Done right, pre-operative patient skin prepping "removes transient microorganisms from the skin, reduces the resident microbial count and inhibits rapid rebound growth of microorganisms," all of which "reduces contamination at the incisional site and may reduce the risk of [surgical site infections]."1,2 Easy enough: Prep right, and you'll help ensure patients don't present with post-op infections.

The problem is, the "prep right" part of the equation isn't getting done as often as infection experts would hope. The state of prepping practice is summed up nicely by the results of a 2005 survey of surgeons: "There was marked variation in shaving of the operative site. A wide range of solutions was used, and 14 different sequences were employed."3 And, lest you think this is an exclusively surgeon-driven problem: "There is variation in the method of skin preparation employed between surgical units and surgeons."

The good news is that there's plenty of evidence backing standardization. Here's what you need to know to get your surgeons and nurses prepped for fighting SSIs.

The pre-op shower
"A pre-operative antiseptic shower bath decreases skin microbial colony counts," writes the CDC in "Guideline for Prevention of SSI." The agency's evidence comes from a study of more than 700 patients who received two pre-op antiseptic showers; chlorhexidine reduced bacterial colony counts ninefold, while povidone-iodine or triclocarban-medicated soap reduced colony counts by 1.3- and 1.9-fold each.4 Others studies corroborate these findings, says the CDC, which also recommends repeated antiseptic showers because several applications of chlorhexidine-gluconate-containing products are needed to be effective.

However, despite the colony count reduction, there is no definitive evidence that such pre-op showers actually reduce SSI rates. As a result, the CDC doesn't endorse pre-op showers with its strongest, category 1A recommendation. And that, some say, is why practice varies.

"There are so many variables in surgery," says Barbara DeBaun, RN, MSN, CIC, the director of patient safety and infection control at California Pacific Medical Center in Sacramento, Calif. "It's hard to know the one thing that makes the difference."

One of the problems with pre-op antiseptic showers is that they aren't done in a controlled environment.

"We give patients CHG to shower with at home before they come in for their operations, but the delivery systems are so poor that the liquid might come flying out of the bottle and only hit the skin for a couple seconds," she says. "They make it tough for patients to get adequate skin contact time, and the patients aren't necessarily that agile to begin with.

"It's not a surprise, then, that we don't have evidence that it makes much difference."

The newest evidence won't help the waffling any, either. Researchers recently reviewed six randomized, controlled trials comparing antiseptic preparations for 10,007 participants to determine the efficacy of pre-op showers.5 Bathing with chlorhexidine compared with a placebo didn't result in a statistically significant reduction in SSIs; there was no difference in SSI risk between using chlorhexidine and bar soap; and no difference was found in the post-op SSI rate between patients who washed with chlorhexidine and those who didn't wash at all.

"This review provides evidence of no benefit for pre-operative showering or bathing with chlorhexidine over other wash products, to reduce surgical site infection," the authors conclude. "Efforts to reduce the incidence of nosocomial surgical site infection should focus on interventions where effect has been demonstrated."

Still, the authors acknowledge that using an "antiseptic skin wash product is a well-accepted procedure for reducing skin bacteria." And until the CDC updates its SSI-prevention guidelines, pre-op showers remain a 1B recommendation: "strongly recommended for implementation and supported by some experimental, clinical or epidemiological studies and strong theoretical rationale."

"Everything plays a role; it all ads up in the end," says Ms. DeBaun. Better evidence is most likely to come as better applications, not better formulas, are developed. "One company puts the product on the cloth itself so the patient can get some good contact time, instead of a little bottle of liquid that goes down the drain. I think that's the future of pre-op antiseptic showers."

Body hair removal
When it comes to removing patient hair, there's not so much to debate. No ifs, ands or buts: Leaving hair alone is best.

"But pre-operative hair removal is still required for most procedures," says Beverley Anderson, RN, CNOR, an outpatient operating room nurse at Methodist Hospital in Houston. When that's the case, removal should be done in the OR, and it should be done with clippers, not a razor. In fact, shaving increases infection rates.

