TOO MANY OPTIONS With iodine-based prepping, nurses at Stanford University Hospital and Clinics were too often conjuring cocktails that had little basis in best practices.

You know there's trouble with your skin-prepping protocols when nurses act more like bartenders than caregivers, mixing 1%, 2% or 3% iodines with alcohol for surgeons who don't use single-use chlorhexidine and povidone-iodine products. That's the reality we faced before surgeons and nurses partnered to limit available prepping options to 3 products, which resulted in lower infection rates and increased satisfaction across the front line. Let's look at how you can standardize patient skin prepping as part of a surgical site infection process improvement project.

FORMULA ONE Stanford's infection control leaders, surgeons and nurses were able to agree on single-use CHG/alcohol products as their preferred choice.

1. Convince with data
Surgeons have 1 of 2 attitudes toward prepping: They're ritualistic and convinced change will end in disaster, or they don't think it makes any difference whatsoever. To dispel both notions, form a staff research team to examine the literature for best practices (as you know, most surgeons base their clinical decisions on peer-reviewed research). Our team found that chlorhexidine gluconate (CHG) combined with alcohol appears to be most effective for skin asepsis, followed by povidone-iodine and alcohol in cases where CHG is inappropriate (such as around open wounds, the eyes or mouth).

During one of your regular education sessions attended by nurses, surgeons and anesthesia providers, present the findings of your literature review and identify which prepping products will be used moving forward. Focus on the evidence that supports the agents that are most effective for the procedures you host, notify the surgical team that surgeon preference cards will be adjusted and remove all non-approved products from the ORs and supply inventory.

Share the same information at a follow-up operative staff meeting, and post a summary of the findings on a prominent bulletin board (or e-mail a copy to the staff). Stress to your nurses that the infection control department (or your infection preventionist) backs the change to the prepping regimen, and that the surgeons have agreed on the standardized products.

Standardized prepping practices will empower nurses, who won't be afraid to suggest the appropriate product when it's called for. They'll remind surgeons in the ORs, "Hey, CHG would be best for this patient, based on the literature and the procedure. We're going to use that, OK?" If another one of your preps is more appropriate, they can suggest its use. This soft-sell approach won't be confrontational if everyone is on board with the effort to standardize your preps.

ADDED BENEFITS
Streamlined, Sterile Supplies

SELECT FEW Nurses aren't the only ones who want prepping options limited to a few effective choices.

After standardizing our preps, the space needed to store prepping products was greatly reduced, as was the manpower required to stock the supplies. We've tried to determine whether there was a realizable cost savings, but our tracking system makes this nearly impossible. I can tell you that we've saved loads of space, because the prep sticks go directly in our specialty packs now. The only prepping agent taking up shelf space is the povidone-iodine for scrub and paint, so materials management is clearly happy with the efficiency of both stocking and picking for cases.

Infection control leaders like that the single-use products are sterile and come with other sterile supplies. Sterile manufacturing of antiseptic products is an issue the FDA keeps revisiting (although it's not yet decided to take action), so we feel as if we're ahead of the curve there. Finally, nurses and surgeons alike have expressed satisfaction. Nurses like that prepping is a much simpler process — no more being asked to whip up cocktails in the OR — and surgeons like that there's no imposition on the rest of their routines. Even for those who still insist on iodine, we didn't take it away; it's just in a standardized, consistent formula.

— Sharon L. Butler, MSN, RN

2. Reinforce compliance
CHG/alcohol single-use products became our first product choice (due to their long-lasting properties), iodine/alcohol single-use second, and traditional povidone-iodine paint-and-scrub third. When all the non-compliant products were removed, there wasn't much complaining, likely because the surgeons had helped initiate the change — it's really key that they be involved from the beginning on any process improvement project.

It also helped that our cardiac surgeons were already using the CHG/alcohol product and that the neurosurgeons were using the iodine/alcohol product. We didn't have to introduce completely new products; it was a matter of reinforcing best practices for the ones we already had in stock.

Consider creating a poster that charts the evidence about effectiveness for each of the prepping agents, including those no longer used at your facility. Hang copies at all the scrub sinks, in clear view of surgeons and staff scrubbing in for procedures. Take every opportunity to communicate with surgeons about their prepping practices and talk up the agents you've put in place.

3. Track the progress
Three months after standardizing prepping products, our infection control department reported a slightly lower SSI rate. Keep in mind, though, that numerous practices affect SSIs, and we can't necessarily attribute the drop solely to changes in prepping agents. But there's no doubt that surgical skin asepsis is an important part of effective SSI-reduction measures and played some part in the reduced infection rates.

Intermittently track your staff and surgeons' behavior to execute a truly successful process improvement program. Conduct infection control compliance audits for a variety of tasks that ensure frontline practices match what's being reflected in medical records. To reinforce and normalize prepping behaviors, add the preferred choice of agent to patients' EMRs or paper records when cases are scheduled. Doing so alerts staff of the optimal options and ensures prepping practices remain standardized and effective. Also know that skin prep manufacturers are actively looking to change products to combat the issue of resistant organisms, so consistently review commercially available preps to ensure your SSI reduction efforts remain current.

AT-HOME PREPPING
3 Tips for Reinforcing CHG Wipe Use

As part of our change in surgical skin prepping, we also began giving all patients chlorhexidine-gluconate-impregnated wipes to use at home before the day of surgery. Current literature doesn't yet show efficacy specific to these wipes, but we know that CHG has lasting effectiveness, and it can't hurt. Here are some tips for integrating take-home CHG wipes into your skin-prepping protocols.

1. Ensure that surgeons educate patients in the pre-op clinic about the importance of using the wipes once a day in the 2 days leading up to surgery, and that they don't use them above the neck or on any exposed membranes (female genitalia, for example).

2. Don't use the 4% product for patients who aren't high-risk. We started giving those to patients, then discovered that doing so required a physician order. So we dropped back to the 2% formulation, which the nurses could hand out without orders or complication. We use the 4% only for select cases.

3. Add the issuing and use of CHG wipes to the nursing documentation. On the surgical day, pre-op nurses should ask patients, "Did you use this product twice before you came to the hospital?" Infection control administrators can then track compliance and whether usage correlates to SSI rates.

— Sharon L. Butler, MSN, RN