Pledge

INTEGRATIVE LITERATURE REVIEW 2

Abstract

Purpose: The purpose of this integrative review is to identify the link between a preoperative

nasal screening and decolonization protocol in orthopedic surgical patients on lowering surgical

site infections (SSI's).

Background: With an increasing number of elective joint replacements and spinal surgeries

performed annually, SSI's represent significant morbidity and mortality placing a financial

burden on the healthcare system. Evidence-based prevention and control strategies are essential

to achieving better patient outcomes.

Method: This is an integrative review in which research was gathered from online databases.

The articles discussed are quantitative studies that were selected based on distinct criteria. The

data was then used to determine the impact of a preoperative screening and decolonization

protocol on lowering SSI's.

Limitations: The most significant limitation is the researcher’s ability to identify pertinent

articles in university and free articles relevant to the PICOT question. Other limitations include

articles not published in English, broad topics and narrowing down to the topic selected.

Results and Findings: The evidence collected for this integrative review reinforces the

perception that implementing nares testing and decolonization protocol lowers SSI's. Other areas

of impact includes cost reduction.

Implications and Recommendations: The implementation of nares testing preoperatively has

the capacity to be valuable for early detection of Methicillin-sensitive staphylococcus aureus

(MSSA) and Methicillin-resistant staphylococcus aureus (MRSA) in informing treatment

protocols in elective orthopedic surgical patients to improve patient outcomes. It is

INTEGRATIVE LITERATURE REVIEW 3

recommended that further research be conducted to affirm these interventions reduce the burden

of SSI’s.
INTEGRATIVE LITERATURE REVIEW 4

Integrative Literature Review

The purpose of this integrated review is to identify correlations between a preoperative

nasal screening and decolonization protocol in orthopedic surgical patients to lower surgical site

infections. SSI's, usually caused by MRSA, are linked to significant morbidity and mortality in

orthopedic surgeries in which hardware is implanted (Bebko, Green, & Awad, 2015). SSI's with

Staph aureus are difficult to treat in orthopedic patients because this organism can form a biofilm

on orthopedic implants, which is resistant to antibiotic treatment and can compromise eradication

of infection. This leads to a huge financial impact on healthcare with increased length of

hospitalization, cost of treatment and hospital readmissions. In the absence of appropriate

evidence-based epidemiological interventions to lower SSI's, the increase in the amount of

surgical procedures performed yearly will result in an increase in the number of SSI's (Campbell,

Cunningham, Hasan, Hutzler, & Bosco, 2015). The aim of this review is to examine and discuss

published data related to the researcher's PICOT question: In patients undergoing orthopedic

surgeries does preoperative nares testing combined with a multi-faceted decolonization protocol

reduce the risk of developing an SSI in patients testing MRSA or MSSA positive compared with

only using skin wipes?

Design and Research Methods

This integrative review focused on five research articles. The search for articles was

conducted utilizing computer-based search engines; Ovid and PubMed. The search yielded 5,117

in Ovid and 56 in PubMed. In the initial Ovid search, the researcher used the subject of nursing

and then further defined to perioperative. The search words were surgical site infection and nasal

decontamination. The articles were filtered to include articles with abstracts, full text

availability, year, English language and relevance to the PICOT question. Many articles were
INTEGRATIVE LITERATURE REVIEW 5

eliminated based on being published in the past five-years, 2013-2018, decreasing to 383.

PubMed was searched using the same terms and the results yielded 56 items, which decreased to

11 based on limitations of abstract, free full text, relevance to PICOT question and published in

last five years.

The articles selected were done so based on relevance to the PICOT question. The

researcher focused on quantitative articles in order to analyze quantified findings. A discussion

on nasal screening and decolonization protocol was a requirement. Relevant and qualified

authors were prioritized; examples of appropriate qualifications include Medical Doctor (MD),

Registered Nurse (RN), Masters of Science in Nursing (MSN), Bachelors of Science in Nursing

(BSN), Masters in Public Health (MPH) and Doctor of Philosophy (PhD). The total number of

articles chosen after these limitations were applied is five, resulting in five quantitative studies

(Bebko et al., 2015; Campbell, et al., 2015; Mehta, S., Hadley, S., Hutzler, L., Slover, J., Phillips,

M., & Bosco, J. A., 2013; Mullen, Wieland, Wieser, Spannhake, & Marinos, 2017; and Sporer,

Rogers, & Abella, 2016). Exclusion criteria of articles are studies not addressing the research

question, qualitative studies and in languages other than English.