• One study cited by the CDC showed SSI rates of 5.6 percent in patients whose hair had been removed by razor compared with 0.6 percent among those who had hair removed by depilatory cream or who had no hair removed.4
• Having patients shave 24 hours in advance may be helpful - infection rates are 3.1 percent versus 7.1 percent for patients who are shaved in the OR, according to another study. But shaving more than 24 hours pre-op causes SSI rates to skyrocket to 20 percent, likely because microorganisms have had time to settle around the operative site.4
• Clipping hair immediately pre-op is strongly associated with a lower risk of SSI than shaving or clipping the night before, according to the CDC, and is therefore the best option because, although infection rates with depilatories are lower, they can sometimes cause hypersensitivity reactions.4
• Shaving (2.5 percent) is associated with more post-op SSIs compared to manual (1.7 percent) or electrical (1.7 percent) clipping.6
• Patients who clip hair the night before surgery have significantly increased risk for post-operative SSIs compared to patients whose hair is clipped in the OR (7.5 percent versus 3.2 percent), indicating again that hair removal should be performed as close to operative time as possible.6

Based on the evidence, the CDC slaps 1A tags on its recommendations to "not remove hair pre-operatively unless the hair at or around the incision site will interfere with the operations" and to "[if necessary,] remove immediately before the operation, preferably with electric clippers."4 The Institute for Healthcare Improvement has added safe pre-op hair removal techniques to its 5 Million Lives Campaign (which builds on the 100,000 Lives Campaign), and the following are among recommended changes for improvement in this area:

• Remove all razors from operating rooms and supply areas.
• Perform hair removal when necessary with clippers right before surgery.
• Establish a protocol for when and how to remove hair in affected areas.
• Provide patient education and materials on appropriate hair removal techniques to prevent shaving at home.7

"Although there is overwhelming evidence that shows the benefits of using clippers versus razors when hair removal is necessary or required, the practice of using razors for pre-op hair removal has remained the first choice by both nurses and surgeons," says Ms. Anderson, whose hospital has undertaken a clipper compliance project, with great success (see "Rid Your Rooms of Razors" on page 42).

But simple habit is no excuse, she says, especially when the evidence is so overwhelming.

"It is challenging to change," says Ms. Anderson. "I won't say it didn't take a while. But when you look at the [Surgical Care Improvement Project], Joint Commission and IHI surgical site infection recommendations, appropriate hair removal is mentioned every single time. If you're not in compliance with something that basic, you have to tackle it."

Prepping agent selection
If you find you're stocking and using a seemingly endless array of prepping solutions, you're not alone.

"Currently, we are using at least eight different varieties of agents," says Ms. DeBaun. "It's mind-boggling. I work in a tri-campus facility, and with three distinct hospitals, there's such variety and such variation. A lot of the reason is, honestly, long-standing surgeon preference. What they learned on is what gets used."

Standardizing also isn't helped any by the fact that there are so many prepping agent choices: alcohol, chlorhexidine, iodine and iodophors, PCMX or chloroxylenol, triclosan and various combinations of the preceding (usually, an alcohol with iodine or iodophor). The products on the market all have formulations that meet the FDA's log reduction standards, though the details may vary. When it comes to picking, AORN recommends selecting agents with a "broad range of germicidal action" based on safety and efficacy "data from current research, manufacturers' literature, [APIC] and the [FDA]."1 Here's what the CDC has to say about the five common active ingredients' efficacy:

• Alcohol. Provides the most rapid kill available; excellent in its effectiveness on both gram-positive and gram-negative bacteria, and good against M. tuberculosis, fungi and viruses. Presents no residual activity.
• Chlorhexidine. Provides an intermediately fast kill; excellent in its effectiveness on gram-positive bacteria, good against viruses and gram-negative bacteria, fair against fungi and poor against M. tuberculosis. Presents excellent residual activity.
• Iodine/iodophors. Provides an intermediately fast kill; excellent in its effectiveness on gram-positive, and good against gram-negative bacteria, M. tuberculosis, fungi and viruses. Presents minimal residual activity.
• PCMX. Provides an intermediately fast kill; good in its effectiveness on gram-positive bacteria, fair against gram-negative bacteria (except for Pseudomonas spp., against which activity is good), M. tuberculosis, fungi and viruses. Presents good residual activity.
• Triclosan. Provides an intermediately fast kill; good in its effectiveness against gram-positive and 'negative bacteria and M. tuberculosis, poor against fungi and unknown against viruses. Presents excellent residual activity.4

"There's a lot of confusion about which agents are the fastest-killing, which are the broadest spectrum, which have the most residual activity," says Ms. DeBaun. "I'm not convinced that surgeons and other practitioners in the OR know what they're using and why they're using it."

