1. www.nursingtimes.net / Vol 112 No 9 / Nursing Times 02.03.16 21
keywords: Decolonisation/infection/
patient group direction/surgery/
surgical site infection
●This article has been double-blind
peer reviewed
A Patient’s guide to
Staphylococcus
aureus decolonisation
authors Annesha Archyangelio was lead
infection prevention and control nurse at
the Royal National Orthopaedic Hospital,
Stanmore and is now infection prevention
and control lead at the BMI Clementine
Churchill Hospital and an honorary
researcher at the Royal National
Orthopaedic Hospital; Amritpal Shakhon is
specialist pharmacist, antimicrobials and
infection control, at Royal National
Orthopaedic Hospital, Stanmore
abstract Archiangelio A, Shakhon A
(2016) Using PGD to reduce surgical
infection risk. Nursing Times;
112: 9, 18-20.
Patients with spinal injuries are at
increased risk of surgical site infection due
to increased numbers of comorbidities
and prolonged surgical procedures. This
article describes the impact of a patient
group direction that was used in a
pre-operative assessment clinic to provide
Staphylococcus aureus decolonisation to
patients with a spinal injury who required
prophylaxis. A post-implementation audit
revealed that, in the main, staff and
patients adhered to the direction, and
infection rates were reduced.
S
urgical site infection (SSI) occurs
when a wound becomes infected
after an invasive (surgical) proce-
dure. These infections account
for up to 16% of healthcare-associated
infections (HCAIs) and are the third most
common HCAI (National Institute for
Health and Excellence, 2013a). Nearly 8% of
patients undergoing a surgical procedure
develop an infection (Health Protection
Agency, 2012), although this rate may be a
lot higher when taking into account infec-
tions that present after patients are
5 key
points
1a patient
group direction
allows health
professionals to
administer
medication to
patients without
the prescriber
seeing each one
2healthcare
staff should be
given adequate
information and
training to
understand the
rationale for pgD
3health
professionals
should ensure
patients subject
to the pgD
understand what
it means
4a decolon-
isation pgD
can help to reduce
surgical site
infection rates
5if a pgD
reduces ssi
rates in patients
undergoing spinal
surgery it can be
used to in other
patient groups
discharged from hospital. SSIs have a neg-
ative impact on patient care, place a socio-
economic burden on all involved and are
associated with:
» Significant clinical, social and financial
cost;
» Lost bed days;
» Morbidity (Gibbons et al, 2011; Graves et
al, 2007).
In financial terms SSIs cost the NHS
around £700m per year (HPA, 2012).
Reducingtheirincidenceinhospitalscould
save £2,100–£10,500 per SSI, although
complex surgery can result in costs of up to
£20,000 per SSI (NICE, 2013a).
Patients with a spinal injury are at
increased risk of SSI due to an increased
number of comorbidities and long surgical
procedures. Following surgery, patients
may be required to lie on their back. This
leads to increased pressure, which compro-
mises blood supply to the wound and can
cause dehiscence. Sweating and lack of
ventilation to the back following surgery
can also increase the risk of infection.
Spinal SSI rates can range from 0.7% to
1.9% based on the complexity of the sur-
gery (Schimmel et al, 2010).
SSI reduction strategies take a zero-
tolerance approach. At the Royal National
Orthopaedic Hospital, the spinal SSI rates
were 2.6% for January-December 2013 and
1.7% for the 2013/14 financial year ending in
March; based on data from Public Health
England (2014), this was three times higher
than national average.
Weusedapatientgroupdirection(PGD)
to provide Staphylococcus aureus, decoloni-
sation treatment in our pre-operative
assessment (POA) clinics for patients with
a spinal injury, which they self-administer
at home.
In this article...
Why spinal patients are at greater risk of surgical site infection
Details of a decolonisation regimen
staff and patient feedback on a patient group direction
Patients undergoing surgery for spinal injuries are susceptible to surgical site
infection so one hospital used a patient group direction to reduce infection rates
Using PGD to reduce
surgical infection risk
A patient
information
leaflet was used
to inform patients
about the PGD
Nursing Practice
Innovation
Infection control

2. 22 Nursing Times 02.03.16 / Vol 112 No 9 / www.nursingtimes.net
Nursing Practice
Innovation
Table 1. spinal injury patients receiving PGD
Month Total spinal
operations
Patients with spinal
injury with PGD
Patients with spinal
injury without PGD
Received
PGD (%)
June 87 3 84 3.4
July 111 25 86 22.5
August 91 46 45 50.5
September 85 37 48 43.5
October 173 141 32 81.5
November 176 151 25 85.8
December 68 46 22 67.6
Total 791 449 342 56.8
Results
From June to December 2014, 613 patients
with spinal injuries were seen in the POA
clinic and 791 spinal operations took place
(Table 1). Overall, 56.8% of those who had a
spinal operation received the PGD and
43.2% did not. The number of patients who
received the PGD increased as staff became
accustomed to distributing it. Fig 1 shows
the reduction in SSI rates; they fell from
2.4% in April to June 2014 to 0.6% in Jan-
uary to March 2015.