Findings and Results

The results and findings of the five reviewed articles clearly identifies a positive link

between risk factors, decolonization and reduction of surgical site infections in orthopedic

surgery patients (Bebko et al., 2015; Campbell et al., 2015; Mehta et al., 2013; Mullen et al.,

2017; Sporer et al., 2016). A summary of the five articles is located in Table 1-Article

Evaluation. The researcher framed the review according to the following categories: prevention

and intervention techniques, variables used for analysis and outcomes with statistical

significance. There was consensus among all five articles representing preoperative risks factors
INTEGRATIVE LITERATURE REVIEW 6

and screening and treatment protocol in preventing SSI's (Bebko et al., 2015; Campbell et al.,

2015; Mehta et al., 2013; Mullen et al., 2017; Sporer et al., 2016). The following is a brief

overview of each articles' findings.

Bebko et al., (2015) sought to decrease SSI's on all orthopedic surgical patients requiring

hardware implants by showing an education video about MRSA decontamination at the

preadmission testing appointment, followed by a decontamination protocol of chlorhexidine

(CHG) washcloths, oral rinse and intranasal povidone-iodine solution. The framework utilized

statistical methods with predictive theories and a quantitative method using an experimental

study design with a focus on comparison of pre and post-implementation protocols. The sample

consisted of two groups totaling 709 patients; control group, 344, and experimental group, 365,

at the Michael E. DeBakey Veterans Affairs Medical Center in Houston, Texas. In this study the

authors used nares swab to check for MRSA. Data was analyzed through a 2 sided t test, the

Pearson X₂test, and the Fisher exact test. The SSI rate in the intervention group was 1.1%; four

of the 365 patients developed an SSI. In the control group, 3.8% developed an SSI; 13 of the 344

patients. This was significantly lower than the control group; with a p value of 0.02. Another

goal of this study was to test for potential risk factors which could lead to a higher incidence of

SSI’s. Demographic and co-morbidity variables such as COPD, CAD, tobacco use, alcohol use,

BMI, length of stay and MRSA colonization status were analyzed. Descriptive statistic was used

to test these variables utilizing univariate analysis and multivariate analysis.

In a quasi-experimental quantitative study Mehta el al., (2013) evaluated the

effectiveness of a decolonization protocol reducing the prevalence burden of MRSA in a

specialty orthopedic surgical hospital, NYU Langone Orthopedic Hospital. The prevalence

density rate was compared to the specialty orthopedic hospital pre-implementation. During the
INTEGRATIVE LITERATURE REVIEW 7

study it was compared with two affiliated hospitals; Tisch Hospital and Rusk Rehabilitation

Center, all comprising NYU Langone Medical Center. Comparison with the two affiliated

hospitals was done to control for changes in MRSA prevalence density, which might have been

independent of the decolonization protocol. A small group of patients, 26, tested a self-reported

compliance rate, and was greater than 95%. The framework utilized statistical methods with

predictive theories. The measurement tool used was the nares culture and questions asked by the

operating room nurse to determine treatment compliance. The article did not state the questions

asked by the nurse. Statistical analysis was used with Dichotomous variables compared using the

Person's Chi Square test. Variables with p value < 0.05 were considered statistically significant.

Campbell et al. (2015) used a statistical, quantitative method with a correlation design.

The study took place at NYU Langone Hospital for Orthopedic Surgery in New York. The

purpose of this study was to identify criteria which could help predict which patients are most at

risk for colonization by MRSA and selectively decolonize these patients. The other goal of this

study was to provide information regarding the general incidence of staphylococcus nasal

colonization within an orthopedic population, delineate and compare specific risk factors for

MRSA and MSSA. The data used was obtained through a prospectively collected database of

patients undergoing elective spinal fusion and total joint arthroplasty of the knee or hip. The

sample size was 1,708 patients during March 2011 to March 2012. They used univariate and

multivariate analysis to identify criteria which could help predict which patients are at most risk

for colonization by MRSA. The measurement tool was a nares culture and patient data including

demographics, medical history, current health status and medications used. Univariate analysis

was initially conducted and variables found to be potentially significant were included in multi-

variate regression analysis. The Campbell et al., (2015) study reviewed race and gender and
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found Caucasian males with asthma and high BMI to be the most at-risk group. This finding

represented a 2.58 fold greater risk of MRSA; statistically significant.

Using the quasi-experimental design, Sporer et al., (2016) determined if a preoperative

nares staphylococcus screening and treatment protocol would decrease the incidence of SSI's in

elective joint arthroplasty patients. The control group consisted of patients undergoing elective

joint arthroplasty during January 1, 2008 to December 31, 2008 and surgical skin preparation,

administration of prophylactic antibiotics and environmental conditions in the operating room

remained unchanged. The framework utilizes a statistical model with predictive theories and data

was analyzed using the t-test and chi square. In this quantitative study, the sample size was 9,690

patients from January 1, 2009 to December 31, 2014 at Central DuPage Hospital. The nares test

was collected within 14 days of surgery to determine if it was MRSA or MSSA positive. All

patients used a decontamination protocol. Following the introduction of this protocol for patients

testing positive, SSI rates decreased from 1.11% prescreening to 0.34% nasal screening; p

value<0.05. After initiation of the process, staph was identified in 66.7% of SSI's before nasal

screening and 33.3% of SSI's after screening. Sporer et al. (2016) realized a decrease in the SSI

rate of 69%; which is statistically significant.

