A LEG UPPatients who prep their sites before the day of surgery can help fight bacteria.

How clean are your patients? Pre-operative baths and showers are believed to help prevent surgical site infections among patients undergoing orthopedic, abdominal and other procedures. In the absence of hard evidence on their effectiveness, though, they can be an inconsistent practice. We surveyed readers to find out how patient-driven skin antisepsis works for their facilities. Here's what more than 170 respondents told us about ensuring compliance and improving results.

Do you instruct your patients to bathe, shower or wash before their scheduled surgeries?

• Yes: 86.5%
• No: 13.5%

While there is strong evidence that patients' pre-op antiseptic bathing, showering or wiping reduces the amount of microorganisms present on the skin before incision, current research is inconclusive on whether this in turn reduces the incidence of SSIs. Public health authorities and professional organizations agree, however, that the potential benefits of pre-emptive skin prepping generally outweigh any risks involved and recommend some form of pre-op bathing.

In prescribing the practice to patients, many find it useful to administer a bit of infection prevention education to highlight its importance. Emphasize that good post-surgical results are a joint effort, and empower patients to play a pre-op role in their own care. Patients at Crestwood Medical Center in Huntsville, Ala., are told that "post-op wound infections are a known complication. We must work together as a team to have the best outcomes for surgery," says Susan Bryce, RN, BSN, MBA, assistant chief nursing officer. "Most wound infections come from the bacteria that naturally exist on your skin, so bathing helps to reduce the amount of bacteria and thereby the chance for a post-op infection."

Who is more likely to instruct patients to take pre-op baths or showers?

• The surgical facility, through a pre-op call: 49.4%
• The physician, during a pre-op visit: 16.7%
• Both: 24.4%
• Neither: 9.5%

According to our respondents, it is incumbent upon a surgical facility's nursing staff to make the recommendation that patients bathe before surgery. "Inform patients at the time of scheduling about pre-op bathing needs, and provide written instructions for patients to take home as a reminder," says Christy Hutto, RN, director of nursing at Carolina Ambulatory Surgery Center in Aiken, S.C.

Remind patients during the pre-op verification call as well as during the arrival time call the day before surgery, says Angela Eggleston, BSN, RN, CNOR, director of nursing services at Union Hospital in Dover, Ohio.

For best results, however, it may be advisable to partner with your physicians' offices to promote the practice. The SSI prevention committee at Lakeland (Fla.) Regional Medical Center is developing a process to get them all onboard. "We are going to standardize the pre-op instructions and include them in 'cleansing kits' we'll provide to our hospital-employed surgeon's office. The same will be made available to non-hospital-employed surgeons," says Cheryle M. Smith, RN, MSN, the manager of pre-admission testing, ambulatory surgery, holding, PACU and anesthesia.

Clearly, repetition never hurts either. "They hear it on their pre-op visit with the physician, it's given to them in writing at that visit and they're re-instructed in their pre-op phone call," says Brenda Vahle, RN, CAPA, clinical director of the BSM Surgery Center in Corvallis, Ore. "The more often we remind them, the less likely they are to forget."

How often do you direct patients to take pre-op baths or showers?

• We don't direct them to: 15.1%
• Once, on the night before or the day of surgery: 32.6%
• Twice, on the night before and the day of surgery: 39.5%
• For 3 days before surgery: 11.1%
• For more than 3 days before surgery: 1.7%

The number of times and the number of days in advance that patients should bathe before surgery to reach the optimal antiseptic effect remain open questions.

This summer the Association of periOperative Registered Nurses revised its recommendations on the matter to read, "The patient should be instructed to bathe or shower before surgery with either soap or a skin antiseptic on at least the night before or the day of surgery." While an AORN infection preventionist admitted that the guidance was slightly vague, she noted conflicting evidence on the practice.

In contrast, the Institute for Healthcare Improvement's Project JOINTS initiative to reduce SSIs after hip and knee replacement surgeries advised 3 days' worth of chlorhexidine gluconate showers back in 2013. The institute's recommendation cited CHG's cumulative effect against skin-based bacteria and a study showing that while 3 days of showers had a greater impact than just 1 day, 5 days was not any more effective than 3 days.

