HANDS ON To standardize your skin prep protocol, give staffers the tools and education they need to do the job correctly.

How many of the skin preps that your surgical team performs are applied correctly? On how many patients is hair around the surgical site removed in pre-op instead of in the OR? How many patients bathe with chlorhexidine-gluconate (CHG) before arriving at your facility? It's probably not as many as you think if recent findings published in the International Surgery Journal are indicative of a larger skin-prepping trend (osmag.net/CpBtM5). The study's authors found that only around one-fourth of 257 hospitals nationwide prepped their patients' skin before surgery according to national standards.

That low number impacts SSI rates, says study author Khaled J. Saleh, MD, MSc, FRCSC, MHCM, CPE, president of the nonprofit organization Orthopaedic Education in Charlottesville, Va. "Skin prepping is so important in infection prevention because it's the simplest step to take," he says. "Standardizing the protocols has been shown to save lives, decrease complications and ultimately lower costs." With those worthy goals in mind, take a look at how you can maintain consistent compliance with these 3 essential skin-prepping practices.

1. Pre-op bathing
According to the CDC and AORN, patients should shower at least once the night before or the day of surgery with soap or an antiseptic solution. Dr. Saleh argues that the science backs up the use of a CHG solution or wipe both the night before and the day of surgery for certain procedures where "an infection can have detrimental effects on the post-operative course, such as total joint replacement."

Although getting patients to comply with pre-op bathing instructions isn't always easy, there are a few ways to increase the likelihood that they follow through with this protocol. Educating patients on how to use the CHG solution — as well as stressing other pre-op protocols like avoiding shaving before surgery — helps boost patient compliance, says Cindy Ripplinger, RN, BSN, MSM, director of surgical services at Sharp Grossmont Hospital in La Mesa, Calif.

"Our pre-anesthesia services department educates patients on the importance of the CHG wipe and the correct way to use it," says Ms. Ripplinger. "Our infection rates are incredibly low, well below the national benchmark, so we must be doing something right."

Other ways to encourage compliance include offering pre-made showering kits complete with the CHG solution, a washcloth, a basin and waterproof directions, so patients have the tools they need to bathe pre-operatively. You could also use services that send patients reminders via e-mail or text message, which have been successful in getting patients onboard with the requirement, according to a study in the Journal of the American College of Surgeons (osmag.net/N6xjQB).

BUZZ CUT Hair around the surgical site should be removed in the pre-op area with clippers.

2. Hair removal
Once a patient arrives for surgery, the next step in the skin prep process could involve hair removal, although Dr. Saleh notes that it's not always needed. Even though national guidelines instruct facilities to use clippers or a depilatory to remove hair only when necessary and to perform the task before patients enter the OR, he says facilities are still having trouble standardizing these steps.

"AORN made a recommendation several years ago that hair removal, if performed, should be done outside of the OR and in a pre-op holding area. Hair removal in the OR, if the situation mandates, should involve a wet clip or vacuum device," he says. "But, here we are 5 years later, and there are still many facilities that are clipping in the OR, which, by and large, will leave hair hanging around that could find its way into the wound to cause an infection."

Ms. Ripplinger notes that her hospital had high variability in this area, spurring a project to standardize the practice. But making the move took more than just updating their policy to say that hair must be clipped in pre-op. When the hospital informed pre-op staffers about the change, they found that they didn't know as much about hair removal as leadership thought they did. "They were removing only a little bit of hair from the expected surgical site, because they were worried about clipping too much," says Ms. Ripplinger.

To fix that, the hospital held several education sessions, purchased easy-to-use clippers and made sure that staffers had access to instructions on how to clip patients. "We made a prep book that's kept in the pre-op area, which shows the diagrams of where to remove hair for certain procedures, so they have reference material," she says. "That really helped inspire the change of practice and ensure that it's done correctly each time."

It's still a work in progress, she notes, but the hospital has made strides toward standardization. Now, after patients are brought into the pre-op area, the pre-op nurse looks at the physician's order to see if hair clipping is needed. If it is, a nursing assistant clips the hair using a battery-powered clipper, according to the pre-op prep guidelines and physician's instructions. Exceptions to the practice include clipping hair on the head and at the perineum and groin, and in cases where the patient is concerned about privacy.

