Abstract
Objective
Staphylococcus aureus (SA) screening and decolonization is a guideline-recommended treatment for the prevention of surgical site infections in cardiac surgery. This study aimed to formally assess the barriers and facilitators associated with its implementation.
Methods
Targeted SA screening and decolonization started at our institution in November 2022. To assess barriers and facilitators to implementation, we conducted focus group interviews informed by the Consolidated Framework for Implementation Research at approximately 6 months after initiation of the intervention. We also regularly collected quantitative data on missed screening and/or decolonization to address gaps in uptake. This was reviewed at 6-month and 1-year time points. Adjustments to implementation were regularly made to address barriers.
Results
At 1 year, 563 nonurgent inpatients and 232 outpatients were consulted to cardiac surgery. Ninety-five percent of the inpatients and 91% of the outpatients considered for cardiac surgery were screened appropriately. Of the patients accepted for cardiac surgery, 50% of positive inpatients underwent decolonization in the first 6 months prior to focus groups compared to 67% in the subsequent 6 months. For outpatients, 77% were decolonized in the first 6 months, compared to 79% in the subsequent 6 months. Major barriers to implementation included delays in receiving screening results, difficulty meeting screening and decolonization timelines, and staffing turnover.
Conclusions
SA screening and decolonization was successfully implemented as a standard of care at our institution with the aid of an implementation science framework. By engaging care partners and healthcare staff throughout the implementation process and regularly addressing barriers, we developed a sustainable SA screening and decolonization program. Adjustments are ongoing to increase and sustain decolonization uptake.
Key Words: implementation science, Consolidated Framework for Implementation Research (CFIR), cardiac surgery, Staphylococcus aureus screening and decolonization
Targeted screening and decolonization protocol.
Central Message.
We present a clear example of using implementation science in cardiac surgery through the introduction of Staphylococcus aureus screening and decolonization.
Perspective.
Staphylococcus aureus (SA) screening and decolonization is a recommended approach to reduce surgical site infections. Despite this, implementation is complex, and protocols vary. This is the first study describing the implementation of SA screening and decolonization for cardiac surgery inpatients and outpatients guided by an implementation science framework.
Staphylococcus aureus (SA) screening and decolonization is a guideline-recommended treatment for the prevention of surgical site infections (SSIs) in cardiac surgery.1, 2, 3, 4, 5 SSIs occur in approximately 2% to 5% of all surgical inpatients in the United States.6 In cardiac surgery done via a sternotomy, SSIs can be broadly divided into superficial or deep sternal wound infections (SWIs) and graft harvest site infections. SWIs are associated with prolonged hospitalizations, readmissions, reoperations, and increased costs.7, 8, 9, 10 SWIs can significantly impact patients’ quality of life and also incur costs due to missed work hours.10
SA is the most common pathogen causing SSIs, accounting for approximately 40% of SSIs in cardiac surgery.7,11,12 Approximately 15% to 30% of adults are nasally colonized with methicillin-sensitive Staphylococcus aureus (MSSA), and 1% to 3% are nasally colonized with methicillin-resistant Staphylococcus aureus (MRSA).13, 14, 15, 16 SA decolonization methods include universal decolonization, in which all patients are decolonized, and targeted decolonization, in which patients undergo screening and are decolonized only if positive for MSSA or MRSA.13, 14, 15, 16 Both methods are associated with significant cost savings by avoiding SSIs.17,18 Universal decolonization is associated with the risk of mupirocin resistance in SA.19,20 The World Health Organization (WHO) global guidelines for the prevention of SSI and systematic review of the use of mupirocin 2% ointment with or without chlorhexidine led to a strong recommendation for its use with moderate quality evidence in cardiothoracic and orthopedic surgery patients who are known SA carriers (odds ratio [OR], 0.46; 95% confidence interval [CI], 0.31-0.69).3 SA screening and decolonization is also recommended by a number of cardiac surgery guidelines.1,2,5 Despite this, our institution had not yet implemented SA screening and decolonization, largely because of barriers associated with the implementation of new therapies. To date, we have not found any study describing an approach to implementation that supports easier translation of this best practice into standard cardiac surgery care.
Implementation science is a field of research that aims to improve the adoption, implementation, and sustainability of new evidence-based therapies and programs in real-world settings.21 Implementation frameworks provide researchers and clinicians with a structured approach to designing, implementing, and evaluating implementation efforts. The Consolidated Framework for Implementation Research (CFIR) is an implementation science framework commonly used to understand implementation considerations in health care settings.22,23 In this study, the CFIR was used to identify factors impacting the implementation of SA screening and decolonization at our institution. Barriers and facilitators to uptake of screening and decolonization were identified and addressed through care partner (previously known as stakeholder) meetings, focus group interviews, and regular assessments of the implementation strategy to promote ongoing adoption and sustainability.
