JOINT EFFORT The invasive and orthopedic nature of many orthopedic procedures makes vigilant skin antisepsis an urgent process.

Surgical site infections in orthopedic cases can be particularly devastating. New guidelines (see "What's New in Hip and Knee SSI Prevention" on page 47) promise to reduce SSIs if you make 3 interventions a standard part of your prepping protocol for hip and knee arthroplasty patients — skin prepping, pre-op patient bathing and screening for superbugs.

There is a continuing debate over whether chlorhexidine gluconate or povidone-iodine preps are preferable for surgical skin antisepsis. In orthopedic cases, skin flora — Gram-positive bacteria against which CHG is highly effective — are the primary infection risk, and several recent studies have touted CHG as the superior agent. But observers have noted that those studies failed to judge povidone-iodine on the same qualities, and povidone-iodine can be used where CHG can't.

Suffice it to say that there are uses for both types of prep solution in a surgical facility. Both provide fast, broad-spectrum antimicrobial activity through different properties. They're not interchangeable, but the antiseptic properties of both are boosted by the addition of an isopropyl alcohol component.

ANTIMICROBIAL ASSIST Whichever skin prep you use, be sure it contains alcohol.

While alcohol has a rapid microbial kill, it doesn't offer much in the way of residual activity. CHG, however, does. And while povidone-iodine's antiseptic effect can be inactivated through contact with blood, body fluids, tissue proteins or other organic matter, alcohol's is not. Alcohol comes with cautions, of course: It's a flammable substance, so you must let preps that contain it dry completely; it can dry the skin; and it shouldn't be used around the eyes or mucous membranes. But for orthopedic cases, it's a valuable assistant.

The CDC and AORN don't currently recommend one type of skin prep over another, but Project JOINTS makes it plain: Whatever prep you use before arthroplasties, make sure it contains alcohol.

The idea of pre-op showers for surgical patients is not new. Previous guidelines, however, recommended the patient shower or bathe with antimicrobial soap on the night before and the morning of surgery. According to Project JOINTS, the cumulative effect of CHG on skin-based bacteria may be worth considering.

"Studies show that repeated use of CHG soap enhances the ability of CHG to reduce bacterial counts on the skin not only during the immediate period after the shower but for a number of hours afterward," says Project JOINTS. Although there's not enough proof to show benefits from 5 days of antimicrobial bathing, 3 days seems to make a difference.

Because the patient must bathe in his home, your surgeons and staff must educate the patient to enlist him in his own infection prevention regimen and to ensure compliance. This education should involve either providing patients with CHG soap (or CHG-impregnated wipes, which the project says may be more convenient if properly used) or letting them know where it can be obtained. Also instruct patients in the agent's use: to wash the whole body, from the neck down, but avoiding the genitals.

You give a lot of information to patients before surgery, sometimes in a hurry, and sometimes it's not as easy to understand or to do as we think. They might be confused, or can't remember everything, or possibly don't have the physical flexibility to reach and wash the surgical site. An explanation, a checklist, a few questions to find out if they can do what you're asking (or have a caregiver who can help) will go a long way toward compliance.

Some interventions that can head off SSIs are outside our control and can be difficult for patients as well. Studies have shown, for example, that obese patients can improve their infection defenses and wound healing abilities by losing weight, and diabetic patients can do the same by getting their blood sugar under control. These factors are patient-dependent, and attaining them doesn't always happen overnight, so unless their planned surgery is a non-urgent elective procedure that can be postponed indefinitely, they are often outside of the allotted schedule.

Screening patients for Staphylococcus aureus, on the other hand, is entirely in your hands, and can have an immediate and useful impact. Patients must make a pre-surgical visit ahead of time for the nasal swab. Be sure to get test results quickly. As far as pre-op testing and treatment are concerned, it requires some advance planning — decolonizing carriers with the intranasal mupirocin before admission and surgery takes 5 days — but it beats the alternative, as staph is carried on the skin and can easily get into the wound of orthopedic surgery patients.

DOESN'T HURT, MIGHT HELP
What's New in Hip And Knee SSI Prevention

SENSIBLE AND PRACTICAL "It doesn't hurt, and it might help" describes the latest thinking for infection prevention in hip and knee cases.

The gold standard for SSI prevention? The evidence-based practices endorsed by the Centers for Disease Control and Prevention. The agency's Healthcare Infection Control Practices Advisory Committee hasn't revised its guidelines since 1999, but is planning to publish a new version late this year or early next that will specifically address joint replacement and other procedures.

While the draft undergoes what will most likely be a stringent vetting process, the Institute for Healthcare Improvement has introduced its own "Project JOINTS" effort to spread the word on the latest thinking for infection prevention in hip and knee cases (www.ihi.org/ProjectJOINTS). While CDC guidelines are founded on an exhaustive evaluation of randomized, controlled studies and other high-level evidence, the IHI tends to popularize the contributory, if not causal, benefits of practices observed through solid publicly reported data from hospitals, states and other sources.

"It doesn't hurt, and it might help," is a more innovative approach, and with the support of the Association of periOperative Registered Nurses and the American Association of Orthopedic Surgeons, IHI's project is "Joining Organizations IN Tackling SSIs."

Backed by its evidence, Project JOINTS suggests you adapt 3 practices as routine preparations for hip and knee arthroplasty patients — skin prepping, pre-op patient bathing and screening for superbugs — alongside the applicable Surgical Care Improvement Project practices (namely, antibiotic delivery within 1 hour before incision and hair removal when appropriate).

— Linda R. Greene, RN, MPS, CIC