A patient's skin is his primary protection against infection, but a surgical incision can literally open him up to the threat of microbial contamination. That's why compliance with the practices and processes of surgical site preparation are critical to your infection control efforts. How vigilant is your staff against SSIs? Take the following quiz and find out.

1. Most prophylactic antibiotics must be administered to surgical patients at least 2 hours before incision time.

a. true
b. false

b. false

According to SSI prevention guidelines from the Joint Commission and the Surgical Care Improvement Project, patients are to receive most antibiotics within 1 hour before incision in order to ensure that an adequate concentration of the drugs reach the tissue at the surgical site during and immediately after the procedure.

The choice of antibiotic to be administered, however, depends on the procedure that's being performed as well as patient allergies, and this choice in turn influences the timing of some doses. While most antibiotics are to be given within an hour of surgery, vancomycin and fluoroquinolones require 2 hours and observation for any adverse reactions.

Some surgical facilities have found that documentation of the drugs' administration time, routine reviews of these logs and including antibiotic delivery as an item to be confirmed during pre-surgical time outs have helped to keep compliance up and SSIs down.

2. The full complement of standard site preparation precautions are not necessary when starting an IV for surgery.

a. true
b. false

b. false

Standard precautions — the battery of infection prevention measures that include hand hygiene compliance, the wearing of personal protective equipment, needlestick and sharps safety efforts and safe injection practices, among others — should always be carried out whenever the skin is breached or there is the possibility of exposure to bodily fluids or non-intact skin.

3. Which is the safest method for pre-op hair removal?

a. razor with soap and water
b. clippers with which you've trained staff in the proper use
c. depilatory cream on the surgical area
d. instructing the patient to shave the area before arrival

b. clippers with which you've trained staff in the proper use

SCIP recommends leaving hair in place when it is possible to do so. But when it presents the potential of interfering with an incision site or laparoscopic port site, professional organizations from AORN to the CDC advise the use of clippers. While clippers offer a close, safe shave, they can cause micro-abrasions if used improperly, so make sure to include training in their use when in-servicing and orienting staff on skin prep practices.

The scraping action of razors prior to surgery increases the risk of wound infections due to the micro-abrasions they leave behind for bacteria residing on the skin to enter. While depilatory creams may seem risk-free, they may end up causing skin irritation. Also, make sure to specifically instruct your patients not to shave their sites themselves, but to allow you to do it, if it is necessary.

4. Clinical studies have conclusively proven that 1 type of antiseptic skin prepping agent is superior to others for all cases.

a. true
b. false

b. false

"No studies have adequately assessed the comparative effects of these preoperative skin antiseptics on SSI risk in well-controlled, operation-specific studies," write the authors of the CDC's guideline on preventing SSIs.

You've got a range of choices in terms of antiseptic skin preps, each with a broad spectrum of activity and unique limitations. Alcohol kills microbes quickly but its effect doesn't last long, plus it can't be used on mucous membranes and it's a flammable substance. Iodine's action is similarly fast with some residual action, and it can be used on mucous membranes and around the eye, but it can be inactivated through contact with blood. Chlorhexidine gluconate (CHG) has a long-lasting antimicrobial effect, but it can cause eye and ear damage, and must be used with caution around mucous membranes, which it may irritate.

While CHG solutions have received high marks in recent studies comparing their effects to those of povidone-iodine, some observers have questioned whether the alcohol that the CHG formulations included didn't give it an uneven advantage. In the final analysis, your choice of skin prep should be driven by the location of the surgical site, the patient's tolerance for the agent, the product's effectiveness and persistence and, once those factors have been satisfied, cost and case efficiency.

5. Skin preps don't always have to be applied in a circular pattern.

a. true
b. false

a. true

Surgical guidelines have traditionally recommended that antiseptic agents be applied in a circular motion, beginning at the incision site and spiraling outward. But this traditional method was developed when painting povidone-iodine with sponges or gauze was the predominant prep. Many newer formulations cleanse more effectively when applied with linear or back-and-forth strokes and friction to work the agents into the skin.

What has not changed in prepping recommendations, however, is the need to start at the least contaminated area and move to the most contaminated area. This will keep the staffer prepping the site from spreading microbes into cleaner areas. Similarly important is to avoid touching prepped areas with sponges or applicators that have already moved to more contaminated areas. New supplies only should be used if more prepping is required.

6. When prepping a patient, it's advisable to use as little of the solution as is necessary to achieve optimal antisepsis.

a. true
b. false

a. true

Enough prep should be applied to cover the surgical site and to prepare for the possibility that the incision will be extended, another incision will be needed or the drape's fenestration shifts. Keep in mind, though, that all of the prepping agent must dry completely before the surgery begins. The contact time is necessary for the agent to take full effect, but the evaporation of alcohol is necessary to mitigate the agent's flammability.

Too much prep can lead to dripping and pooling beneath patients and even between devices such as pneumatic cuffs and their skin. Besides the undetected fire hazard this may present, the prolonged exposure can also result in skin irritation or chemical burns.

7. There is clinical proof that surgical drapes are effective in preventing SSIs.

a. true
b. false

b. false

In theory, the practice of draping is intended to create an aseptic barrier that maintains the sterile field and protects a patient's surgical wound from contamination by the bacteria residing elsewhere on their skin. But the CDC, addressing the existing evidence-based literature on the subject, admits that there is little conclusive proof to show that drapes reduce the incidence of SSIs. "The wide variation in the products and study designs make interpretation of the literature difficult," the agency notes in its guidelines.

While there is no guarantee that drapes shield the surgical site from the threat of SSIs, when used properly they do no harm, and are still recommended by the CDC and AORN.

8. Which of the following situations during draping necessitates that the process be redone?

a. when the drape looks wrinkled
b. when non-sterile equipment is placed in the field
c. when a surgical staffer touches the drape with sterile gloves
d. when the drape touches the skin prep product

b. when non-sterile equipment is placed in the field

In the event that any non-sterile equipment comes into contact with any part of the sterile field, the draping process must be restarted.

Drapes should be opened and applied by a surgical staffer wearing sterile gloves. They should be handled and placed cautiously to avoid inadvertently contaminating the gloved hands or the drapes. They should also be handled as little as possible, so as not to stir up the operating room's air, lint or bits of wood pulp from the drapes, and the airborne bacteria for which the particles can be vectors. Once placed, the drapes should not be moved in order to avoid compromising their sterility.