Prepped to Perfection

Patient Experience

By: Mary Wilson

Published: 12/19/2019

Share:

How we made proper skin prepping a top priority.


Skin prepping is serious business at our facility. So serious, in fact, that the staff who prep patients before surgery wear different colored gowns than the rest of the OR team. The designated pink gowns — a visual signal to everyone in the OR that nurses and doctors in pink are performing a critical process and are not a member of the sterile field — are a part of our standardized skin prep protocol that we rolled out in 2017. Like all changes, it hasn't always been easy to convince staff the extra steps — not to mention attire — were necessary. But with patience and persistence, we've managed to ingrain these critical safety standards into the collective psyche of our staff. Here's how we made proper skin prep a top priority, and how you can do the same.

1. Preppers wear pink gowns. Like the bulk of our protocols, we started wearing designated prep gowns as a direct result of AORN's skin antisepsis guidelines, which require the person doing the prep to have her arms fully covered to contain shedded skin particles. Whenever AORN puts out or revises a practice standard, it's evidence-based, so our goal is to meet that guideline. Of course, these guidelines don't tell you every granular detail of what you need to do. It's up to you to figure out a way to make everything work in your specific setting. For us, that meant some trial and error. We knew we wanted to have the staff who did the actual prepping wear something that made them stand out from the rest of the team in the OR. After all, the Joint Commission requires you to have some way of signifying a critical process is taking place; a designated skin prep gown certainly checks that box. But it took a little while to settle on what we wanted them to wear.

Initially, we tried disposable scrub jackets, which we found were too baggy and loose for the prepping task. We ultimately settled on a level-3 gown, which was more convenient and appropriate for staff to wear. Plus, at $1 to $1.50 per gown, it was a cheaper option.

The vendor we went with is very committed to breast cancer awareness, so the gowns are pink — a color that really stands out from the rest of the blue scrubs in the OR. When a nurse dons a pink gown in our ORs, the surgical team knows she's there for one critical task: to prep the patient for surgery with a surgeon-approved skin prep antiseptic. Everyone knows that a critical process is underway and the person/persons in pink (most prepping is handled solely by our circulator, but some cases will require 2 staff members) aren't members of the sterile field. The gowns not only cut down on disruptions — everyone knows not to interrupt the person prepping the patient — but they also help us prevent infection, as the gown fully covers the nurses' arms so those squamous epithelial cells don't fall into the sterile field.

If you're thinking of going the designated gown route, be prepared: You're bound to at least get an influx of questions in the beginning. Why do we need an extra gown? What's wrong with the way we've always done things? As a facility leader, you'll need to be patient, persistent and, above all, informative about the "why" part of your processes.

A LEG UP The longer you prep, the better you're able to reach the deeper skin layers.   |  Pamela Bevelhymer, RN, BSN, CNOR

Tell staff we're taking these extra precautions because surgical site infections are the most common type of infection associated with surgery (500,000-750,000 annually), and any basic skin movement releases 1,000 skin particles per minute and is a major source of microbial contamination and transmission in the perioperative setting.

2. Reduce variation and standardize. Standardization is another key component of skin prepping. You want to make sure staff follow the same exact process for each and every patient to reduce the variations or shortcuts that tend to crop up when time gets tight. While we do let our surgeons choose which antiseptic agent they want applied to the patient — an alcohol-based solution with 2% chlorhexidine gluconate (CHG), an alcohol-based solution with iodine povacrylex or betadine — we require the prepping to follow the manufacturer instructions for use to a T.

Take, for example, alcohol-based CHG, our most commonly used antiseptic agent. When applying this prep, you start at the incision site and work your way out toward the periphery, doing a back-and-forth friction scrub for a minimum of 30 seconds for dry surfaces (2 minutes for moist areas), and making sure you don't reverse back toward the incision because it could spread contaminants. You also need to consider the size of the body part you're prepping and how many solution sticks you'll need to do the job. Too few and you'll wind up with insufficient coverage; too many and you'll have pooling.

Last but not least is the dreaded dry time. Alcohol-based prep solutions require a minimum dry time of at least 3 minutes before draping to not only prevent surgical fires, but also to reduce the bacterial load on the skin. Let me tell you, the dry time struggle is real. For a surgeon, 3 minutes in the OR is like a year-and-a-half. As a surgical facility leader, you need to continually reinforce the necessity of waiting the full 3 minutes. We've made it part of our timeout and our fire risk assessment. When our circulator does the prep, she verbally calls out when the prep is dry. If for whatever reason the surgeon didn't wait the 3 minutes, it gets called out and is noted as a deficiency in the time out. Depending on your culture, you may also want to set a timer. I know several facilities that do this, and it's quite effective.

3-MINUTE DRY TIME To ensure that preps have enough time to dry, place a store-bought timer in each OR and magnetically attach it to your whiteboards. You can't drape the patient until the timer goes off.

3. Audit and educate accordingly. It's difficult to ensure your staff is following your prepping standards without having a system in place to verify it. That's why periodic audits are a facility's best friend. It doesn't have to be complex or time-consuming; you just need to periodically check in to make sure nothing's amiss. When skin prep is on our list, we conduct quarterly back-to-basics audits. Using back-to-basics checklists, we audit whether the correct prepping agent is being used; whether staff is wearing the correct attire (designated gown and sterile gloves); and if they followed our policy/manufacturers' recommended instructions for use. With a dozen people doing these, we wind up performing 90 to 100 audits per month at our facility. Of course, we're a 33-OR academic hospital. The resources we have simply aren't feasible for a small ASC. The key with audits is to do what's reasonable for your setting — hone in on a target you can hit consistently.

In terms of education, everyone received formal training once we overhauled our prep process to include the designated prepping gown. Then, after that, we generally hold an annual education in-service on skin prepping. But if our audits reveal any slips in technique or process completion, we'll hold impromptu refreshers. Speaking of education, there's no need to reinvent the wheel. Take advantage of what your vendor reps offer in the form of clinical education. One of our solution vendors has a clinical person who comes into our facility and offers education — not just on her company's product but also on the other antiseptic solutions. She has the PowerPoints and delivers a whole education session on the differences between the various products, why and when you should use each, and detailed instructions for use and technique. Her role is education, not sales, so she does a really thorough job addressing all the variations in prepping solutions and techniques. It's not that we couldn't do this type of education in-house, but it takes a lot of time to develop the content. If your vendors have those resources readily available, why not take advantage?

Lessons learned

One thing our revised prepping protocol taught me is you can change your culture simply through patience, persistence and transparency. When we rolled out our skin antisepsis protocol 2 years ago, 77.1% of staff complied with the designated prep gown requirement. Today, we're at 100% compliance. In the beginning, staff used to say Why do we need another gown? Now it's second nature, and whenever it's time to prep they automatically ask Where's my pink gown? OSM

Related Articles