The final study conducted by Mullen et al., (2017) at Baylor Orthopedic and Spine

Hospital, a 23 bed facility located in Arlington, Texas. A quantitative study using quasi-

experimental design, it consisted of a sample size of 1,073 in and outpatient surgical spine

patients. The framework utilized statistical methods with predictive theories. It was undertaken

to determine if implementation of an antiseptic nasal decolonization, Nozin Nasal Sanitizer,

without prescribed antibiotics, would reduce Staphylococcus spp, refers to all variants or strains

of staph, SSI rates. The preoperative protocol instituted during the intervention period was
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Nozin Nasal Sanitizer given to all spine surgical patients by trained staff. Treatment was

continued three times a day for five to seven days after surgery. Optional use was encouraged for

preoperative staff. Analysis was conducted using 2-tailed student t test or in instances of a failed

normality test, the Wilcoxon-Mann-Whitney rank-sum test. The results of the study revealed the

mean infection rate significantly decreased by 81% from 1.76 to 0.33 per 100 surgeries during

the 15 month trial, when compared to the prior nine month baseline. The findings may be more

applicable to acute single focus surgical facilities.

Discussion and Implications

The articles selected indicate a beneficial impact in reduction of SSI’s. The researcher

framed the review according to the following categories: prevention and intervention techniques,

cost reduction and patient outcomes with statistical significance. The following is a discussion on

the implications of the articles; it is organized with common themes and PICOT question

relevance.

Prevention and Interventions Techniques

Early detection and treatment of a positive MRSA or MSSA test in an orthopedic surgical

setting is key to preventing the development of an SSI, directly relating to the PICOT question.

In all of the studies, the authors discussed significant morbidity and mortality associated with

SSI's (Bebko et al., 2015; Campbell et al., 2015; Mehta et al., 2013; Mullen et al., 2017; Sporer

et al., 2016). Staph aureus is considered one of the most common infecting organisms in early

SSI. Four of the articles used a nares swab to test for MRSA and MSSA. (Bebko et al., 2015;

Campbell et al., 2015; Mehta et al., 2013; Sporer et al., 2016). Nares testing is a valid and

reliable way to test for MRSA and MSSA. This is a valuable test prior to surgery because

prophylactic treatment for a positive MRSA or MSSA test can occur before surgery and can help
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lower risk of SSI's. Bebko et al., (2015); Mehta et al., (2013) and Sporer et al., (2016) support the

treatment of these measures to promote optimal outcomes. Four of the articles use skin

decolonization with CHG showers or wipes, along with decolonization of the nares; (Bebko et

al., 2015; Mehta et al., 2013; Mullen et al., 2017; Sporer et al., 2016). Since the population of

patients requiring joint replacements and spine surgeries is increasing, an implication of this

research is to implement best practice strategies to help reduce the incidence of SSI

Three of the five studies reviewed used similar testing, treatment and intervention

techniques; Bebko et al., (2015), Mehta et al., (2013) and Sporer et al., (2016). Bebko et al.,

(2015); Mehta et al., (2013) and Sporer et al., (2016) utilized a nares swab to check for MRSA

and MSSA. All three incorporated CHG showers, baths or wipes the evening and day of surgery

as part of the decolonization. These three studies incorporated antibiotics or other treatment

therapies for patients testing positive for either MRSA or MSSA. Even though Mullen et al.

(2017) did not participate in nares testing, they implemented a protocol of a nasal antiseptic;

Nozin Nasal Sanitizer to use on all spine surgeries.

In Bebko et al., (2015) for MRSA positive results, the treatment consisted of bactroban

ointment and CHG, for a total of five days before surgery, contact isolation and preoperative

antibiotics changed to vancomycin two hours before surgery. If MSSA positive, the treatment

consisted of bactroban ointment and CHG wipes for five days before surgery and no change in

preoperative antibiotics. Mehta et al., (2013) and Sporer et al., (2016) utilized vancomycin

preoperatively for antibiotic prophylaxis for MRSA positive patients and Sporer et al., (2016)

MRSA positive patients were placed on contact isolation. All three studies realized a decrease in

SSI rates within their orthopedic surgical patient population resulting in an economic savings to

the respective institution.

INTEGRATIVE LITERATURE REVIEW 11

Sporer et al. (2016), all patients used a protocol of showering the night before surgery

and applying a 6-cloth CHG regimen to all skin, except face and genitals, a minimum of one

hour following showering. Topical skin preparation with CHG cloths was repeated the morning

of surgery in the preoperative holding area. The nares swab to determine if MRSA or MSSA

positive was collected within 14 days of surgery.

