DON'T BE SHY The boundaries of the skin prep should be much wider than the planned incision site.

How do your prepping practices compare to those of your colleagues at surgical facilities across the country? To find out, we presented 103 facility managers with 10 short patient scenarios and asked them to choose how they'd prep the patient in the case. Read on to see what our national reader panel had to say, as well as what I, the director of infection prevention and control at Rochester (N.Y.) General Health System, view as the best way to prep. As you'll see, we don't always agree.

1 A female, 36, presents for a gynecological procedure that will require a combination vaginal and abdominal prep. What's the best choice of prep solutions?

a. a povidone-iodine/alcohol or chlorhexidine/alcohol combination for both preps

b. a non-alcohol-containing prep solution for both preps

c. a povidone-iodine/alcohol or chlorhexidine/alcohol combination for the abdominal prep followed by a non-alcohol-containing prep for the vaginal area

d. prep according to surgeon preference

Survey says: Nearly 7 of 10 (68.6%) respondents chose c. (a povidone-iodine/alcohol or chlorohexidine/alcohol combination for the abdominal prep followed by a non-alcohol-containing prep for the vaginal area). One commented, "Povidone-iodine paint to vaginal area and chlorhexidine/alcohol combination for the abdominal prep."

My take: Two types of skin preparations appear to have superior efficacy in terms of antimicrobial properties. These include but are not limited to iodophor-based compounds with alcohol and chlorhexidine with alcohol. However, alcohol isn't recommended for mucosal areas such as the vagina.

2 A male, 45, presents for a knee arthroscopy. He's been on crutches since his injury. During the pre-op assessment, you recommend pre-op skin cleansing. Which of the following would you recommend?

a. a pre-operative shower with 2% chlorhexidine

b. cleanse the area with a 2% chlorhexidine cloth

c. a pre-operative shower with 4% chlorhexidine

Survey says: Responses were pretty evenly split: 31.1% chose a., 31.1% chose b. and 23.3% chose c. "We do a pre-op shower with 2% chlorhexidine and also cleanse the area with a 2% chlorhexidine cloth," says one respondent. "We recommend a shower the evening before and morning of surgery with antibacterial soap such as Dial with special attention to the operative area," says another.

My take: Based upon patient assessment, either b. or c. could be correct. But because the patient is on crutches and may have difficulty cleansing the site in the shower, a chlorhexidine cloth might be more effective. A suggested risk reduction strategy has been the pre-admission shower or skin cleansing with chlorhexidine gluconate (CHG). Although older clinical trials question the clinical efficacy of cleansing with CHG, recent evidence-based studies support 2 types of CHG application — a 2% CHG-coated cloth or 4% CHG soap — using a standardized, timed process before hospital admission as an effective strategy for reducing the risk of post-operative surgical site infection. Most recent AORN guidelines recommend 4% chlorhexidine over 2% chlorhexidine.

3 All of the following areas, which generally have high microbial counts, should be prepped last except for _________ .

a. vagina

b. groin

c. umbilicus

d. rectum

Survey says: Nearly 3 out of 4 (71.8%) correctly chose umbilicus; 1 in 5 (20.4%) chose groin.

My take: Contaminated areas require special attention and generally should be prepped last. Areas of high microbial counts, including the axilla, groin, perineal region, anus and vagina, are prepped last (discard each sponge after use and never reuse). The exception is the umbilicus. The umbilicus is considered contaminated, but any time it's a part of the skin prep, it's prepped first, most often with the use of prep-solution soaked cotton-tipped applicators. This prevents debris from the umbilicus from splashing onto the prepped abdomen.

4 A male, 51, presents for inguinal hernia repair. Which skin cleansing protocol would you recommend?

a. a pre-op shower with 2% chlorhexidine soap

b. a pre-op shower with regular soap

c. a pre-op shower with 4% chlorhexidine soap

d. no special pre-op skin cleansing

Survey says: There wasn't a clear consensus amongst our survey respondents for this case. Most (37.9%) went with a pre-op shower with 2% chlorhexidine soap, followed by no special pre-op skin cleansing (24.3%), a pre-op shower with regular soap (19.4%) and a pre-operative shower with 4% chlorhexidine soap (18.4%).

My take: AORN Guidelines recommend a chlorhexidine shower as an effective risk-reduction strategy. Studies support 4% chlorhexidine soap.

5 Which solution is not recommended for surgical skin preparation when used as a single agent?

a. chlorhexidine

b. betadine

c. alcohol

d. none of the above

Survey says: Nearly 3 in 4 (73.5%) chose alcohol. Another 13.7% chose betadine and 3.9% chose chlorhexidine. 12.7% went with "none of the above."

My take: Alcohol is an accepted antiseptic agent, but you shouldn't use it as the single agent. Rather, use alcohol as part of the skin prep regimen.