The objectives of this study were to implement SA screening and decolonization for patients undergoing open heart (OH) surgery and to study the effectiveness of SA screening and decolonization implementation through healthcare worker feedback and prospective chart reviews. By outlining the exact steps taken to implement our intervention, we aimed to create a general outline that other clinicians and researchers can use to successfully implement other interventions/protocols.
Methods
This implementation study focused on the introduction of SA screening and decolonization as a new standard of care for cardiac surgery outpatients and inpatients at the Halifax Infirmary in Nova Scotia, Canada between November 21, 2022, and November 21, 2023. The Halifax Infirmary is a tertiary care center that provides cardiac surgery for the entire province of Nova Scotia, as well as patients from other Atlantic provinces. The division of cardiac surgery at the Halifax Infirmary performs approximately 1100 OH and endovascular/transcatheter cases per year. Approval for this study along with a waiver for consent was granted by the Nova Scotia Health Research Ethics Board (1027504) on June 28, 2022.
A mixed-methods approach was used. Qualitative data from focus group interviews helped identify barriers and facilitators to screening and decolonization, while quantitative data collected from chart reviews provided proportions of patients that were successfully screened and, if indicated, decolonized. To assess whether uptake of screening and decolonization increased over time, the data were divided into two 6-month time periods, defined as pre-focus group and post-focus group.
The CFIR was chosen as the implementation framework based on its ease of use, robust research in healthcare settings, and the research team's experience. The CFIR includes 5 domains: intervention, outer setting, inner setting, characteristics of individuals, and implementation process.22,23 Under each domain are several constructs that were considered as potential barriers or facilitators if relevant to our study.
Patient Population and Intervention Methods
All patients consulted to cardiac surgery were considered for SA screening. SA-positive patients accepted for OH surgery were candidates for decolonization. In the context of this study, OH surgery refers to procedures done with a sternotomy. Exclusion criteria included emergency procedures (within 24 hours of assessment) and allergy to mupirocin and/or chlorhexidine. SA screening involved performing a nasal swab of the anterior nares. The swab determined whether a patient was positive for SA and if positive, whether they were positive for MSSA or MRSA. If positive for either MSSA or MRSA, the patient underwent decolonization with mupirocin 2% nasal ointment to both nares twice daily and chlorhexidine 2% wipes to body sites below the neck once daily, both for 5 days prior to their OH surgery. To avoid prolonging inpatient wait times, if a positive patient was scheduled for surgery within 5 days of treatment, mupirocin was continued postoperatively to complete a total of 5 days of treatment. Chlorhexidine wipes were used only preoperatively. Decolonization was considered successful if 5 days of mupirocin were completed entirely preoperatively or started preoperatively and finished postoperatively.
Inpatients consulted to cardiac surgery were swabbed for screening by a floor nurse as soon as possible to provide time for screening results to return. If positive, decolonization was started.
Outpatients were screened by the clinic nurse if accepted for OH surgery at the time of their cardiac surgery consult appointment. If positive, a clinic nurse called the patient to inform them of their result and provided them with instructions on using mupirocin and chlorhexidine. These patients also were provided with a prescription for mupirocin 2% nasal ointment, SA decolonization instruction sheet (Figure E2), and 3 packs of chlorhexidine 2% wipes at their clinic visit or mailed once a positive result returned. When a patient was contacted by the surgery booking coordinator, they were reminded to start their decolonization 5 days prior to surgery.
Figure E2.
Outpatient informative pamphlet for Staphylococcus aureus–positive patients.
Data Collection and Analysis
Quantitative data were collected by following patients prospectively and completing chart reviews after the study period to collect any missing data. Parameters included demographic data; cardiac risk factors; additional comorbidities associated with higher rates of SA colonization; dates of consultation, admission, and discharge; screening and decolonization uptake measures; and operative data. Baseline characteristics were assessed to identify any significant differences in preoperative demographic variables and medical characteristics between inpatient and outpatient groups. For baseline characteristics, continuous variables used independent-samples t tests or Mann-Whitney U tests, depending on whether data were normally distributed. Categorical variables were compared using either the Fisher exact test or χ2 test. All analyses were conducted using SPSS version 27.0 (IBM). Significance levels were set at 0.05.
Patients consulted to cardiac surgery who did not receive appropriate screening and/or decolonization were categorized by barrier. To assess whether screening and/or decolonization uptake improved with time, the data were divided into pre-focus group and post-focus group time periods (approximately 6 months each). The pre-focus group data extended from November 21, 2022, to June 8, 2023, and the post-focus group data extended from June 9, 2023, to November 21, 2023.