In two similar quantitative studies researchers reviewed demographic variables and co-

morbidities to predict which patients are most at-risk for MRSA colonization and would receive

the most benefit from a decolonization protocol. These studies were conducted by Campbell et

al., (2015) and Bebko et al., (2015). Both studies reviewed similar data including; demographics

and co-morbidities such as COPD, CAD, tobacco and alcohol use and BMI. Both studies found

similar risk factors associated with development of an SSI or MRSA colonization, including;

COPD or Asthma, length of surgery, BMI >30. The information from these two studies could be

used within smaller community based health systems to develop a best practice cost effective

protocol of screening patients most at risk.

Cost Reductions

The development of an SSI increases the length of hospitalization, cost and hospital

readmissions. Directly relating to the PICOT question, they are preventable, considered a

measure of clinical quality and a significant burden to the health care budget (Bebko et al., 2015;

Campbell et al., 2015; Mehta et al., 2013; Sporer et al., 2016). Implications for instituting best

practices for preventive measures are mandatory as healthcare payers, such as Medicare,

scrutinize hospital acquired infections and the Patient Protection and Affordable Care Act

determines how hospitals are paid for the delivery of care, including non-reimbursement. Overall

universal decontamination could be considered as prevention strategies but warrants further

INTEGRATIVE LITERATURE REVIEW 12

research (Bebko et al., 2015; Campbell et al., 2015; Mehta et al., 2013; Mullen et al., 2017;

Sporer et al., 2016). Bebko et al., (2015); Mehta et al., (2013) and Sporer et al., (2016) All three

studies realized a decrease in SSI rates within their orthopedic surgical patient population

resulting in an economic savings to the respective institution.

Patient Outcomes

By instituting preventive measures, patient care is optimized, decreasing the chances of

developing an SSI. This theme is directly related to the PICOT question. Each study incorporated

different strategies and in all, the SSI rate decreased significantly (Bebko et al., 2015; Campbell

et al., 2015; Mehta et al., 2013; Mullen et al., 2017; Sporer et al., 2016). It is recommended by

incorporating patient education and compliance before surgery, it will help health care systems

realize optimal patient outcomes.

Limitations

In conducting this integrative review, the researcher faced several limitations. During the

article search process, there were articles which appeared relevant to the PICOT question but the

researcher was not able to access the full article. Articles more than five years old further limited.

Also, narrowing to orthopedic surgeries further limited the availability of articles. An additional

limitation is this is the first integrative review conducted by the researcher.

In all of the studies, the sample size was sufficiently large enough to get a true effect of

treatment and interventions demonstrated. It supports a stratified sampling in order to make the

sample representative of the target population. The lack of group randomization increases the

risk of selection bias as the selection included all orthopedic patients. The attrition rate was low

and reasons for elimination included, patients who did not meet the specific inclusion criteria,

lack of culture results, and also one that was lost.

INTEGRATIVE LITERATURE REVIEW 13

Hierarchy of evidence is assigned to studies based on the methodological quality of

design, validity and applicability to patient care. The quality of the studies was strong,

consistent, generalizable results with sufficient sample size for the study design, adequate

control, definitive conclusions, consistent recommendations based on literature review which

includes thorough reference to scientific evidence. It provides strong evidence to change and

improve clinical best practices. The variables were clearly operationalized. The measurement

tools indicates nares swab testing as a valid and reliable test to determine if the patient had

MRSA or MSSA colonization.

Conclusion

The evidence complied for this integrative review supports the implementation of

preoperative nares testing for MRSA and MSSA followed by a decolonization protocol in

reducing the risk of SSIs in orthopedic surgery patients (Bebko et al., 2015; Campbell et al.,

2015; Mehta et al., 2013; and Sporer et al., 2016), directly relating to prevention and intervention

techniques, cost reduction and patient outcomes. The cost of instituting these protocols is

minimal compared to the development of an SSI. All five studies demonstrated a significant

decrease in SSI; Mullen et al., (2017) was the only study in which nares testing was not done

preoperatively, instead using a presurgical application of a nonantibiotic nasal antiseptic. Even

though patient outcomes were significant, further research needs to be done to determine long

term effects. In relation to the PICOT question being addressed with orthopedic surgery patients,

the literature reflects using both preoperative nares testing and skin decolonization to lower the

risk of SSI.
INTEGRATIVE LITERATURE REVIEW 14

References

Bebko, S. P., Green, D. M., & Awad, S. S. (2015, March 4). Effect of a Preoperative

Decontamination Protocol on Surgical Site Infections in Patients Undergoing Elective

Orthopedic Surgery With Hardware Implantation. Journal of American Medical

Association, 150(5), 390-395. https://doi.org/10.1001/jamasurg.2014.3480

Campbell, K. A., Cunningham, C., Hasan, S., Hutzler, L., & Bosco, J. A. (2015). Risk Factors

for Developing Staphylococcus aureus Nasal Colonization in Spine and Arthroplasty

Surgery. Bulletin of the Hospital for Joint Diseases, 73(4), 276-281. Retrieved from

http://hjdbulletin.org/files/archive/pdfs/v73n4/BHJD%2073(4)%202015%20pp%20276-

281%20Campbell%20et%20al.pdf

Mehta, S., Hadley, S., Hutzler, L., Slover, J., Phillips, M., & Bosco, J. A. (2013, February 20).