There is, however, a practical logic to recommending a middle path of 2 antiseptic showers, the night before and the morning of, says Cindy Williams, surgical services coordinator at the Medical Development Corporation in Hudson, Fla. "This way we know they will do it at least once."

Which product do you recommend patients use?

• CHG liquid soap: 45.8%
• We don't specify a particular product: 18.1%
• CHG wipes: 10.2%
• Household bath soap: 9%
• An antiseptic skin prep solution: 2.4%
• Other: 14.5%

Just as current research has not determined the optimal frequency for pre-op bathing, so it has not to date addressed the comparative effectiveness of the available antiseptic agents. Even AORN's recent revision leaves the evaluation and selection decision up to each provider.

Several observers have speculated that the use of 2% CHG-impregnated wipes after patients' showers may have a stronger effect than the use of 4% CHG liquid soap, since lathered-up soap is soon rinsed off but wiped-on solution is not. At least one survey respondent, however, noted the wipes' higher cost.

Respondents who checked "Other" predominantly named antibacterial versions of common brands of bath soap, with a few others suggesting the combination approach of a CHG shower followed by a CHG wipe.

You can improve compliance by making your recommended product readily accessible to your patients, which 53.3% of respondents do.

SKIN DEEP A pre-op wipe-down with CHG can supplement skin prepping's antimicrobial effects.

Do you instruct patients to wash their entire bodies, or just their surgical sites?

• Their entire bodies: 87.6%
• Just their surgical sites: 12.4%

Because they take place outside of the perioperative environment, pre-op baths and showers rely on patients' following to the letter the instructions that your team has standardized. "Be sure to give written instructions as well as oral ones," says Jane Stobinski, RN, director of nursing at Cottonwood (Ariz.) Day Surgery, "and have the patient repeat them back."

Pend Oreille Surgery Center in Ponderay, Idaho, posts directions on the facility's website for reference anytime, says Kris Sabo, RN, executive director.

Patients can wash with antiseptic products from the neck down, as long as they avoid their genital areas. If you instruct them to wash just the surgical site, visual aids may come in handy. "Give patients written instructions with pictures as to where to clean," says Rachelle Cho, RN, BSN, director of surgical services for Corona (Calif.) Regional Medical Center.

You'll also want them to stay clean after they've washed. "We ask that they sleep on clean linens and wear clean pajamas or gowns," says Eloise Whitton, BSN, RN, CNOR, manager of surgical services at Higgins General Hospital in Bremen, Ga.

Do you remind patients to pre-op bathe or shower via text messages, e-mails or phone calls?

• Yes: 34.9%
• No: 65.1%

Roughly two-thirds of respondents consider early instructions during physicians' office visits or surgery scheduling calls sufficient to spur patients into antiseptic action. But researchers from the Medical College of Wisconsin in Milwaukee believe that electronic intervention can improve patients' compliance, as they explained in a study published in the August issue of the Journal of the American College of Surgeons. Researchers asked 80 volunteers to shower with a CHG liquid soap for 2 or 3 days. Half of the volunteers received text messages reminding them to shower with the antiseptic. The researchers found that those who'd received the texts also had about 66% higher skin-surface concentrations of CHG, not to mention less of the soap left over at the end of the study.

Do you wash the surgical site in pre-op, before the skin is prepped in the OR?

• Yes: 44%
• No: 56%

"If we are in doubt it happened, we do it again," says Justine Murphy, RN, BSHA, director of perioperative services at Brandywine Hospital in Coatesville, Pa., adding that CHG-permeated wipes make a quick pre-op cleanse convenient.

"We recently began writing the recommended CHG wash on the medication reconciliation form," says Nancy Wynne, BSN, RN, nurse manager at MetroWest Medical Center in Natick, Mass. "That way the topic is revisited pre-operatively on the day of surgery to confirm the wash occurred."

If it didn't, the surgeon is informed that the patient declined to do so. But, she says, "no MD has ordered a pre-op bath to make up for it."