Preoperative Decolonization Reduces Surgical Site Infections at Rush Copley Medical Center

General Information

Institution Name: Rush Copley Medical Center

Authors: Kristin DiNaso, MSN, CNOR, Matt Canning, BSN, RN, CIC, and Samantha Kipley, BSN, RN

Name of Case Study: Preoperative Decolonization Reduces Surgical Site Infections at Rush Copley Medical Center

Identification of Local Problem

Surgical site infections (SSIs) have a significant impact on a patient’s recovery, often causing delayed wound healing, longer admission time, and potentially a return to the operating room (OR). In August 2024 at Rush Copley Medical Center (RCMC), Director of Perioperative Services Kristin DiNaso, MSN, CNOR, along with Infection Preventionist Matt Canning, BSN, RN, CIC, and Clinical Nurse Manager of Infection and Quality Surveillance at the time Kristin Simmons, MHA, BSN, CIC, RNC-MNN, identified an increase in SSIs. Drilling down the data showed the SSIs could not be contributed to one single procedure type, or even one particular service line. In the years leading up to this QI project, RCMC was averaging 21 SSIs per calendar year, and 2024 had a total of 24.

Context of the QI Activity

Kristin DiNaso, Kristin Simmons, and Matt Canning came together to develop a plan to decrease SSIs at RCMC. Each of these nursing leaders had experience in this arena and their collective knowledge was instrumental for this QI project. While reviewing current practices, an opportunity to standardize perioperative skin antisepsis procedures and implement a nasal decolonization process within perioperative services was identified. Following the guideline recommendations set forth by the Centers for Disease Control and Prevention (CDC) and the Society for Healthcare Epidemiology of America (SHEA), a preoperative bundle to decrease SSIs was identified.

Intervention: Staff Education

Clinical nurse educators lead staff education, and educational materials were created. An educational flyer regarding CHG bathing was created by Clinical Nurse Educator Katharine Certa, MSN, RN, CCRN, CPAN. Image 1, below, is part of the flyer that Katharine created, and is given to patients to help them understand where the CHG wipes should be used.  Flyers were distributed in the preoperative areas, which reinforced patient education. The perioperative nurses were directed to chart the completion of the preoperative decolonization bundle in a progress note in Epic.

Implementation Strategy

The preoperative bundle includes the use of ≥2% chlorhexidine gluconate (CHG) for bathing and nasal decolonization with an anti-staphylococcal agent. The team researched potential ways to source these items and ultimately found that purchasing the items individually was the most cost-effective solution, as opposed to purchasing the items in an already bundled package. As service lines across the board were struggling with SSI rates, it was decided to begin this project with elective General Surgery. On July 16th, 2025, the program began with a goal of decreasing SSIs by 25% in a calendar year. Three months into the project, the decision was made to include open-heart surgeries as well.

Costs and Funding Sources 

Aside from purchasing the components of the decolonization bundle, there were no additional institutional costs associated with this project.

Tracking the Results

With the roll-out of this project came a new process to help track the results. Since the nurses were charting the completion of the decolonization bundle in a progress note within Epic, those progress notes became a source of truth. When a patient was diagnosed postoperatively with an SSI, a chart review was performed to see if the patient was part of the cohort that received the preoperative decolonization bundle.

Overall Results and Analysis 

As previously stated, in the years leading up to this QI initiative, RCMC was averaging 21 SSIs per year. In the 365 days since the launch of the project, there have been 15 SSIs, and only 6 of those are from January-July 2026 (Image 2). Of those 15, only 1 case was in the cohort that was receiving the preoperative decolonization protocol. With the number of patients in the cohort totaling over 70, the results thus far are promising. These results have been shared with staff and discussed at the Perioperative Leadership meetings, as well as the Department of Surgery meetings. With the roll-out of this project being so successful, expanding the project to all service lines has been set into motion. There is great potential for this project to make an even larger impact once implemented to all eligible cases, and the results will continue to be tracked and shared.

Limitations

A limitation that was discovered after the roll-out was patients swabbing their own noses with the povidone-iodine swab. Some patients were not comfortable doing this, and in turn the swabbing was not done effectively. This caused a shift in the protocol to have the nurse administer the nasal decolonization swabbing instead of the patient performing this action.

Lessons Learned 

Lessons were learned with the implementation of this project at RCMC. Recently, an IT ticket was submitted to Epic so the nurses can move away from documenting the completion of the bundle in a progress note, and rather have discrete fields to chart in. Discrete fields in Epic make tracking and pulling reports much easier, as opposed to a manual chart review. Once Epic discrete fields are in place, using those fields for future reporting will strengthen long-term sustainability and measurement. The effectiveness of decreasing SSIs with the use of the preoperative decolonization bundle has been outstanding. As such, this program went house-wide on August 3rd, 2026. What started as an idea to decrease SSIs has truly become a standard of practice at RCMC.