Impact of Preoperative MRSA Screening and Decolonization on Hospital-acquired

MRSA Burden. Clinical Orthopaedics and Related Research, 471(7), 2367-2371.

https://doi.org/10.1007/s11999-013-2848-3

Mullen, A., Wieland, H. J., Wieser, E. S., Spannhake, E. W., & Marinos, R. S. (2017, February

8). Perioperative participation of orthopedic patients and surgical staff in a nasal

decolonization intervention to reduce Staphylococcus spp surgical site infections.

American Journal of Infection Control, 45, 554-556.

https://doi.org/10.1016/j.ajic.2016.12.021

Sporer, S. M., Rogers, T., & Abella, L. (2016). Methicillin-Resistant and Methicillin-Sensitive

Staphylococcus aureus Screening and Decolonization to Reduce Surgical Site Infection in

Elective Total Joint Arthroplasty. The Journal of Arthroplasty, 31(9), S144-S147.

https://doi.org/10.1016/j.arth.2016.05.019
INTEGRATIVE LITERATURE REVIEW
TABLE 1 – ARTICLE EVALUATION
First Author (Year)/Qualifications
Background/Problem Statement
Conceptual/theoretical Framework
Design/Method/Philosophical/Underpinnings The study uses a quantitative method with a quasi-experimental design.
Sample/ Setting/Ethical Considerations
Major Variables Studied (and their
definition), if appropriate
15
Scott M. Sporer, MD (2016); Department of Orthopaedic Surgery, Northwestern
Medicine Central DuPage Hospital, Winfield, Illinois
Deep infections following elective total joint arthroplasty remains a devastating
complication. Approximately, one in fifty patients will develop a surgical site
infection. The researchers undertook a preoperative staph screening and treatment
program to determine if it would decrease the incidence of SSI's in elective joint
arthroplasty.
Statistical Model, Predictive Theory
The researchers included all patients undergoing total joint arthroplasty, either total
hip or total joint replacement from January 1, 2009 to December 31, 2014 at Central
Dupage Hospital. In total 9,690 patients were included in this study.
The control group consisted of patients undergoing similar elective joint
arthroplasty from January 1, 2008 to December 31, 2008. These patients had surgery
pre-implementation using surgical skin preparation, administration of prophylactic
antibiotics and environmental conditions in the operating room remained unchanged
during this time.
There were not any ethical considerations.
The dependent variable is reducing the incidence of surgical site infections in total
joint arthroplasty patients through use of nares testing to determine if a patient tests
positive for either MRSA or MSSA.
Patients who test positive for MRSA or MSSA undergo a more aggressive treatment
INTEGRATIVE LITERATURE REVIEW 16

protocol to determine if it will decrease surgical site infections.

The independent variable is the treatment protocol patients are instructed to

implement if they test positive for either MRSA or MSSA. Treatment protocol
described below.

If MRSA positive, the treatment consists of bactroban ointment for 5 days and
chlorhexidine for 5 days total before surgery, contact isolation, preoperative
antibiotics changed to vancomycin.

If MSSA positive, the treatment consists of bactroban ointment for 5 days and
chlorhexidine wipes for 5 days total before surgery.

All patients were required to utilize a protocol of showering the night before surgery
and applying a 6-cloth CHG regimen to all skin, except the face and genitals, a
minimum of one hour following showering. The topical skin preparation with
chlorhexidine cloths was repeated the morning of surgery in the pre-operative
surgical holding area.

Measurement Tool/Data Collection Method Nasal swab within 14 days of surgery.

Data Analysis T-test and chi square test

Findings/Discussion SSI rates have decreased from 1.11% pre-screening to 0.34% nasal screening;
p<0.05.

After initiation of the process, staph was identified in 66.7% of SSI's before nasal
screening and 33.3% of SSI's after routine screening. p<0.05