Care Partner Meetings
Care partners identified at our institution were those that had a management and/or administrative role in the Division of Cardiac Surgery, Cardiology, or Microbiology. Care partner meetings were held in September 2022 after development of the implementation protocol and identification of perceived preimplementation barriers by the research team. The goals of these meetings were to review the SA screening and decolonization protocol and to identify any relevant barriers. Care partner discussions were guided by questions related to the broad domains of the CFIR specifically, individual knowledge of SA screening and decolonization, identifiable barriers across domains, and suggestions for the implementation process. Adjustments were made to the implementation strategy based on care partner feedback.
Another discussion topic during care partner meetings was cost analysis. At our institution, mupirocin 2% ointment cost approximately $35, and 3 packs of chlorhexidine 2% wipes cost approximately $15 (in Canadian dollars). After presenting research showing significant cost savings upward of $45 million (US dollars) by avoiding SSIs, each group was willing to absorb supply costs themselves in the inpatient setting.17 Outpatients received chlorhexidine wipes from the hospital but were responsible for obtaining mupirocin from their local pharmacy. These initiatives also were approved by hospital administration.
Focus Group Interviews
Focus group interviews were completed at approximately 6 months after the initiation of the study in June 2023. Participants included cardiology and cardiac surgery residents, staff, nurse practitioners, administrators, and nurses involved in the screening and decolonization process. Healthcare workers were divided into subgroups (nursing, clinic staff, etc) to encourage unique perspectives and avoid restriction of discussions that may be influenced by positional hierarchy. Open-ended questions informed by the CFIR were used to encourage open and candid discussion about barriers and facilitators to SA screening and decolonization. Focus group interviews were audio-recorded with participant consent and transcribed verbatim using REV (Rev.com). Transcripts were verified for correctness by comparing them to the audio files. Thematic analysis was used because of its well-described approach for analyzing semistructured interview transcripts and ease of use.24 This method involved line-by-line deductive coding of the transcripts under the CFIR domains as barriers or facilitators, and further review of the codes led to the generation of 4 inductive common themes. Nvivo 10 software (QSR International) was used to organize the data to find consistent patterns and themes. To increase trustworthiness, 2 investigators (D.d.W. and R.G.), coded and analyzed the transcripts independently, and direct quotes from participants were used to support identified themes. A single Nvivo file was created to combine codes and results were discussed by the coding investigators. There were no disagreements requiring review from the research team.
Results
Baseline Characteristics
From November 21, 2022, to November 21, 2023, 795 nonurgent patients (563 inpatients and 232 outpatients) were consulted to cardiac surgery for OH surgery. The average age was 66 years for inpatients and 64 years for outpatients (P = .07). Females accounted for 24.7% of inpatients and 32.8% of outpatients (P = .02). Inpatients were more likely to have diabetes (P < .001), a family history of coronary artery disease (CAD) (P < .001), a history of CAD (P < .001), and dyslipidemia (P = .01). Demographic information for both groups are shown in Table 1.
Table 1.
Baseline characteristics of patients consulted to cardiac surgery for open heart surgery
| Characteristic | Inpatients (N = 563) | Outpatients (N = 232) | P value |
|---|---|---|---|
| Age, y, mean ± SD | 66 ± 11 | 64 ± 11 | .07 |
| Female sex, n (%) | 139 (24.7) | 76 (32.8) | .02 |
| BMI, kg/m2, mean ± SD∗ | 30 ± 6 | 29.8 ± 5.5 | .78 |
| Diabetes, n (%) | 257 (46) | 64 (28) | <.001 |
| Hypertension, n (%) | 418 (74) | 161 (69) | .16 |
| Family history of CAD, n (%) | 111 (20) | 10 (4) | <.001 |
| History of CAD, n (%) | 433 (77) | 110 (47) | <.001 |
| Smoking status, n (%) | |||
| Previous | 221 (39) | 94 (41) | .14 |
| Current | 115 (20) | 35 (15) | .13 |
| Obesity, n (%) | 220 (39) | 96 (41) | .55 |
| Dyslipidemia, n (%) | 392 (70) | 138 (60) | .01 |
| Chronic renal failure, n (%) | |||
| Not requiring dialysis | 74 (13) | 23 (10) | .21 |
| On dialysis | 9 (2) | 2 (1) | .42 |
| End-stage liver disease, n (%) | 2 (0.4) | 0 | .36 |
| HIV, n (%) | 0 | 0 | - |
| Skin disease, n (%) | 10 (2) | 4 (2) | .96 |
| Cerebrovascular event, n (%) | 59 (11) | 18 (8) | .24 |
BMI, Body mass index; CAD, coronary artery disease; HIV, human immunodeficiency virus.