"Make sure you have the tools and equipment staffers need before you try to implement a new process," says Ms. Ripplinger. "Give them the rationale and explanation of your hair removal protocol. It's easier if everything's done upfront and if they know why they're doing what they're doing."

CONTINUING EDUCATION
Standardize and Simplify To Improve Prepping Performance

APPLICATION OF LEARNING It's important to hold regular skin-prepping training sessions, even for veteran nurses.

Just because your OR nurses have plenty of experience in skin prepping doesn't mean that they don't need a refresher on how to do it properly. In fact, a new study published in Surgical Infections found that nurses who routinely perform patient skin antisepsis still make plenty of mistakes (osmag.net/vJPmM2).

The study's authors looked at 30 nurses at 4 different hospitals who routinely perform surgical skin preparation. The nurses completed a questionnaire asking about their familiarity with two of the most common skin prep formulas: chlorhexidine gluconate-isopropyl alcohol and povidone-iodine scrub and paint. The OR staffers prepped one ankle of a healthy patient using either the CHG or povidone-iodine formula. They then prepped the opposite ankle using the other prep solution. Two independent evaluators reviewed their work using standardized checklists based off each prep manufacturer's instructions for use.

They found that even though the nurses had worked in the OR for an average of 13 years and had 9 years of skin prepping experience, none of them performed all of the manufacturers' steps correctly. All essential formula-specific application steps were performed correctly 90% of the time with the CHG solution, compared with only 33.3% of the time with the povidone-iodine formula. There was no correlation between the nurses' experience or familiarity with the product and the number of correct steps completed with either formula.

"This study demonstrates existing problems with infection prevention, as those tasked with pre-operative skin preparation do so with tremendous incongruence according to manufacturer guidelines," the study's authors write. "Standardization of the prep solutions as well as simplification and education of the correct techniques may enhance protocol compliance."

— Kendal Gapinski

3. Skin antisepsis
Because surgeon preference often drives skin antisepsis decisions, it can be hard to standardize the practice. But you can give surgeons free rein while encouraging uniformity through education, says Ms. Ripplinger. She notes that while her facility lets surgeons choose which preps they want to use, the overwhelming majority use a CHG prep after learning how it dries quickly, is easy to apply and is effective at eliminating microbes on the skin.

Dr. Saleh also says that a CHG-alcohol based solution was the most popular skin prep included in his study, though he notes that other formulas backed by clinical evidence can still be effective antiseptics — as long as they're applied correctly. But that doesn't happen as often as you might think. Dr. Saleh, who received funding from Carefusion and several other companies and organizations for the International Surgery study, notes that skin prepping practices at almost 40% of the 257 hospitals his research team observed were non-compliant with either the application or dry times of the skin preps they used, and only 25% were compliant with the manufacturers' directions for use.

His research team found a few factors that seemed to affect compliance rates among all of the preps studied, which included CHG-, CHG-alcohol, iodine- and iodine-alcohol-based preps. A single-step, CHG-alcohol solution applied in a back-and-forth manner correlated with higher compliance. In addition, surgical teams using an aqueous-chlorhexidine, iodine or iodine-alcohol prep, or those performing 2 or more preps per patient, exhibited lower compliance rates. The findings show that simplifying the prepping process may make it more likely that staffers follow the directions and can encourage standardization among surgeons, suggests Dr. Saleh.

However, he stresses that you won't create a culture of compliance by just moving to a new prep product. Instead, it requires streamlining your choices as much as possible and then educating and re-educating staff on the proper applications of the prepping products based on the manufacturers' instructions.

"The first obstacle we observed to compliance in the study was that the facilities did not look at evidence-based protocols to gather the information they needed to identify the key ingredients or mechanisms for applying the prep to the patient," says Dr. Saleh. "The top-performing facilities tended to have a consistent program of educating people and held regular review sessions."

Overall, the key to standardization is to ensure that the person prepping the patient for surgery — whichever staffer, surgeon or specialty it may be — has the tools and knowledge she needs to do the job correctly each time. "If Ms. Smith is taught to scrub differently than Ms. Donald, that's where misalignment occurs," says Dr. Saleh. "It shows the facility did not look at the best science and standardize its protocol accordingly." OSM