Look at your patients' skin. Look closer. You can't see them, but they're there. Millions of microorganisms that have the potential to cause infection if they flake off into surgical incisions. That's not unlikely to happen, either, considering that skin sheds approximately 10 million particles each day. Skin antisepsis is therefore the critical first step of eliminating a major source of microbial contamination and transmission in the OR, but standardizing prepping practices is no easy task. It took us 2 years and lots of hard work to integrate uniform routines into routine practice. Here are the keys to our ongoing efforts to protect patients from themselves.

1. Partner with patients

Patients who are scheduled to undergo complex procedures such as joint replacements should be required to shower the day before surgery with chlorhexidine gluconate (CHG) soap. Also have them treat their skin with CHG wipes before donning gowns in pre-op. ?Educating patients about how to use CHG products, stressing the importance of prepping the skin before surgery and even providing patients with kits that contain all the supplies needed for pre-op bathing will boost their compliance with your directives.

2. Make it easy

Staff should be able to implement standardized prepping protocols without a lot of extra effort. Include needed prepping ?supplies on surgeons' preference cards to ensure the items are picked and ready in the room before each case. You don't want to give your staff the opportunity to not comply with your prepping protocols with ?"supplies aren't easily accessible" ?and ?"it's inconvenient" ?excuses. ?The goal is to make your standardized skin prep methods easy to implement and impossible to ignore by giving staff the ?tools and knowledge they need to do the job correctly each time.

3. Wear proper PPE

Staff members who perform preps should wear long-sleeved scrub tops or jackets, according to AORN recommended practices. The coverage provided by long sleeves prevents squamous epithelial cells from falling into the sterile field and increasing the risk of infection. ?The Joint Commission also recommends that you clearly identify the staff members who are performing preps. We chose distinctive pink prepping gowns to make it clear who in the OR is responsible for prepping the patient's skin for surgery. The pink gowns alert members of the surgical team that a critical stage of the procedure is taking place and that the nurses should be allowed to apply the prep without interruption and distraction. ?

4. Follow instructions for use

The procedure type, location of the surgery and patients' allergies influence what prepping agent to use and how to apply it. For example, CHG-based products can't be used on mucous membranes or around the eyes. ?Povidone-iodine, on the other hand, can be used around mucous membranes and is a good alternative for patients who are sensitive to CHG solutions. Always refer to prep manufactures' instructions for use and follow them to the letter. We require staff to sign off that they consulted and followed manufactures' instructions whenever preps are applied.

Once we standardized our prep application practices, it took some time to gain acceptance from the surgeons. ?Some surgeons still wanted to apply preps in their preferred way, which proved challenging. We try to enforce our standardized application methods, but if they chose not to comply with the directives we document their refusal in the operative report. ?Still, even with the occasional push back from surgeons, their compliance increased from 40% to over 70%.

5. Be consistent

The goal is to make compliance routine, which requires constant reinforcement of your facility's prepping practices. Provide reminders of proper prep application methods and constantly educate and train the surgical team about accepted practices. Eventually, following standardized practices will become second nature.

We also audit proper prepping techniques — donning of the pink gown, staff hand hygiene practices and confirmation of the prep application during time outs initiated by the surgeon — and clinical leaders randomly pop into ORs to observe prepping in action. We've found that periodic audits keep staff focused on constantly striving to apply preps properly and the same way every time. OSM