Appraisal/Worth to practice Yes, the studies done and the results of statistical significance in lowering SSI's.
INTEGRATIVE LITERATURE REVIEW
First Author
(Year)/Qualifications
Background/Problem
Statement
Conceptual/theoretical
Framework
Design/Method/Philosophical A quantitative study using a quasi-experimental design.
Underpinnings
Sample/ Setting/Ethical
Considerations
17
Sapna Mehta, MD (2013)- Department of Infection Control, NYU Langone Medical Center, New
York, NY
Healthcare payers, such as Medicare, consider hospital acquired infections (HAI's) to be preventable
and a measure of clinical quality. The recently enacted Patient Protection and Affordable Care Act
includes provisions which will change how hospitals are paid for delivery of medical care, including
non-reimbursements for many hospital acquired infections.
Hospital acquired infections and Surgical Site Infections, caused by Staphylococcus aureus (MRSA)
are a source of morbidity and mortality. Staph aureus is the most common pathogen in prosthetic
joint infections and the incidence of MRSA is increasing.
The purpose of this study was to evaluate the effect of a decolonization protocol on decreasing the
prevalence density of hospital MRSA in an orthopaedic surgery population.
1. to determine the MRSA prevalence density rate at a specialty orthopaedic hospital before and
after implementation of a screening and decolonization protocol.
2. to compare the prevalence density with that of an affiliated university hospital to control for
changes in MRSA prevalence density that might have been independent of the colonization
protocol.
3. to measure the admission prevalence density rate of MRSA in elective orthopaedic surgery
population and the compliance rate of 26 patients with the protocol.
Statistical model testing
In October 2008, the orthopaedic hospital implemented a staphylococcal decolonization protocol
during preadmission testing clinic visits for all patients undergoing elective joint arthroplasty and
spinal fusion. All patients followed the same pre-surgical testing and treatment protocol. Surgical
patients were tested for MRSA through a nasal swab. All patients, both positive and negative, were
INTEGRATIVE LITERATURE REVIEW 18

asked to use the same decolonization protocol of mupirocin nasal ointment and chlorhexidine skin
antisepsis.

On the day of surgery, results were available of the nares testing

Those who were MRSA positive, received vancomycin preoperatively for antibiotic prophylaxis at
least 30 minutes before incision and every twelve hours thereafter for twenty-four hours.

Patients who were MRSA negative were administered standard perioperative antibiotic prophylaxis
of either cefazolin or clindamycin at least 30 minutes before incision and for 24 hours
postoperatively.

Since the prevalence density rate was being measured these patients accounted for a total of 63,860
patient days.

On the day of surgery a small group of 26 patients were asked a series of questions by the operating
room nurse about treatment compliance. The article did not include questions asked.

The university and the rehabilitation hospitals served as the control group which did not implement
an updated decolonization protocol.

New York University Hospital for Joint Disease is a 226 bed specialty orthopaedic hospital
performing more than 16,000 surgeries annually. Tisch Hospital, is a 726 bed university hospital and
the Rusk Institute, a 161 bed acute rehabilitation hospital. All three hospitals comprise the NYU
Langone Medical Center, an urban teaching institution in New York City, USA.

The study was reviewed by NYU's IRB.

Major Variables Studied The dependent variable is the decrease of the MRSA prevalence density rate. To determine the
(and their definition), if prevalence density rate, hospitals typically multiply the total number of beds, by the daily census.
appropriate
The independent variables includes the pre-surgical decolonization protocol followed by all patients
and on the day of surgery the treatment protocols for MRSA positive and MRSA negative patients.
INTEGRATIVE LITERATURE REVIEW 19

The questions asked by the operating room nurse of the 26 patients used to test compliance of the
decolonization protocol.

Measurement Tool/Data The measurement tool is the nares culture to check for MRSA and MSSA and the questions asked by
Collection Method the operating room nurse to determine treatment compliance.

Data Analysis Statistical analysis was used. Dichotomous variable were compared using Pearson's Chi square test.
Variables with p < 0.05 were considered statistically significant.

Findings/Discussion Pre-implementation of preoperative staphylococcal decolonization protocol, there were 79 MRSA

positive cultures identified in 64,327 patient days for a prevalence density rate of 1.23 per 1,000
patient days. The MRSA prevalence density at the specialty hospital was similar to that of the
university hospital. Post-implementation protocol, there were 53 MRSA positive cultures identified
63,860 patient days for a rate of 0.83 per 1,000 patient days. The prevalence density at the specialty
hospital was 33 % lower than the university hospital. The MRSA admission prevalence was 3.02%.
The compliance rate was greater than 95%.

Appraisal/Worth to practice Yes. This is worthy to practice because of implementation of staphylococcal decolonization protocol
at a single specialty orthopedic hospital decreased the prevalence density of MRSA.

First Author Serge P. Bebko (2015)- MD Department of Surgery, Baylor College of Medicine, Houston, Texas
(Year)/Qualifications and Department of Surgery, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas

Background/Problem SSI's commonly caused by MRSA are associated with significant morbidity and mortality,
Statement specifically when hardware is implanted in the patient. Staphylococcus aureus is the most common
cause of SSI's and it is estimated that 40-60% of cases are preventable.

The objective is to examine the effectiveness of a decontamination protocol on SSI's in patients

INTEGRATIVE LITERATURE REVIEW 20

undergoing elective orthopedic surgery with hardware implantation.

Conceptual/theoretical Statistical Method with predictive theories.

Framework

Design/Method/Philosophical Quantitative method using experimental study design.

