Skin prep sets the stage for surgery. As a precaution against post-surgical infection, antiseptic pre-operative skin site preparation is automatically done before any incision is made. In the outpatient field, where the clock meets the bottom line and all hands are waiting on start time, a lot depends on the prep. Can the process be improved? Here are a few tips on joining economy and efficiency in prepping your patients.

First, some cautions
Keep in mind that there are no shortcuts to the recommended practices compiled by AORN, the CDC and other organizations.

"It is important to do skin preps thoroughly," says Joan Blanchard, RN, MSS, CNOR, CIC, a perioperative nursing specialist at AORN's Center for Nursing Practice, Research and Health Policy in Denver. "Taking shortcuts in skin preparation may result in surgical site infections: surely not a cost savings, but an additional cost in patient readmission and treatment."

For example, if hair removal is absolutely necessary, "what's most important is the use of clippers rather than razors," says Ms. Blanchard. "Razors may be less expensive supplies, but their use increases the possibility of a surgical site infection," since they leave microscopic cuts that can harbor bacteria.

While some attempts to economize may impair the efficiency and safety of the prepping process, others may simply inconvenience the OR staff.

"Some facilities create their own prep sets that include fewer sponges and towels," says Ms. Blanchard. "But sponges are very inexpensive. That's not how you save money. ' Decreasing supplies such as the number of sponges, the amount of antiseptic or towels for barrier protection is not recommended."

Appropriate amounts
There are two good reasons you should consistently match the amount of prep you use to the procedure you're using it for. One is the threat of contaminated solution; the other, the threat of wasted money.

Perhaps staff members are repeatedly pouring antiseptic solution from a large bottle for a series of cases. Keep in mind that such bottles are single-use. "The edge of the container is considered contaminated and any remaining solution cannot be considered sterile," says Ms. Blanchard. "You should not recap the bottle."

Amy Hughes, BSN, CNOR, infection control manager for Lankenau Hospital in Wynnewood, Pa., agrees: "Don't use a bottle of Betadine that's been sitting around the OR for weeks. [An opened bottle] is an opportunity for bacteria to colonize.

"Only open what you think you can use in a day," she adds, "because you're going to be throwing the unused portion out."

Ms. Blanchard admits that determining the appropriate amount of prep solution to be used in a case - and, as a result, the appropriate size unit of solution to be purchased - is based largely on experience.

But buying large bottles of prep for specialties and procedures that regularly deal in small surgical sites may weigh down your supply budget. "If you're using too much, or if you're not using it all, you're wasting money," she says.

Two steps or one?
A study published in the November 2005 issue of the Journal of the American College of Surgeons compared the outcomes of two patient populations that had each undergone a different method of pre-surgical skin preparation.

The first group got a five-minute scrub with povidone-iodine soap, absorption with a sterile towel and a paint with povidone-iodine solution. The second group got a povidone-iodine paint only. When the study's results showed post-surgical infection rates at 30 days to be equal between the two groups, the study's authors suggested the scrub-and-paint method might be abandoned in favor of a paint-only prep.

"Right there, you're going to be saving money," says Karen Ritchey, RN, MSN, CNOR, a nurse educator at Johns Hopkins Hospital in Baltimore. After reading the study, she acknowledged that scrub-and-paint may be a sacred cow among some surgeons and OR staff, but also points out the extra supplies - dish, basin, sponge, gloves, soap mix, towel, change of gloves - and minutes that a scrub takes to arrive at the same result.

"Time is money in the OR," she says. "It affects anesthesia time and case time."

The difference is especially dramatic if your OR paints with a one-step alcohol and iodine solution in a self-contained, single-use applicator. Drying time is reduced, says Ms. Ritchey, and you can use clean exam gloves instead of sterile surgical gloves to handle the applicator stick.

Glove use during prepping can raise a debate, however. Ms. Blanchard doesn't recommend exam gloves for prepping, as they're not as strong as surgical gloves and are more prone to develop tears or holes.

