It's a phone call you never want to get. A patient who was recently operated on at your facility has developed a surgical site infection. How did it happen? Was it a lapse in your surgical prepping practices? With something as routine as prepping, it's easy for inefficiencies and missteps to creep into everyday practice. Follow these 7 steps to ensure that every patient is prepped correctly, every time.

Step 1: Recruit dynamic leaders. With several different prepping solutions to choose from and different application methods for each one, there's no one gold standard that every facility should adopt. Start by assembling a team of frontline staff, including your surgeons, to help you devise a prepping system that will work for your facility. You may find that a single combination prep solution applied using a gentle, hands-free scrubbing method will work best for most of your procedures. If you have a very fast-paced facility, you may want to spend more on preps that come in ready-to-use applicators. The people who build the system must be the people who are most familiar with the day-to-day practices in your ORs and who'll be working with the new system once it's in place. Choose people who don't necessarily agree with each other — dynamic, opinionated staff members who are willing to question the status quo and whose opinions are valued by their peers.

Step 2: Watch and learn. Next, take a look at the big picture and determine what products and processes will work best for your staff and caseload. Start by observing all your surgical team members as they prep patients. Vary the shifts, staff and procedure types you observe so you get an accurate and complete picture of how your teams are prepping patients for surgery. Do they all use the same products for the same procedures? Do they apply them the same way? Or is there a lot of variance in the products and techniques they use?

Step 3: Remove product barriers. As you observe prepping practices at your facility and gather information from team members, take note of any barriers standing in the way of compliance. These barriers are likely to be of 2 varieties: product or process.

• Too many preps. How many different types of skin preps do you keep on the shelves? Have you addressed this with your medical staff? Can you standardize and eliminate as much variation as possible? Each product has its own specifications — amount to be applied, application method, dry time. It's easier for staff to get it right every time if they don't have to remember so many different prepping methods.
• Preps that are ineffective. Maybe you've recently standardized to 1 or 2 preps, but while they seemed effective during your product trials, they just don't get the job done in practice. Perhaps there's an issue with the applicator, or you went with a cheaper product that has proved to be more trouble than it's worth. Chances are your staffers are well aware of these problems and are compensating in their own ways, for instance, by hoarding supplies they like and ignoring the ones they don't.

If your staff isn't satisfied with or isn't using the preps you have, don't keep stocking your shelves with them. Have your leadership team work with supply chain managers to seek out a standard prepping solution, plus contingency products to have on hand in cases where the chosen solution is not appropriate. The 2 most common skin prep solutions are povidone-iodine and chlorhexidine gluconate (CHG). Combining 1 of those solutions with an alcohol-based prep provides additional benefits. For example, a CHG-isopropyl alcohol solution combines the alcohol's fast-acting kill effect on microorganisms with the persistent antimicrobial activity of CHG, which slows the re-population of skin flora.

Step 4: Conduct a trial. When evaluating your potential preps, the key question you want to ask is, "Does this product support the processes we have in place at our facility?" After you've examined the clinical evidence of the prep's effectiveness, trial the product in a variety of scenarios; your staff should be able to apply the prep quickly, efficiently and effectively in each case. For example, if you do a lot of procedures on obese patients, you want a prep that can be applied effectively to skin surfaces with lots of folds and crevices. If you have a very fast-paced, high-volume facility, you may want to spend a little extra money on preps that come in ready-to-use applicators to cut down on preparation and application times. It's not worth going with a cheaper product if it doesn't support the real-world circumstances of your practice.

Step 5: Streamline the process. Once you've decided on the best product for your needs, focus on standardizing the skin prep process at your facility. For many years, nurses were trained to apply skin preps using concentric circles. But more recent evidence has shown that this method isn't necessarily better than other ways of applying preps, so some of your newer nurses may prefer another approach. For example, an applicator that enables a scrubbing action can yield a more substantive prep than a gentle concentric circle. You should work with your team to devise a uniform system that will work best for your staff and your caseload and that adheres to the manufacturers' guidelines for the prepping solution you've chosen (see "Skin Prep Fundamentals").

Step 6: Show, don't tell. The best way to educate your staff about your new prepping system is to show them, not just tell them, how the system works and why it's important for everyone to adhere to it. Set aside some time for your surgical team members to practice applying skin preps in a simulated environment. You can use mannequins, human patient simulators or volunteer staff members to pose as patients. Your leadership team should demonstrate how patients are to be prepped for surgery in various situations, on different body parts and for different procedure types. Then, your staff should take turns practicing on the patient simulators, giving the leadership team a chance to observe their practice and help them learn how to prep the site correctly and consistently.

Without this hands-on education, you can't be sure that your staff is really learning the new system or that the system itself will work in practice. If a majority of staff members are having problems with the product or process during the training sessions, you may decide to go back to the drawing board and come up with a better system.

Step 7: Monitor and adapt. After you've implemented your standard skin prep system, continue to monitor the practice by conducting random, unannounced observations and audits. You may also want to incorporate a prepping checklist into your pre-op documentation or surgical time out to add an extra layer of routine monitoring into the system. Hold refresher training sessions once or twice a year, and stay up to date on the latest literature on the subject of surgical site prepping. While your system should be consistent, it should also be flexible enough to adapt to changes, such as new infection prevention standards, the introduction of a new procedure or specialty at your facility or new members of your surgical team.