Reliable height and weight data for 147 patients not accepted for open heart surgery was missing, and thus BMI data are missing for these 147 patients.
Preimplementation Barriers
The implementation strategy was originally formulated by the research team. To identify factors affecting implementation prior to meeting with care partners, the CFIR domains and constructs were reviewed, and relevant barriers were considered and addressed. Relevant constructs that were considered barriers included adaptability of the intervention, cost, available resources, implementation climate, and healthcare worker engagement. Adaptability of SA screening and decolonization—specifically, timing to complete, process, and release SA screening results—was limited. To address this in the inpatient setting, early education was planned with a focus on sending a screening swab as soon as a consult was sent for inpatient cardiac surgery consideration (regardless of whether a patient was formally accepted for OH surgery). Additionally, SA decolonization was adapted to allow starting decolonization within 5 days of surgery and completing any remaining doses of mupirocin postoperatively. In the outpatient setting, there was more flexibility with timing, as it was expected that most patients would not go to surgery within a week of their clinic visit.
Cost was considered a barrier at the inception of the implementation strategy; however, with the presentation of robust research on SA screening and decolonization, a facilitator, as well as local SSI rates warranting its implementation, it was accepted as a standard of care, and costs were incurred by Nova Scotia Health.
Regarding available resources, the original study protocol involved the use of mupirocin 2% nasal ointment and chlorhexidine 4% wash instead of 2% wipes. In the preimplementation period, chlorhexidine 4% wash became difficult to obtain due to a hospital storage issue. Prompt recognition this supply availability issue early allowed quick transition to chlorhexidine 2% wipes, which were readily available. Another resource that was not readily available prior to the study was microbiology media or an established procedure to process these SA specimens. The microbiology lab coordinators were engaged early in the implementation design process to address this issue, and they developed a protocol and obtained the necessary supplies for SA screening swab testing.
The implementation climate and healthcare worker engagement were considered barriers because of the increased workload for some healthcare workers and possible resistance to change. Nova Scotia Health uses a paper-based system; therefore, physical orders had to be produced, swabs had to be completed, and results required follow-up. This was addressed by involving care partners broadly and including them in preimplementation discussions, as well as providing education around the benefit of SA screening and decolonization, sending regular updates, and seeking feedback throughout the implementation process.
Care Partner Meetings
A barrier identified by many care partners was the lack of adaptability regarding the timing required for targeted SA screening and decolonization (approximately 48 hours for screening results and 5 days of decolonization if positive). Care partners were assured that inpatient wait times would not increase, as mupirocin could be given postoperatively if required.
Another identified barrier was the lack of knowledge around SA screening and decolonization practices. An introductory email for all staff, informative resources (Figures E1 and E2), and regular nursing education sessions were suggested, implemented, and revisited throughout the study period.
Early Implementation Barriers
Early in SA screening and decolonization implementation, inpatient ordering was dependent almost entirely on the primary investigator owing to lack of healthcare worker engagement and knowledge of proper written orders for screening and decolonization. To promote independence and sustainability, a preprinted order sheet was created with clear instructions for SA screening and, if positive, decolonization. This order sheet was officially released for use on all floors in February 2023.
An inner setting barrier that was identified was adapting microbiology lab requisition forms for SA screening swabs. On existing requisition forms, there was an MRSA screen checkbox that often would be checked by staff without recognizing that it was a different type of test. Education was provided to address this error for both nursing and lab staff. A stamp was created for requisitions to streamline the SA screening swab request and decrease the number of incorrect screens being performed. Additionally, early positive screening results took an average of 3 days or longer to return, which led to missed decolonization. The delay was related to a 48-hour period required to determine whether the sample was positive for SA, followed by an additional test to determine whether it was MRSA or MSSA. Discussions were held with the microbiology lab care partners, and a solution to this barrier was to release preliminary SA results at approximately 48 hours.
The adaptations to the implementation strategy are summarized in Figure 1.
Figure 1.
Implementation timeline of Staphylococcus aureus screening and decolonization.
Focus Group Interviews
Four focus group sessions were held. The groups were composed of 4 outpatient clinic staff (2 nurses, 2 administrators), 3 nurse practitioners (1 cardiology, 2 cardiac surgery), 2 cardiac surgery residents, 2 cardiology residents, 1 cardiac surgeon, 1 cardiologist, and 5 inpatient nurses. All participants provided consent, and interviews were led and audio-recorded by D.d.W. following a focus group interview guide.
Four major themes developed from the thematic analysis, as identified below along with relevant quotes from participants. To ensure anonymity, participant demographic information was not included in the transcription process.
Theme 1: Benefit of the Intervention
In general, healthcare staff felt SA screening and decolonization were beneficial for patients.