Staff feedback
Staff said no patients objected to the PGD,
although one patient was identified as
having a peanut allergy and did not receive
the PGD because Naseptin nasal cream
contains arachis (peanut) oil.
All seven staff who distributed the PGD
said they:
» Used the patient leaflet to inform
patients about the PGD;
tested positive. Those who tested positive
received the standard MRSA decolonisa-
tion regimen along with the PGD.
Evaluation
A post-implementation audit and review
of the PGD was carried out from June to
December 2014, in which patients were
identified using an electronic data capture
system. We wanted to find out:
» How many patients received the PGD;
» Why some patients who should have
received the treatment did not;
» Whether infection rates fell in response
to this innovation.
All eight POA clinic nursing staff were
interviewed to help us understand the
implementation process and difficulties
encountered. Semi-structured interviews
included 15 questions on patient adherence
to the PGD decolonisation regimen, but
staff were free to ask questions during the
interview, which took about 20 minutes to
complete. One staff member did not dis-
tribute the PGD because her patients did
not meet the inclusion criteria, so the
results are based on seven people.
We carried out surveys using question-
naires with 30 patients to understand how
decolonisation treatment was explained to
them and how they used it in practice.
Implementing the PGD
A PGD is a written instruction for the
supply and/or administration of a named
licensed medicine for a defined clinical
condition. It allows a range of specified
registered health professionals to supply
and/or administer a medicine directly to a
patient with an identified clinical condi-
tion without the patient having to see a
prescriber. The health professional using
the PGD is responsible for assessing
patients and ensuring they fit the criteria
set out in the direction (NICE, 2013b).
Box 1 outlines our decolonisation
regimen. We wanted to find out whether
the PGD could reduce spinal SSIs.
Intervention participants
Patients with a spinal injury who attend
POAclinicsweregiventhePGDandpartici-
pated in the decolonisation regimen. Those
with MRSA were subject to the PGD as well
as their normal decolonisation regimen.
The PGD was started in the POA clinics
because 85% of patients undergoing spinal
surgery attend the clinics.
Patients were excluded if they:
» Did not have a spinal injury and were
undergoing surgery;
» Had a spinal injury but did not attend
the POA clinic;
» Had a spinal injury but were not under-
going major spinal surgery.
A PGD protocol, patient information
leaflet and implementation presentation
were written in collaboration with the
pharmacist, microbiologist, spinal sur-
geon, infection prevention and control
(IPC) team and the POA team. The antimi-
crobial pharmacist and the IPC lead nurse
trained staff in how to implement the PGD.
Implementation started in June 2014.
POA staff marked each patient’s electronic
computer record to indicate recipients of
the PGD; in this way, adherence and distri-
bution of the PGD could be monitored.
All patients continued to be screened
for MRSA so they could be isolated if they
Box 1. The pgd
decolonisation
regimen
The products used for
decolonisation are:
● Mupirocin 2% nasal ointment
● Chlorhexidine digluconate
0.2% mouthwash
● Chlorhexidine gluconate 4% body/
hair wash liquid
These are to be used for five days
before surgery.
The patient group direction was
timed so patients would have the last
doses the night before and morning of
surgery.
The decolonisation protocol was
timed for specific times of the day for
all patients and they were given a
booklet to record this.
0
50
100
150
200
250
300
0%
1%
2%
3%
4%
5%
6%
7%
8%
Prophylaxischangedfrom
cefuroximetoteicoplain PGDcommenced
Jan-Mar
2013
Apr-Jun
2013
Jul-Sep
2013
Oct-Dec
2013
Jan-Mar
2014
Jan-Mar
2015
No.of operations
Infectionrates
SS%
Apr-Jun
2014
Jul-Sep
2014
Oct-Dec
2014
Fig 1. Spinal SSI rates before and after PGD

3. www.nursingtimes.net / Vol 112 No 9 / Nursing Times 02.03.16 23
» Explained its purpose;
» Asked patients to use the products in
the PGD on all areas of the body.