Underpinnings

Sample/ Setting/Ethical The sample size was 709 patients undergoing elective orthopedic surgery with hardware
Considerations implantation; 344 control patients and 365 intervention patients. The control group was defined as
patients operated on from October 1, 2012 to April 30, 2013. The intervention group consisted of
patients operated on from May 1, 2013 to December 31, 2013.

This study took place in Houston, Texas at the Michael E. DeBakey Veterans Affairs Medical Center
during October 1, 2012 to December 31, 2013. Cohorts before and after the intervention were
compared.

It was a retrospective review of de-identified data and therefore oral or written informed consent was
waived. The study was conducted under a protocol approved by the IRB.

Major Variables Studied The dependent variable is the decrease in SSI's.

(and their definition), if
The independent variables are an educational video about MRSA decontamination shown to all
appropriate
patients at their preoperative visit and a decontamination protocol of chlorhexidine washcloths, oral
rinse, intranasal povidone-iodine solution undergoing orthopedic surgery with hardware implants.

Measurement Tool/Data Nares swab to check for MRSA.

Collection Method

Data Analysis Descriptive statistics were calculated for the variables on demographics, co-morbidities, MRSA
colonization status and length of surgery for both control and intervention groups. This was done to
verify the absence of any significant difference and minimize selection bias. Univariate analysis was
 INTEGRATIVE LITERATURE REVIEW 21

performed between two groups of patients. This was performed using a 2 sided t test, the Pearson X²
test, and the Fisher exact test, as appropriate. Multivariate analysis was used to identify independent
predictors of SSI. Data was collected on demographics, co-morbidities such as COPD, CAD, tobacco
use, alcohol use and BMI. Multivariate logistic regression analysis was done to assess the
relationship between the development of SSI and previously identified covariates, at the primary end
point of 30 days.

Findings/Discussion
Preoperative MRSA decontamination with chlorhexidine washcloths and oral rinse and intranasal
povidone-iodine decreased the SSI rate by more than 50% among patients undergoing elective
orthopedic surgery with hardware implantation. All patients completed the MRSA decontamination
protocol. The SSI rate in the intervention group was 1.1%; 4 of the 365 patients developed a SSI and
the control group was 3.8%; 13 of the 344 patients developed an SSI. Of the 709 patients, 17 (2.4%)
developed a SSI. The intervention group was significantly lower than the control group; with a P
value of 0.02. The predictors in the multivariate analysis were identified as potential risk factors;
age, hypertension, COPD, duration of surgery, and decontamination. Out of these variable, only
COPD, duration of surgery greater than 150 minutes, and decontamination showed statistical
significance. The researchers also compared costs of different decontamination protocols currently
used within the medical community for joint replacement patients and the one used in this study was
lower than others currently in use.

Appraisal/Worth to practice Yes. This treatment protocol is worthy to practice in decreasing overall SSI in orthopedic patients.
The data shows the treatment protocol is shorter duration, cost effective compared with polymerase
chain reaction-based protocols, and potentially fewer concerns with long term antibiotic resistance.

First Author Anildaliz Mullen, RN (2017)- RN BSN Baylor Orthopedic and Spine Hospital at Arlington, Arlington,
(Year)/Qualifications Texas

Background/Problem Transient and sustained carriage of potentially pathogenic bacteria in the nasal vestibule, including both
MRSA and MSSA and coagulase-negative staphylococci, are recognized to contribute significantly to the
 INTEGRATIVE LITERATURE REVIEW 22

Statement risk of post-surgical infection

The screen and treat protocols, which have become an accepted best practice, are resource intensive.
Universal antibiotic treatments before an orthopaedic surgery, which has shown to be more effective than
screen and treat protocols can be a challenge to antibiotic stewardship.
This study was undertaken to determine if implementation of an antiseptic nasal decolonization, without
prescribed antibiotics, in patients and staff would be associated with a reduction in Staphylococcus spp,
refers to all variants or strains of staphylococcus, SSI rates.

Conceptual/theoretical Statistical method using predictive theory.

Framework

Design/Method/Philosophical Quantitative method using the quasi-experimental design.

Underpinnings

Sample/ Setting/Ethical All patients scheduled for spine surgeries were included in the study. There was a sample size of 1,073
Considerations surgical spine patients, which includes both inpatient and outpatient procedures. There were 400 patients
during the baseline period and 673 for the intervention period.

The study took place at Baylor Orthopedic and Spine Hospital, a 23 bed facility, located in Arlington,
Texas.

No ethical considerations. This article stated there was not a conflict of interest.

Major Variables Studied The change to the preoperative protocol is the independent variable. The preoperative change instituted
(and their definition), if during the intervention period was the use of a nasal antiseptic called Nozin Nasal Sanitizer. This was
appropriate applied to all spine surgery patients by trained preoperative staff and continued three times a day for five
to seven days post-surgery.