“Personally, I'm just so excited about the idea of lowering infection rates. We're on 7.1 and we see them all day, everyday, and those patients, they're just so upset to be back kind of thing, so I'm really excited about anything that can help these patients, just understanding its importance is really cool to me.” – Nursing group participant.
Theme 2: Culture Promoting Change
Healthcare staff were eager to provide solutions to help sustain SA screening and decolonization. They also felt that momentum was building over the first 6 months, with a promise of sustainment.
“And also, I think sometimes, once you start something, if it gets momentum, which it feels like it kind of already is. And hopefully, that kind of keeps going. Because the problem I find is starting something.” – Nurse practitioner and cardiology resident group participant.
Theme 3: Barriers to Uptake of SA Screening and Decolonization
Several barriers to SA screening and/or decolonization uptake were highlighted by staff, mostly in the inpatient setting. These included issues with protocol awareness, staffing turnover, and ability to meet SA screening and decolonization timelines before surgery.
“There was a patient on 7.1 who came back positive for staph, but nothing was ever ordered.” – Cardiovascular clinic group participant.
Staffing turnover and protocol awareness went hand in hand, with many focus group interviewees highlighting that nursing turnover was related to lack of knowledge around SA screening and decolonization by new staff.
“I know upstairs there's been a few days where it's been mainly off service staff. It's not even primary staff. And so they wouldn't probably know what to do. They've been so short.” – Cardiovascular clinic group participant.
Meeting screening and decolonization timelines continued to be a barrier expressed by all focus groups. For inpatients, difficulties were linked to short waitlist times and delays receiving screening results.
“Yeah, I find, for us, for inpatients by the time the test results are back, they could already be in the OR.” – Cardiovascular clinic group participant.
For outpatients, timing for most patients was not an issue, but for surgeons with short waitlists, patients could end up going for surgery before results returned or they had time to pick up supplies. Other outpatients might not have been seen in person and then were admitted prior to surgery for consent and investigations, leading to missed screening.
“If they just couldn't get the prescription in time. Or sometimes they said like, “Oh, we don't have the wipes because the clinic, they were out that day, they're being mailed.” Cardiovascular clinic group participant.
Theme 4: Facilitators to SA Screening and Decolonization
Education sessions, the preprinted order sheet, and the microbiology requisition stamp were highlighted as facilitators in the process of implementation.
“I think that the orders that were written are very helpful. I think that a lot of people were really confused, especially floats and travel nurses that are coming in, being consistent with those, because it's just so, so new.” – Nursing group participant.
Another facilitating factor was having a dedicated researcher (D.d.W.) present throughout the process. This also could be viewed as a barrier due to dependence.
Screening and Decolonization Uptake
After 1 year, 58 inpatients and 2 outpatients at the time of consult were not considered candidates for OH surgery and thus did not require screening. At the time of admission or clinic visit, 25 inpatients and 1 outpatient were already positive (colonized or infected with) MSSA or MRSA and did not require an SA screening swab. These patients received decolonization if accepted for OH surgery. Successful screening was completed for 95.2% of inpatients and 91.3% of outpatients considered for OH surgery (Table 2). This was calculated by adding the number of SA screening swabs sent and positive on admission patients and dividing this total by the total number of patients accepted for OH surgery.
Table 2.
SA screening uptake of patients considered for cardiac surgery
| Variable | Inpatients (N = 563), n (%) | Outpatients (N = 232), n (%) |
|---|---|---|
| Successfully screened | 481 (95.2) | 210 (91.3) |
| Missed | 24 | 20 |
| SA screening swab sent | 456 | 209 |
| Screening not required | ||
| Positive on admission | 25 | 1 |
| Not accepted for OH surgery | 58 | 2 |
SA, Staphylococcus aureus; OH, open heart.
To evaluate the change in SA screening and decolonization uptake over time, the data were divided into pre-focus group and post-focus group time periods. The midpoint was approximately 6 months. Within the inpatient group, 94.2% of patients in the first 6 months underwent screening, compared to 96.5% in the subsequent 6 months (Table 3). Barriers leading to missed screening included the floor missing the order, a swab being processed as MRSA only, no order written, a swab collection issue, and a patient located on an off-service floor (Table E1).
Table 3.
SA screening uptake of inpatients considered for cardiac surgery pre-focus group and post-focus group
| Variable | Pre-focus (N = 310), n (%) | Post-focus (N = 253), n (%) |
|---|---|---|
| Successfully screened | 258 (94.2) | 223 (96.5) |
| Missed | 16 | 8 |
| SA screening swab sent | 244 | 212 |
| Screening not required | ||
| Positive on admission | 14 | 11 |
| Not accepted for OH surgery | 36 | 22 |
SA, Staphylococcus aureus; OH, open heart.
