PREVENTIVE PRACTICE Skin antisepsis is an essential part of perioperative infection prevention efforts.

Your staff has applied thousands of skin preps, using friction and concentric circles to reach the layers and cracks where harmful bacteria breed. They might get lost in the routine of it and lose focus on the importance of decolonizing the patient's first line of defense against SSIs. It's up to you to review the prepping options and ensure the right agent is applied correctly before each incision is made.

Overcoming barriers
It's been my observation that the most common obstacle to pre-op skin antisepsis is not having a system to guide the practice. Skin prepping is hardly complex, but it is by no means a simple or mundane process.

Take the initiative to review prep manufacturers' directions and compare them to what's actually being performed in the ORs. A culture of effectiveness and improvement starts with leadership. In surgery, we have a tendency to rely on authority. "Dr. Johnson showed me how to do this," we reason, "so this is always the best way to do it." Well, maybe, or maybe not: How do we know? Since members of the surgical team are often hesitant to question surgeons' orders, you must step in to ensure skin prepping is being done correctly.

Create a culture of system improvement ("We failed this patient because we didn't have a system in place for ensuring proper skin preparation") instead of casting individual blame ("Our patient suffered a wound infection because you didn't prep properly"). Work to educate and train the nurses, physician assistants, techs and other frontline employees who are actually prepping the skin. There is nothing complex about skin prepping, but there is a correct way to do it and an infinite number of incorrect ways (see "Skin Antisepsis Done Right").

Standardizing practices is another key to improvement. The circulator who preps patients probably works with several surgeons. As a result, she must keep all of their orders and requested methods straight, for prepping as well as for everything else. This not only risks utter confusion, it also increases the likelihood that a member of the surgical team strays from manufacturers' instructions for use and compromises the preps' effectiveness.

Speak with your surgeons about standardizing prepping products and techniques to make the circulator's performance more consistent, to prevent costly SSIs, to provide better patient care and even to offer the financial incentives of volume purchasing deals and simplified inventory management.

PREPPING POINTERS
Skin Antisepsis Done Right

SOLE SOLUTION Different prepping agents may be differently effective for different body parts and before different procedures.

In an effort to better protect its patients from surgical site infections, West Virginia University Health Care formed interdisciplinary teams to assess potential risk factors and take multimodal action against them. The resulting quality improvement initiative was presented as a poster at AORN's Surgical Conference and Expo in March (osmag.net/X0LdIy). Jesse Hixson, MSN, RN, CNOR, an OR manager at WVU Health Care, oversaw the project's skin antisepsis arm and offers the following thoughts on pre-operative preparations.

• Focus on technique. Antiseptic skin prepping is "the last chance you have before you make the incision to get as much bacteria as possible away from the site. It's one of the most important things a nurse does in the OR, a practice where they have a chance to affect surgical outcomes," says Mr. Hixson. "But you'd be surprised at how many variations people put into their own practices. If someone has bad technique, they're bringing a breach in sterility to the surgical table."
• Narrow the options. Standardize your skin prepping techniques and make sure you're following manufacturers' instructions for use for each antiseptic agent, particularly how much to use and the manner in which it is to be physically applied. "The most common problem is not using the product in the way it was intended, specifically not allowing it to dry," he says. "You have to let it have time to dry to reach antimicrobial efficiency," not to mention for fire safety when using alcohol-containing preps.
• Monitor practices. After educating your staff, audit their prepping performance. "Don't assume anything," he says. "Healthcare providers should hold each other to higher standards when it comes to antiseptic skin prepping."
• Gather data. The choice of prep is often based on physician preference, but a review of clinical studies can offer pointers on which agent is best for which patient care if you're looking to standardize the products you have on hand. "Engage the surgeons in the process or you won't get buy in," he says. "Surgeons want to see evidence, if you're asking them to change their practices."
• Partner with patients. Instruct your patients to take part in their antisepsis. "We have an important rule: Our inpatients do not come down to the OR without pre-op bathing or showering," says Mr. Hixson. "It's a hard stop unless that's completed. For outpatients, if they have not taken an antiseptic shower, we direct them to do it here."
• Do your part. Eliminate unnecessary OR traffic and have providers doing preps cover their arms to prevent contamination from skin cells and hair. WVU's surgical managers are also looking to include single-use gowns in a different color from standard surgical garb to its procedure packs in order to designate them as the prepper and prevent distractions or requests for assistance.