Before the beginning
In terms of prep efficiency, patients can play a role, too, by showering the night before or the morning of surgery, or both.

"In the outpatient arena, we've found the physician isn't necessarily encouraging the patient to shower," says Shannon Oriola, RN, CIC, COHN, infection prevention and control officer at Sharp Metropolitan Medical Campus in San Diego and chairwoman of the public policy committee for the Association for Professionals in Infection Control and Epidemiology. "That's something that hospitals have focused on. We're beginning to request that our elective patients do that, though."

Experts say that providing patients with or recommending them to antimicrobial soaps containing chlorhexidine gluconate, a povidone-iodine solution or even triclosan, and instructing them to shower before their arrival for surgery can make preps more effective by reducing the bacteria count on the skin.

Shop wisely
You can classify your skin prep choices into three product types: povidone-iodine solutions, chlorhexidine gluconate preps and "one-step" solutions of alcohol combined with iodine or chlorhexidine gluconate. While the first two are packaged in bottles or as part of a prep procedure pack, one-step solutions are often provided in self-contained, single-use applicators.

The product your OR uses often depends on the surgeon's technique and preference or what the staff is used to. Keep in mind, though, each product's balance between cost and convenience.

"Unless you're looking at a patient with iodine allergies, the tried-and-true povidone-iodine preps are just as effective as, and generally less expensive than, the trendier new products," says Karen Marion, MSN, RN, nurse manager at the Johns Hopkins Outpatient Center in Baltimore. She notes that a surgery center that buys the prep by the bottle can assemble its own gauze, sponges, gloves and other supplies into a prep kit.

The one-step solutions have their considerations, though. "With iodine-alcohol preps, you take them out of the package, wipe them on, they dry quickly and they're ready to go," says Ms. Marion. Compared to povidone-iodine's need for a basin and several minutes of drying time, the one-steps let you get to work faster, but convenience has a higher cost, she says.

From an effectiveness standpoint, says Ms. Hughes, it's close to an even match. "In my opinion, there's no one product that's better than another," she says. "The market's been inundated with different things, but I'm not sure they're all worth the expense of switching to."

Ms. Hughes stands by an "if it's not broke, don't fix it" attitude toward preps. "You want something with persistence, with a good microbial kill, and you want to prep properly using good technique," she says. "If you don't have an infection control problem, you don't need something more expensive."

Maybe you've seen this situation: Vendors' representatives visit your facility and talk with your surgeons, or your surgeons meet them at the conferences they attend. Your surgeons are handed product samples, which they're more than willing to try. Shortly afterward, one surgeon wants Product A stocked, another wants Product B, and the next thing you know you've got five different products to do the same thing on the shelves. Skin preps aren't immune to this duplication.

"It helps to standardize the preps among your physicians," says Ms. Ritchey. It can be a difficult task, but it can simplify the ordering of supplies, pulling items for a case and slimming down your supply budget.

Your materials manager can help you determine which preps are most cost effective, but Ms. Ritchey suggests another tack toward getting your doctors on board.

"Here we've had a big buy-in from our infection control department," she says. Having trialed the products themselves, read the scientific studies or spoken to users in other institutions, your IC staff can draw the line on which preps are acceptable for your facility.

"You can even run your own data on infection rates and outcomes," says Ms. Ritchey. "Tell the doctors, the data show this is more effective in a number of cases than what you're using. Some-times you get support that way."

Don't neglect negotiation
As with the purchase of all OR staples, leverage your buying power to get the best deal you can. Negotiating contracts with your vendors for pre-prepared skin prep kits can net you cost savings.

Small facilities may not have the influence to buy in bulk, admits Ms. Blanchard, but that shouldn't stop them from seeking out vendors with whom they can negotiate on volume and price based on OR observation.

"If you can determine how many units you use, you can contract with them to buy a certain number of kits in a month," she says. "You'll be able to obtain a better price based on a defined quantity."