For outpatients, 89.6% of patients underwent screening in the first 6 months, compared to 93.3% in the subsequent 6 months (Table 4). Barriers leading to missed screening included the patient leaving the clinic before being swabbed, not being seen by a clinic nurse due to incorrect booking type or they were a phone consult, and not being completed by the clinic nurse (Table E2).
Table 4.
SA screening uptake of outpatients considered for cardiac surgery pre-focus group and post-focus group
| Variable | Pre-focus (N = 126), n (%) | Post-focus (N = 106), n (%) |
|---|---|---|
| Successfully screened | 112 (89.6) | 98 (93.3) |
| Missed | 13 | 7 |
| SA screening swab sent | 111 | 98 |
| Screening not required | ||
| Positive on admission | 1 | 0 |
| Not accepted for OH surgery | 1 | 1 |
SA, Staphylococcus aureus; OH, open heart.
Among the patients considered for cardiac surgery, 113 inpatients (23.5%) and 44 outpatients (20.9%) screened positive for SA. Of the SA-positive inpatients, 105 (21.8%) were MSSA-positive and 8 (1.7%) were MRSA-positive. The SA-positive outpatients included 41 (19.5%) MSSA-positive and 3 (1.4%) MRSA-positive.
Decolonization data also were compared between the pre-focus group and post-focus group. Decolonization was considered completed if a patient received a full 5 days of preoperative mupirocin and chlorhexidine or partial treatment preoperatively and the remaining mupirocin treatment postoperatively. Of the 113 positive inpatients, 35 were not accepted for OH surgery (13 pre-focus, 22 post-focus). Fifty percent of positive inpatients were decolonized in the first 6 months, compared to 66.7% in the subsequent 6 months (Table 5). The average uptake over 1 year was 59%. Barriers leading to missed inpatient decolonization included being booked within 5 days from consult, a screening swab result delay of longer than 48 hours, the floor missing the order for decolonization, no order being written, patient required an urgent surgery, and decolonization not being started (reason unknown) (Table E3).
Table 5.
Decolonization of SA-positive inpatients accepted for cardiac surgery pre-focus group and post-focus group
| Variable | Pre-focus (N = 49), n (%) | Post-focus (N = 64), n (%) |
|---|---|---|
| Received 5 d of mupirocin | 18 (50) | 28 (66.7) |
| Completed preoperatively | 6 (16.7) | 12 (28.6) |
| Completed preoperatively and postoperatively | 12 (33.3) | 16 (38.1) |
| Missed decolonization | 13 (36.1) | 12 (28.6) |
| Received partial decolonization preoperatively only | 4 (11.1) | 1 (2.4) |
| Received decolonization postoperatively only | 1 (2.8) | 1 (2.4) |
| Not accepted for OH surgery | 13 | 22 |
SA, Staphylococcus aureus; OH, open heart.
Of the 44 positive outpatients, 2 were not accepted for surgery (1 pre-focus, 1 post-focus) and 1 was still awaiting surgery (1 post-focus). Decolonization occurred in 77.2% of positive outpatients who underwent OH surgery in the first 6 months, compared to 78.9% in the subsequent 6 months (Table 6). The average uptake over 1 year was 78%. Barriers leading to missed outpatient decolonization included being booked within 5 days of their history and physical, patient noncompliance, and lack of follow-up regarding a positive result or the need to decolonize (Table E4).
Table 6.
Decolonization of SA-positive outpatients accepted for cardiac surgery pre-focus group and post-focus group
| Variable | Pre-focus (N = 23), n (%) | Post-focus (N = 21), n (%) |
|---|---|---|
| Received 5 d of mupirocin | 17 (77.2) | 15 (78.9) |
| Completed preoperatively | 14 (63.6) | 13 (68.4) |
| Completed preoperatively and postoperatively | 3 (13.6) | 2 (10.5) |
| Missed decolonization | 5 (22.7) | 4 (21.1) |
| Received partial decolonization preoperatively only | 0 | 0 |
| Received decolonization postoperatively only | 0 | 0 |
| Not accepted for OH surgery | 1 | 1 |
| Awaiting OH surgery | 0 | 1 |
SA, Staphylococcus aureus; OH, open heart.
To ensure that SA screening and decolonization uptake were improving over time after the study period, we conducted a quality improvement review of SA screening and decolonization from November 2023 to June 2024. We found that 97% of inpatients and 96% of outpatients were successfully screened. Inpatient decolonization remained at approximately 67%, while outpatient decolonization increased to 89%. The barrier of timing constraints prior to booked OH surgery remained the greatest barrier in the inpatient setting.