They all asked whether patients needed
help as part of the usual assessment pro-
cess, and said the training on imple-
menting the PGD was sufficient. Some
patients were confused about the number
of days or times per day when the PGD was
to be used, but staff ensured they reviewed
the product leaflet with these patients and
that they received a booklet with the
schedule of when the decolonisation
product should be used.
Patient feedback
Thirty questionnaires were distributed to
patients on the ward and 20 were returned.
In total, 17 patients said they understood
the importance of the PGD, 15 were satis-
fied with the advice given and 17 felt they
had the opportunity to ask questions
about the PGD.
Seventeen patients said they had no
problems applying the products but five
said they could not reach all areas of their
back. Some said the chlorhexidine body
wash dried their hair and that no staff
checked they had used the products on
admission to hospital for their surgery. All
ward nurses now check that patients
undergoing spinal surgery who have
received a PGD pack have used it. They now
document the patient responses on the
admission sheet.
Other SSI measures
Other SSI reduction measures imple-
mentedsinceOctober2013,suchasembed-
ding antimicrobial stewardship, sterile
techniques and staff training on pre-
venting SSIs, may have also contributed to
the reduction in these infections. For
example, in October 2013 the surgical
prophylaxis for orthopaedic procedures
was changed from cefuroxime to teico-
planin and gentamicin.
Recommendations
It is important that staff provide patients
with the PGD and information about how
to use it in the POA. Staff are advised to tell
patients who cannot reach their back to use
a long brush or sponge or ask a relative or
carer to help them apply the body wash to
their back to ensure effective application.
There is a time lag with confirmation of
SSI rates, as patients usually take a few
weeks or longer to develop infection,
making it difficult to assess the true impact
of implementing the PGD. SSIs present up
to one year after surgery so patients should
be followed up for one year.
Table 2. the patient feedback questionnaire
I understand the importance of using the decolonisation treatment? Yes/No
Which of the following best describes your answer above?
The decolonisation is important because:
● The risk of infection reduces after surgery
● It helps you recover faster after surgery
● It improves the outcome of the surgery
● It reduces the length of surgery
Please answer the following by circling Yes or No
I received a patient information leaflet Yes/No
I read the leaflet or had it explained to me Yes/No
I was given instructions on how to use the products Yes/No
I had the opportunity to ask questions about the PGD Yes/No
I used the decolonisation based on all the instructions on the patient
information leaflet
Yes/No
I have health challenges which make it difficult for me to apply the
decolonisation products
Yes/No
I can’t reach all areas of my back Yes/No
I have had previous surgery or was too unwell, which affects my ability
to apply the decolonisation
Yes/No
I applied the decolonisation treatment to all areas of my body Yes/No
How well did you follow the instructions on the label or as explained by the nurse for
use of the Body Wash, Mouthwash and Nasal cream/Ointment?
A. Used fully as stated B. Hardly used C. Used mostly as stated, only few doses
omitted D. Used irregularly many doses omitted. E. Used not at all
How many days were you told your PGD decolonisation treatment would for?
A. 10 days B. 3 days C. 4 days D. 2 days E. 5 days
Did you encounter any problems while using the decolonisation?
Yes No Not sure
If yes, please state the problems encountered:
We are considering whether a standard
decolonisation regimen is warranted for
all orthopaedic patients before surgery
and how to include those who cannot
attend POA clinic. We will review the pos-
sibility of delivering the regimen on
admission to those patients who do not
attend the POA clinic. It is recognised that
patients who do not have a POA before
admission or who are assessed over the tel-
ephone will otherwise always be omitted
from the protocol.
Conclusion
Evidence-based policies, strategies and
standardsforSSIprevention,care,control,
monitoring and implementation aim to
improve infection monitoring and
management processes to ensure better
outcomes after surgery by reducing
infection rates and the pain associated
with them. Evaluation of the impact of
the PGD on SSI rates in patients with
spinal injuries can be used to help to meet
these aims. NT
References
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Graves N et al (2007) Effect of healthcare
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and Cost. Infection Control and Hospital
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Health Protection Agency (2011) English National
Point Prevalence Survey on Healthcare associated
infections and Antimicrobial Use.
Bit.ly/AntimicrobialPPS
National Institute for Health and Care Excellence
(2013a) Surgical site infection quality standard
number 49. London: NICE
www.nice.org.uk/guidance/qs49
National Institute for Health and Care Excellence
(2013b) Patient Group Directions: Medicines
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Bit.ly/NICEPGDs2013
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Bit.ly/PHEssi
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Simor A E (2011) Staphylococcal decolonisation:
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