The preoperative staff was encouraged to use the nasal antiseptic for self-decolonization prior to surgical
procedures.
 INTEGRATIVE LITERATURE REVIEW 23

The dependent variable was the baseline protocol of Chlorhexidine (CHG) bathing and surgical site
decolonization with wipes preoperatively.

Measurement Tool/Data Patient record data and information in tables and figures in quarterly reports.
Collection Method

Data Analysis 2-tailed student t test or in instances of a failed normality test, the Wilcoxon-Mann-Whitney rank-sum test
was done.

Findings/Discussion The mean infection rate significantly decreased by 81% from 1.76 to 0.33 per 100 surgeries during the 15
month trial, when compared with the prior 9 month base line.

Appraisal/Worth to practice This is a statistically significant finding, the authors stress the findings may be more applicable to acute
surgical facilities with a similar focus and not generalizable to larger facilities

First Author Kirk A. Campbell (2015)- MD Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases,
(Year)/Qualifications New York, New York

Background/Problem Annually the number of orthopaedic surgeries continues to increase, with many studies predicting an even
Statement larger growth over the next thirty years. Surgical site infections can represent up to 38,000 surgical
complications annually. Surgical site infections (SSI's) are a significant source of morbidity and mortality
for surgical patients comprising approximately 31% of total hospital acquired infections and increasing
the financial burden to both the patient and the health system. Staphylococcus aureus is the most common
cultured bacteria from SSI's and preoperative nasal colonization of staph aureus is described in literature
as an independent risk factor for the development of SSI.

Many hospitals do not have the resources or expertise to implement a comprehensive nasal screening and
decolonization program. The primary goals of this study is to identify criteria which could help predict
which patients are most at risk for colonization by MRSA and these hospitals could selectively decolonize
patients identified as the most at risk. The secondary goal is to provide information regarding the general
 INTEGRATIVE LITERATURE REVIEW
Conceptual/theoretical
Framework
Design/Method/Philosophical Quantitative method using correlational study design.
Underpinnings
Sample/ Setting/Ethical
Considerations
Major Variables Studied
(and their definition), if
appropriate
Measurement Tool/Data
Collection Method
Data Analysis
24
incidence of staphylococcal nasal colonization within the orthopedic population and delineate and
compare specific risk factors for both MRSA and MSSA colonization.
Statistical method
The data used for this study was obtained from a prospectively collected database of patients undergoing
elective spinal fusion, total joint arthroplasty of the knee or hip, including primary or revision. The
sample size was 1,708 patients at the NYU Hospital for Joint Disease. The database of 1,708 patients
represented surgeries conducted from March 2011 to March 2012.
No conflict of interest noted.
The dependent variable is to lower the chances of developing a SSI.
The independent variable(s) included patient demographics such as; body mass index, presence of asthma
or COPD, presence of diabetes, tobacco use, ASA score, renal disease, HIV status and
immunosuppressive medication use. All of these variables were initially reviewed through univariate
analysis and variables found to be potentially significant were included in multi-variate regression
analysis
At the preadmission testing visit, anterior nares were swabbed and cultured for Staphylococcus aureus. At
this visit, additional patient data was collected including; demographic, medical history, current health
status and medications used.
Univariate analysis was initially performed on demographic data such as; body mass index, presence of
asthma or COPD, presence of diabetes, tobacco use, ASA score, renal disease, HIV status and
immunosuppressive medication use in order to identify potential risk factors. The variables considered to
 INTEGRATIVE LITERATURE REVIEW
Findings/Discussion
Appraisal/Worth to practice
25
be potentially significant from the univariate analysis were included in multivariate regression analysis.
Other demographic data such as; age and gender were used to further identify the group of most at-risk
patients for developing an SSI from either MRSA or MSSA.
Univariate analysis showed Caucasian males with asthma history were at greatest risk for Staphylococcus
aureus nasal colonization and had a twofold greater risk of MSSA and MRSA colonization compared to
females. Multivariate analysis showed obesity with BMI > 30 combined with the male gender or asthma
is a significant risk factor for both MSSA and MRSA colonization. Patients whose BMI's range from 30
to 39 who are considered obese to severely obese and have asthma have a 2.56-fold greater chance of
colonization (95% CI 1.227, 5.321; p=0.012. Patients who are obese and morbidly obese, BMI > 40, and
have asthma have a 2.58-fold greater risk of MRSA (95% CI 1.241, 5.364, p=0.011.
Yes. With the large sample size it allowed the study to determine statistically significant risk factors for
colonization in the orthopedic surgical population. Epidemiologic investigations can lead to a better
understanding of the pathogenesis of infection and play a crucial role in improving evidence-based
prevention and control strategies in the context of surgical site infections. It is of greatest benefit to health
systems without significant resources or staff expertise in developing and implementing a selective
decolonization protocol targeting patients most at risk for developing an SSI.