Discussion
In the inpatient setting, SA screening occurred in 95.2% of patients. A review of the trend over time in the pre-focus and post-focus groups showed that screening uptake improved, likely due to increased individual knowledge, ongoing education, and preprinted orders. Throughout the study, the primary investigator slowly withdrew from ordering SA screening and decolonization while continuing to monitor uptake and prompted staff only when required. In the outpatient setting, SA screening occurred in 91.3% of patients, with a less notable trend in uptake over time as the clinic staff were quick to implement the strategy. To increase uptake in the outpatient setting, education was extended to nurses regularly covering vacations/leaves for full-time clinic nurses. Patients accepted for surgery as a phone consult unfortunately missed screening, which was the main barrier to outpatient screening uptake. Compared to the current literature, these rates were higher than well-established programs, in which 20% to 40% of patients missed screening.25, 26, 27 Success was supported by having engaged staff, like the nurse navigator, and having a dedicated researcher reviewing all consults and providing regular education for healthcare staff, particularly nursing, when knowledge gaps were noted.
A review of the 1-year uptake of decolonization found that 59% of patients in the inpatient setting received decolonization, compared to 78% in the outpatient setting. While implementing SA screening and decolonization, Schweizer and colleagues27 had 39% full adherence and 44% partial adherence. Similarly, Saraswat and colleagues26 had only 42% of MRSA-positive patients complete a full 5 days of preoperative mupirocin. In our setting, many inpatient barriers to decolonization efforts were noted, including a delay receiving screening results, lack of results follow-up, insufficient time to start decolonization prior to OH surgery, missed or lack of orders, and sudden need for urgent surgery. When dividing the data into the pre-focus and post-focus groups, there was a 16.7% increase in inpatient decolonization uptake during the study period, which occurred while the primary investigator slowly withdrew their clinical support. This improvement was likely due to ongoing education and promotion of independence by engaging staff in low-uptake areas and prompting when necessary. Although many barriers improved over time with increased knowledge about the protocol and provision of educational tools, timing before surgery remained a barrier. An impactful change to decolonization uptake that occurred at the end of our study period was having lab staff call with positive results. The adaptability of the microbiology lab throughout the study was a major facilitator in SA screening and decolonization uptake.
In the outpatient setting, barriers to implementation included timing before surgery, patient noncompliance, and lack of patient follow-up. Regular covering nurses were educated on the protocol to improve uptake related to lack of follow-up. Frequent education and quality improvement follow-up are key factors in creating change and sustainability. One reason for the lack of further uptake was the change of our booking clerk twice during the study period. Regular education around flagging SA-positive patients and reminding them to start decolonization 5 days prior to surgery was required for each new staff member. We did see an increase in decolonization uptake in the outpatient setting after the 1-year study period.
Many centers use a universal decolonization approach to avoid the barriers related to screening. After reviewing with our infectious disease and microbiology colleagues, although omitting screening may have increased decolonization uptake by reducing the barrier of timing constraints prior to surgery, the risk of mupirocin resistance could not be ignored. Current literature describes ranges of resistance from 1% to 81%, with higher resistance seen at centers with regular mupirocin use.19,20 For centers with universal decolonization, rates of resistance over time should be explored. Another nasal decolonization strategy, intranasal povidone-iodine, has less risk of resistance but has not been shown to be as effective as mupirocin.28 Steriwave (Ondine Biomedical) is a nasal photodisinfection system that has shown promising results in decreasing SSIs in other surgical specialties.29 Theoretically, it should not cause resistance and may be a promising SSI reduction strategy; further research in cardiac surgery is required.
When considering implementation outcomes,30 overall implementation success was achieved. SA screening and decolonization were perceived as appropriate for our cardiac surgery setting and feasible in both the inpatient and outpatient settings. It was widely accepted by care partners and healthcare staff involved in SA screening and decolonization. Costs were absorbed by each division, recognizing that SA screening and decolonization ultimately led to SSI cost savings. Adoption of SA screening and decolonization required frequent engagement with care partners and education but ultimately improved over time. Fidelity was achieved as we screened and decolonized in a manner similar to our original protocol, with minor changes to the mode of chlorhexidine administration. Most cardiac surgery consults were reached. After the 1-year study period, SA screening and decolonization have been sustained, with similar screening uptake and improving decolonization uptake.
Limitations
This implementation strategy was developed for a single center that does not currently have an electronic medical record, and therefore some of our barriers might not be applicable to all centers. Change management of barriers and facilitators usually varies depending on institutional culture; however, an implementation framework can aid in the adoption of new therapies or protocols at any center. The present study provides an example of successful use of an implementation framework.