— David Bernard

The great prep debate
Expert discussions have centered on which skin prep is the most effective. This is an important issue that hasn't yet been adequately answered. The 3 most commonly used skin prep agents in the United States are (in no particular order) a combined chlorhexidine and isopropyl alcohol paint, a combined iodine povacrylex and isopropyl alcohol paint, and a 2-stage povidone-iodine paint and scrub. The first 2 products have been compared head-to-head in 3 small randomized controlled trials that, due to their size, had to employ skin decontamination outcomes as a surrogate marker for SSIs. Intuitively this makes sense, but it's unclear what amount of decontamination translates into a decrease in surgical site infections, so these trials give us very limited information on which of the 2 alcohol-containing products are most effective.

An industry-funded study published in the New England Journal of Medicine (osmag.net/D4jHtO) in 2010 garnered much attention for touting chlorhexidine and isopropryl alcohol over povidone-iodine as tested on patients undergoing elective, clean-contaminated abdominal, thoracic, gynecologic and urologic surgeries. The study left unanswered, however, whether it was the chlorhexidine or the addition of alcohol that provided the superior effect.

Further confusing the issue, the observational data does not square with randomized data. Non-randomized studies have generally found no antiseptic differences between chlorhexidine- and iodine-based products. One even found iodine superior; however, it contained several flaws. For an effective comparison of prep effectiveness, the clearest answers will come from well-designed, randomized controlled trials.

Skin preparation can even begin before the patient arrives in pre-op, in the form of antiseptic bathing, showering or site-wiping (see "CHG Treatments Begin at Home"). The evidence we have shows this practice effectively reduces skin flora colonization. In a systematic review published by the Cochrane Collaboration in February 2015, Webster and Osborne found that chlorhexidine bathing before surgery was more likely to reduce surgical site infections than no bathing did. It must be noted, however, that 3 randomized controlled trials (comprising a total of 1,192 patients), which compared bathing with chlorhexidine to bathing with household bar soap, found no difference in SSIs between the 2 approaches.

PREPPING PLUS
CHG Treatments Begin at Home

WASH WARRANTED Empower your patients to participate in pre-op skin antisepsis.

Charles Edmiston Jr., PhD, CIC, hospital epidemiologist for the Medical College of Wisconsin in Milwaukee and director of its Surgical Microbiology Research Laboratory believes in the effectiveness and potential antiseptic benefits of having patients treat their skin with chlorhexidine gluconate in the days leading up to surgery. In a study published last year in the Journal of the American College of Surgeons (osmag.net/SeA7nK), Dr. Edmiston and his colleagues provided 11 steps toward ensuring that this patient-driven aspect of pre-op skin prepping is complied with and carried out with consistent results.

1. Use electronic alerts (text messaging, emails, voice mails) to remind patients about completing the applications.
2. Emphasize the overall benefits of the treatment.
3. Provide both oral and written instructions to patients.
4. Define a precise amount of CHG used for each treatment.
5. Instruct patients to take a 60-second time out prior to rinsing.
6. Tell patients to avoid application of lotions, creams, emollients or perfumes following CHG application, as they may impair antimicrobial activity or heighten skin sensitivity.
7. Direct patients to wear loose-fitting clothes following CHG application.
8. Advise patients to rinse the CHG product immediately if significant burning or itching occurs, and to report occurrence to their healthcare provider.
9. Instruct patients to keep CHG away from the eyes and ears and, if exposed, rinse immediately.
10. Provide the CHG product to patients.
11. Include a telephone contact for patients to call with questions or concerns.

— David Bernard