NEW GUIDANCE? Experts think the CDC now has enough clinical evidence to strongly recommend alcohol-based skin preps.

No one knows exactly when the Centers for Disease Control's much-anticipated revised Guidelines for Prevention of Surgical Site Infection will be published. Chances are the revision — the first since 2009 — won't see the light of day until this summer. But the experts we talked to believe that one of the key components is going to be a strong recommendation to use alcohol-based skin preps before surgery.

Don't expect the CDC to recommend which antiseptic combination is preferable — alcohol combined with povidone-iodine or with chlorhexidine, says Linda Greene, RN, MPS, CIC, manager of infection prevention at Highland Hospital in Rochester, N.Y. But what Ms. Greene says you can count on is that a high degree of evidence will back the CDC's potential recommendation that you use an alcohol-based prep. The value of alcohol-based preps may be increasingly clear, but for surgeons and staff who are used to other preps, the transition won't necessarily be seamless.

Against their religion?
When the CDC releases its new prepping guidelines, your challenge will be to get your surgeons to incorporate the changes in practice.

"Some surgeon preferences are very strongly based on where they did their residencies and how they were taught," says Jennifer Zinn, RN, MSN, CNS-BC, CNOR, who co-authored a 2010 AORN study on intraoperative skin preps (tinyurl.com/ljzfqqf). "I think what is going to be important is to really establish strong clinical studies that the recommendations are based on.

"It'll be interesting to see the literature review and background that supports the CDC recommendation," adds Ms. Zinn, a clinical nurse specialist for perioperative services at Moses Cone Health System in Greensboro, N.C.

Orthopedic surgeon Anthony DiGioia III, MD, agrees. "I always liken surgical preps to religion," he says. "If you try to get surgeons to change, it's hard to even discuss, because even though you may have best practices, it's so entwined in what we do. There's always resistance to change."

But Dr. DiGioia, the medical director of the Bone and Joint Center at Magee-Womens Hospital of UPMC in Pittsburgh, Pa., has seen reluctance evolve into acceptance and enthusiasm over the last couple of years, as his facility took part in the IHI Project JOINTS program. One of the components of the program's "bundle" approach toward reducing SSIs is alcohol-based skin preps.

"There are 6 surgeons in our program, including 1 or 2 that were less willing to switch," Dr. DiGioia recalls. "But everyone came around, and once it was adopted, people saw the positive consequences. We have not had anyone opt out at all. Now it's just part of our routine."

Unexpected benefits
Though the evidence may not be 100% conclusive, it's definitely there, says Dr. DiGioia. "That's what it came down to," he says. "There is science behind it. There's more peer-reviewed literature for the alcohol-based preps than there is for the other parts of the bundle (pre-op bathing with CHG soap for 3 days and MSSA/MRSA screening)."

Beyond taking a hard look at the evidence, a team-oriented approach was essential, he says: "The surgeon can't just walk into the OR one day and say, 'I'm going to start using alcohol-based preps.' It has to involve the whole OR team. So part of our strategy was to engage each person — the circulating nurse, the scrubs, the PAs, the surgeons, the residents — in the whole process. It's important to make it a conversation, rather than just having one person mandate it.

"The other strategy we used was to always view all care through the eyes of patients and families. Focusing on what's best for the patient often removes the defensiveness about change. It's no longer a question of what the surgeon is saying, or the scrub tech or the PA. It's What's best for the patient?"

Once the transition was underway, the team got some pleasant surprises: "There were a lot of practical benefits that we didn't think about, but we found helpful," says Dr. DiGioia. "One was a huge improvement in efficiency. We all used different preps before. Now, having every surgeon do the same thing — that's a huge help for our OR staff. Also, the application is very efficient in that you literally paint the area with the prep and the paint has a teal color, so you can see exactly where you've prepped and where you didn't prep. That also minimizes pooling, which is always a concern with alcohol."

One big hazard
Of course, pooling is an issue because alcohol is a significant fire hazard. As Ms. Zinn points out, surgeons and staff who are used to water-based preps are going to have to be keenly aware of that. "Four percent of all the OR fires that we see can be attributed to an alcohol-based prepping solution," she says. "But as long as organizations have robust education and really follow manufacturers' recommendations, I don't see challenges in that transition."

How much drying time is needed? "The minimum is 3 minutes, but if the area being prepped out is very hairy, it can take up to an hour," she says. "So physicians and staff who have been using water-based solutions may have to alter their practice to allow the alcohol-based solution to dry."

Dr. DiGioia says that hasn't been a problem for his staff: "We didn't have to change our routine. My PAs do the prep and then the drape. By the time I come in and we go through our checklist in the OR, it's always dried. We haven't had to slow anything down by any means."