The results were heavily influenced by the work of the primary investigator, who slowly retreated from the frontline of ordering SA screening and decolonization throughout the study period. This was intentional, as having a dedicated implementation scientist responsible for frequent education, prompting, and clarification aids uptake. Given the relatively small sample size of patients who missed screening and decolonization, only trends over time related to improvement in barriers can be inferred. Additionally, a lack of patient compliance in the outpatient setting occurred for 2 patients, but compliance was determined based on a mupirocin prescription being filled, which is captured in a pharmacy database, as well as the word of the surgery booking clerk who reminds positive patients to start decolonization 5 days preoperatively. While guaranteeing outpatient compliance is always a challenge, especially in real-world settings, future work could include a patient survey. In the inpatient setting, nursing staff documented completed doses and thus provided a more reliable measure.
Conclusions
Changing practice is faced with many challenges. Implementation science frameworks can help identify how and what challenges influence practice change. Here we described the implementation of SA screening and decolonization in cardiac surgery patients at a single center. Screening was swiftly integrated, while decolonization practices were more nuanced due to barriers. Engaging care partners and healthcare staff throughout implementation is an important step to ensuring early adoption and acceptability. Regular education can address knowledge gaps related to staff turnover. A key facilitator in supporting adoption was having a dedicated implementation researcher. They can have a positive impact on the uptake of new treatment strategies. To improve the uptake of decolonization, we will continue to adjust our implementation strategy to address ongoing barriers.
To the best of our knowledge, this study is the first to describe the implementation of SA screening and decolonization using an implementation framework. There are varying results on SA screening and decolonization uptake in the literature with no streamlined protocol. This stepwise approach can provide institutions with a guide to implementing sustainable practices.
Conflict of Interest Statement
Dr de Waard is a paid consultant of Johnson & Johnson MedTech. Dr Bonnar is actively conducting research with the AXDEV Group and is a recipient of CIHR grants. Dr Sim is a co-investigator on CIHR and Research Nova Scotia grants. All other authors reported no conflicts of interest.
The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.
Acknowledgments
We would like to acknowledge the Cardiology and Cardiac Surgery healthcare staff at the Halifax Infirmary and the Queen Elizabeth II Health Sciences Centre Microbiology Lab, who stepped up to embrace this new screening and decolonization strategy and made it a sustainable program. This study was part of a master's thesis that received funding support from the Dalhousie Medical Research Foundation–Harold and Ruth Babcock Stipend, Killam Predoctoral Scholarship, Dr Patrick Madore Clinical Investigator Traineeship, Nova Scota Graduate Scholarship, and Ross Stewart Smith Scholarship.
Footnotes
Research Ethics Board approval 1027504.
Appendix E1. Educational Material
Figure E1.
Flow diagram for healthcare staff outlining Staphylococcus aureus screening and decolonization for cardiac surgery patients. MRSA, Methicillin-resistant S aureus; MSSA, methicillin-sensitive S aureus.
Appendix E2. Barriers to Screening and Decolonization
Table E1.
Reasons for missed inpatient SA screening pre-focus group and post-focus group
| Variable | Pre-focus (N = 16), n | Post-focus (N = 8), n |
|---|---|---|
| Floor missed order | 6 | 3 |
| Processed as MRSA only | 3 | 0 |
| No screening order written | 6 | 4 |
| Collection issue | 1 | 0 |
| Off-service floor | 0 | 1 |
Collection issue refers to refusal of swab by microbiology lab due to incorrect collection. Off-service floor refers to a floor outside of cardiology and cardiac surgery, which received no training on S aureus screening or decolonization.
MRSA, Methicillin-resistant S aureus.
Table E2.
Reasons for missed outpatient SA screening pre-focus group and post-focus group
| Variable | Pre-focus (N = 13), n | Post-focus (N = 7), n |
|---|---|---|
| Left clinic before being swabbed | 2 | 0 |
| Not seen by clinic nurse | 11 | 4 |
| Not completed in clinic | 0 | 3 |
Table E3.
Reasons for missed inpatient SA decolonization pre-focus group and post-focus group
| Variable | Pre-focus (N = 13), n | Post-focus (N = 12), n |
|---|---|---|
| Booked within 5 d of consult | 4 | 7 |
| Swab delay from lab >48 h | 3 | 0 |
| Floor missed order | 3 | 1 |
| Urgent surgery | 1 | 2 |
| Decolonization not started | 2 | 1 |
Table E4.
Reasons for missed outpatient SA decolonization pre-focus group and post-focus group
| Variable | Pre-focus (N = 5), n | Post-focus (N = 4), n |
|---|---|---|
| Booked within 5 d of consult | 4 | 7 |
| Patient noncompliance | 3 | 0 |
| Lack of patient follow-up | 4 | 1 |
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