4 Steps to Better Skin Prepping

How difficult is it to prep the skin for surgery? You pick an antiseptic agent and paint it on in concentric circles, beginning at the incision site and working outward, or scrub it in with a back-and-forth brushing motion. What can possibly go wrong? As it turns out, plenty — and your OR team might not even be aware they're slacking.

When infection prevention experts at the University of Texas Southwestern Medical Center in Dallas noticed an uptick in surgical site infection rates, they audited the surgical team's prepping practices during 51 procedures performed in May 2017.

"We noticed staff didn't always meet required application times, use the correct application method or allow enough time for preps to dry," says Doramarie Arocha, PhD, MS, MT(ASCP)SM, CIC, FAPIC, epidemiologist and director of infection prevention and control at UT Southwestern. "In fact, they were performing those basic prepping steps correctly in less than 50% of observed cases."

Dr. Arocha says these results are on par with national averages, suggesting improper prepping is a problem in ORs across the country, possibly even yours. The essential first step to improving prepping practices is to get out from behind your desk, slip on some scrubs and observe your surgical team in action.

Audit your staff's compliance with a prep's specific application method, application time and dry time, says Barbara Hasnain, BSN, RN, CIC, an infection preventionist who was involved in most of the staff observations conducted at UTSW. She says the application mistakes she saw were consistently inconsistent, and varied based on prepping product and across service lines.

There were, for example, significant variances in how staff performed the 2-step scrub and paint application process of povidone-iodine preps. Ms. Hasnain also noticed that staff achieved the required 30-second application time for CHG-alcohol preps during only 6% of cases, missing the mark by an average of 15 seconds.

"Nurses were applying the solutions based on surgeon preference or how they were originally trained, however long ago that might have been," she says. "Even if staff had originally been instructed on proper application techniques, drift happened over time and they became lax in their practice."

Ms. Hasnain saw the issues firsthand, and huddled with her colleagues to formulate a plan on how to address them.

2. Limit the options

Those efforts began with paring down the multiple versions of the same prepping agent the hospital bought from various manufacturers. Each prep came with different instructions for use, which led to inconsistencies in how the products were applied, says Julie Trivedi, MD, medical director of infection prevention at UTSW. She suggests you identify the preps you use for your high-volume procedures, categorize them according to prep type and identify a single manufacturer to supply them. That's how UTSW trimmed the number of prepping products it used from 10 to 4.

Dr. Trivedi also points to the importance of reviewing where various prepping products are stored, how they're supplied to the ORs and if surgical teams ultimately end up using them as supplied. At UT Southwestern, for example, some prepping solutions and supplies were included in pre-packaged OR kits. Surgeons, however, would instead request an off-the-shelf option. "There were a lot of free-floating products in use, and that didn't help our efforts to limit the choices," says Dr. Trivedi.

Also involve your facility's purchasing and supply chain managers, who are the gatekeepers for which products enter your facility. Work with them to identify the best manufacturers from whom to buy prepping agents, limit the number of options you stock and make sure only intended products reach the OR.

3. Bring in outside help

Ask the manufacturers of each prep you settle on for the instructions for use, says Ms. Hasnain. "Each company provided us with up-to-date information on how their product is supposed to be applied, and the reasons for the specific application methods," she says.

You can also ask prep manufacturers to perform in-house audits of your staff's prepping practices and educate them on the proper way to apply their products — Dr. Trivedi says staff might not understand the science behind prepping and why you need to apply products in exact accordance with instructions for use. For example, you must apply CHG preps in a multidirectional method so the positively charged CHG bonds with the negatively charged microbial cell membrane of the skin and penetrates the first 5 layers of the epidermis, says Ms. Hasnain.

4. Prepare for pushback

One challenge the leaders at UT Southwestern faced was trying to convince surgical teams that there were gaps in their practices and serious work needed to be done to fill them, says Dr. Trivedi. Staff members asked: Where's the data showing our prepping practices aren't effective? What's the science behind the preps' instructions for use? Why do we need to change how we've always prepped skin?

The questions were valid and appropriate. "Be direct in explaining the reasoning behind proper prepping practices — this is how it has to be done if you want to get the proper log reduction of bacteria and the highest, sustained kill rate on the patient's skin before making an incision," says Ms. Hasnain. "Staff were more willing to buy in when they realized there was an evidence-based rationale behind what we wanted done."

In part, UTSW brought in prep manufacturers to audit and educate to help convince staff to change their prepping ways. "We wanted them to know our efforts were part of an unbiased quality improvement project," says Dr. Trivedi. "Once surgical team members bought in, interest in improving our prepping practices began to build. And once interest increased, the whole project gained momentum and expanded."

Stress to surgeons that improved prepping practices not only benefit patient care, but also pad their stats. "Surgeons are mindful of their own SSI rates, and recognize applying skin preps properly is low-hanging fruit," says Dr. Trivedi.

Striving for perfection

In November 2018, UTSW conducted a follow-up audit of the staff's prepping practices and saw marked improvements across the board. Staff met the 30-second application time for CHG-alcohol preps 50% of the time, a 44% increase from the initial audit, and dry-time compliance increased from 48% to 84%. Overall prep time compliance for CHG-alcohol, aqueous CHG and povidone-iodine products increased from 4% to 39%, and dry time compliance for the 3 prep types jumped from 42% to 82%.

Those are significant and impressive increases, but efforts to improve the prepping practices at UTSW are ongoing.

"We're relentless and persistent," says Ms. Hasnain. "Are we at 100%? No, not yet. Do we need to be? Every facility should aim for that goal." OSM

Those efforts began with paring down the multiple versions of the same prepping agent the hospital bought from various manufacturers. Each prep came with different instructions for use, which led to inconsistencies in how the products were applied, says Julie Trivedi, MD, medical director of infection prevention at UTSW. She suggests you identify the preps you use for your high-volume procedures, categorize them according to prep type and identify a single manufacturer to supply them. That's how UTSW trimmed the number of prepping products it used from 10 to 4.

Dr. Trivedi also points to the importance of reviewing where various prepping products are stored, how they're supplied to the ORs and if surgical teams ultimately end up using them as supplied. At UT Southwestern, for example, some prepping solutions and supplies were included in pre-packaged OR kits. Surgeons, however, would instead request an off-the-shelf option. "There were a lot of free-floating products in use, and that didn't help our efforts to limit the choices," says Dr. Trivedi.

Also involve your facility's purchasing and supply chain managers, who are the gatekeepers for which products enter your facility. Work with them to identify the best manufacturers from whom to buy prepping agents, limit the number of options you stock and make sure only intended products reach the OR.

Ask the manufacturers of each prep you settle on for the instructions for use, says Ms. Hasnain. "Each company provided us with up-to-date information on how their product is supposed to be applied, and the reasons for the specific application methods," she says.

You can also ask prep manufacturers to perform in-house audits of your staff's prepping practices and educate them on the proper way to apply their products — Dr. Trivedi says staff might not understand the science behind prepping and why you need to apply products in exact accordance with instructions for use. For example, you must apply CHG preps in a multidirectional method so the positively charged CHG bonds with the negatively charged microbial cell membrane of the skin and penetrates the first 5 layers of the epidermis, says Ms. Hasnain.