The CDC notes that "no studies have adequately assessed the comparative effects of these pre-operative skin antiseptics on SSI risk in well-controlled, operation-specific studies."4 But a couple new studies may be worth taking a look at:

• Three-way comparison. A 2005 study evaluated the efficacy of three surgical skin prep solutions for their abilities to eliminate potential bacterial pathogens from the foot (previous studies have shown higher infection rates after orthopedic foot and ankle procedures compared to procedures on other areas of the body). The prospective study evaluated 125 consecutive patients undergoing surgery of the foot and ankle. Each lower extremity was prepared with one of three randomly selected solutions: 0.7% iodine and 74% isopropyl alcohol, 3% chloroxylenol (PCMX) or 2% chlorhexidine gluconate and 70% isopropyl alcohol; culture specimens were obtained from three locations after preparation.

The results: In the PCMX group, bacteria grew on the culture of specimens obtained from 95 percent of the hallux sites, 98 percent of the toe sites and 35 percent of the control sites. In the iodine/alcohol group, bacteria grew on the culture of specimens obtained from 65 percent of the hallux sites, 45 percent of the toe sites and 23 percent of the control sites. In the CHG/alcohol group, bacteria grew on the culture of specimens from 30 percent of the hallux sites, 23 percent of the toe sites and 10 percent of the control sites.8

• Alcohol-free CHG effectiveness. A poster at the 2007 AORN congress presented an evaluation of the antimicrobial properties of alcohol-free 2% CHG solution against seven drug-resistant microorganism strains. Each challenge organism - two multi-drug-resistant strains of Acinetobacter baumannii and five methicillin-resistant strains of Staphylococcus aureus - was exposed to test solutions for 15 seconds and one, three, six, nine, 12 and 15 minutes; reductions in microbial counts were calculated.

The results: The CHG solution reduced microbial counts by 99.9 percent in drug-resistant strands of A. baumannii and S. aureus at exposure times of 15 seconds and three minutes, respectively, and demonstrated efficacy at significant dilutions.9

The takeaway, says Ms. DeBaun, the study's author, is that CHG is "fast-acting, broad-spectrum and stays on the skin for a long time. That's what's most appealing to me about this agent."

But ototoxicity and keratitis are concerns with CHG, says the CDC, so the agent poses the risk of skin irritation. Alcohol dries skin and is flammable. And patients may be allergic to iodine/iodophors. PCMX is non-irritating to mucous membranes and is safe for use around the eye, making it the only alternative agent for patients who present with iodine allergy.10 To account for all this, you're going to have to stock at least two or three prepping agents in order to cover all the bases.

"There's never going to be an agent that's perfect," says Ms. DeBaun. "There's always going to be a risk of allergies - no one agent will be applicable to everybody for every purpose."

A prep-free future?
The end of surgical skin prepping is unlikely, as clinicians and researchers alike seem to agree that it's logical to assume that a reduction in skin colonization decreases the chances of surgical site infections. But a 2005 study raises an interesting point to ponder, at least for very minimally invasive procedures: Researchers prepared patients by showering the surgical site with soap and water and rinsing it with normal saline in 905 cases of outpatient, clean-wound plastic surgery. In another 905 cases that served as the control group, the traditional method of pre-operative shower and scrub with chlorhexidine or povidone-iodine was used. In both groups, there was no incidence of wound infection.11

References
1. "Recommended practices for skin preparation of patients," in Standards, Recommended Practices, and Guidelines (Denver: AORN, Inc, 2005) 443-446.
2. Dohmen PM. "Influence of skin flora and preventive measures on surgical site infection during cardiac surgery." Surg Infect (Larchmt). 2006;7 Suppl 1:S13-7.
3. McGrath DR and McCrory D. "An audit of pre-operative skin preparative methods." Ann R Coll Surg Engl. 2005 Sep;87(5):366-8.
4. "Guideline for Prevention of SSI." Centers for Disease Control and Prevention. April 1999.
5. Webster J and Osborne S. "Preoperative bathing or showering with skin antiseptics to prevent surgical site infection." Cochrane Database Syst Rev. 2006 Apr 19;(2):CD004985.
6. Kjonniksen J, Andersen BM, Sondenaa VG and Segadal L. "Preoperative hair removal - a systematic literature review." AORN Journal. 2002 May;75(5):928-32, 940.
7. "Avoid Shaving Operative Site." Institute for Healthcare Improvement. Accessed 11 April 2007.