6 What is the single most important principle to remember when applying a pre-op skin preparation?

a. follow manufacturers' directions for application

b. apply gently, moving in concentric circles from clean to dirty

c. use a back-and-forth scrubbing motion

d. follow directions of the surgeon

e. all of the above

Survey says: More than two-thirds (68.9%) of respondents went with "follow manufacturers' directions for application." Nearly 1 in 5 (19.4%) thought that a gentle application, moving in concentric circles from clean to dirty, was the right choice. Another 15.5% went with "all of the above."

My take: Follow manufacturers' directions for application. Many preps have specific guidelines from the manufacturer. Although OR personnel have been traditionally taught to apply gently in concentric circles, moving from clean to dirty, other preps require a back-and-forth scrubbing motion.

7 Which statement about skin preps is most accurate?

a. use as little of the prep as possible to prevent pooling

b. use enough prep solution to cover the surgical site and to prepare if the incision is extended or the drape's fenestration shifts

c. prep as small an area as possible and don't prep beyond the intended incision site

d. let preps dry for at least 1 minute

Survey says: Nearly three-fourths chose b. One added, "Prep the area, allowing for extension of incision, and let the prep dry per manufacturer recommendations."

My take: The prep's boundaries should be much wider than the planned incision site in order to reduce the SSI risk. You also want to allow for lengthening of the incision and placement of trocars, possible conversion from an endoscopic to open procedure and placement of wound drains.

8 Clinical evidence suggests that surgical drapes in combination with an adequate surgical skin prep can reduce the risk of SSIs.

a. true

b. false

Survey says: More than 9 of 10 (93.1%) agreed with this statement.

My take: False. Currently, there's not sufficient clinical evidence to support the claim that drapes in combination with an adequate skin prep can reduce the risk of SSIs. The key phrase is "clinical evidence." Theoretically, covering the patient should reduce the risk of bacteria reaching the surgical site and could reduce the risk of surgical site infections. However, the limited peer-reviewed evidence shows mixed results. Even the CDC, which recommends using surgical drapes, admits that there is limited data linking drapes to fewer surgical site infections. The current CDC guidelines were published in 1999; an updated version may be released sometime this year. It's possible that more robust peer-reviewed studies could yield stronger clinical evidence.

9 Which statement reflects current recommendations for infants younger than 2 months old?

a. don't use solutions containing iodine or iodophor

b. don't use solutions containing alcohol

c. don't use solutions containing chlorhexidine

d. choose skin preps based upon assessment of the infant, procedure and surgeon preference

Survey says: Two-thirds (66.7%) of respondents choose preps based upon assessment of the infant, procedure and surgeon preference. One in 5 (20.2%) don't use solutions containing chlorhexidine.

My take: Current manufacturers' instructions recommend that you don't use chlorhexidine on patients under 2 months of age. This may change as more evidence on its use and safety becomes available. Povidone-iodine is an acceptable prep in the pediatric patient population.

10 All of the following statements about alcohol-based skin preps are true except:

a. the antimicrobial action of alcohols is the denaturing of proteins

b. studies have shown that alcohol-based solutions immediately lower the skin's microbial count more effectively than other solutions

c. alcohol has broad-spectrum antimicrobial properties, including the ability to destroy gram-positive and gram-negative bacteria

d. application of alcohol either as a dual agent prep or applied as a 2-step process with each agent applied individually is considered a best practice approach

Survey says: Responses were pretty evenly spread: 24.5% chose a., 18.4% chose b., 20.4% chose c. and 36.7% chose d.

My take: The National Quality Forum recommends use of an antiseptic that contains a combination of CHG or iodine in combination with alcohol in its safe practices for surgery. You could conclude that alcohol's rapid bactericidal activity is key to successful skin prep and that dual-agent skin preps are superior. It's important to note that any product containing alcohol must have a second active ingredient. CMS recommends using skin prep solutions that are: 1) packaged to ensure controlled delivery to the patient in unit-dose applicators, swabs or other similar applicators; and 2) provide clear and explicit manufacturer/supplier instructions and warnings. Carefully follow these instructions for use.

WORDS OF WISDOM

Prepping Pearls
From Our Readers

• A messy prep is a good prep!
• The prep is the start to a successful case. Never underestimate the importance of it.
• Use cloth towels or disposable Chux to cover and protect linens, gowns, tourniquets and even patients' hair from invariable dripping and staining when using Duraprep or Chloroprep solutions in hand-held applicators.
• Let it dry long enough
• Clean off the prep before final dressing to prevent skin maceration.

— Jon-Marc Weston, MD, FACS

Dr. Weston ([email protected]) is the medical director of the Vision Surgery and Laser Center in Roseburg, Ore.