Standardize Your Skin Prepping Practices

Imagine working in a facility where 50 orthopedic surgeons have their own unique skin prepping protocols. Factor in 20 nurses who are trying to support the variations in prepping each of these surgeons brings to the OR and that’s asking for problems, says Khaled J. Saleh, MD, MPH, MHCM, FRCS(C), CPD, the CEO of Saleh Medical Innovations Consulting and Sphere Orthopaedics & Regenerative Health.

“The risk of error increases significantly when there’s a great amount of variation in technique,” says Dr. Saleh, who also serves as executive director of EPIC Health System Advanced Multispecialty League, is a clinical professor of surgery at Michigan State University and an attending surgeon and section chief at the Surgical Outcomes Research Institute VAMC.

“Error is the threat to successful surgery. You have to have a standardized system in place to minimize variation.”

A standardized system is an imperative with a process like skin prepping, in which rampant variation can exist in everything from training to solutions to application technique.

Every solution includes its own specific manufacturers’ instruction for use (IFU). If you’re serious about reducing variation in your skin prepping practices and the expense of buying solutions from several manufacturers, look to scale back on the number of skin prep solutions your facility uses. “I always tell administrators they’ve got to limit the choices to four or five at the most,” says Dr. Saleh.

But if you’re going to ask surgeons to do away with the prepping solutions and protocols to which they’re accustomed, you need to do it the right way.

“Surgeons are driven by numbers and data,” says Jesse Hixson, MSN, RN, CNOR, director of nursing at Allegheny Health Network in Monroeville, Pa.

“You have to show them the current cost per case and what the cost per case is likely to be after the changes to the prepping protocols are made.”

Mr. Hixson approached surgeon leaders with a proposal to standardize the prepping and draping material at his facility, so that everything was incorporated into a customized pack. The streamlined and standardized approach was trialed within the orthopedics service line.

While the surgeons did have to make some sacrifices for the greater good, they were happy with the results of the standardization in terms of cost containment, efficiency and efficacy, says Mr. Hixson. The small test run had a domino effect with other specialties. In the end, the facility reduced their main skin prep solutions to just three, plus a povidone-iodine prep for ophthalmic cases.

Dr. Saleh was able to reduce the number of prepping products a facility stocked by teaming up with administration to look at the clinical and business cases for each. Surgeons had to list the Strengths, Weaknesses, Opportunities and Threats (SWOT) associated with their products of choice. The analysis revealed two dozen products were being used for prepping, so a meeting was held to focus on the essential products they planned to keep. Then, administration came in with critical information in terms of pricing, supply availability and the ever-important customer service component.

“If a product’s vendor will instruct my team on exactly how to use a prepping solution according to its IFUs, provide regular teaching support and pick up the phone whenever we call, that’s going to have significant play in terms of my decision,” says Dr. Saleh.

Limiting your choices of prepping solutions will cut down on variations in application requirements, but you still need to be vigilant to prevent poor prep. “You have to keep entering the OR and conducting blind audits,” says Mr. Hixson. “If you’re not constantly critiquing staff, they get lax in their practice.”

During audits, make sure staff follow these basic skin prepping practices:

• Proper application. Have a clear understanding of how each prepping solution needs to be applied. For example, when performing a chlorhexidine gluconate prep, start at the incision site and work out in concentric circles. Don’t reverse direction once you move away from the site. “Some clinicians have a tendency to [go back] into the area they just prepped,” says Mr. Hixson. “Explain to them that moving from a dirty to clean area can contaminate the area around the surgical site.”
• Adequate coverage. Properly assess the patient prior to prepping with a focus on the size of the extremities. When using CHG application sticks, don’t assume the same number of sticks will work for each patient. “Prepping a former football player for a shoulder arthroscopy will require more solution than what’s needed for a 70-year-old woman,” says Mr. Hixson.

That seems obvious, but he’s seen a lot of nurses try to stretch the contents of a single applicator instead of reaching for another one because they didn’t properly account for differences in body types. That shouldn’t happen. Always use the amount of prepping solution needed to adequately cover the area around the surgical site.

• Avoid shortcuts. In the heat of the moment or when pressed for time, staff might engage in seemingly harmless workarounds that could jeopardize patients. A nurse who is prepping the abdomen might reach across the patient, instead of walking around the table, without realizing their scrubs are contaminating the prep site.

Mr. Hixson says proper and effective skin prepping is ultimately about eliminating variables, streamlining the process wherever possible and getting everybody on the same page to maintain a laser-focus on proper patient care. “Everyone in the OR has the same intention,” says Dr. Saleh.

“Nobody wants infections to occur in their patients.”

Standardizing your prepping products and protocols will help them meet that universal goal. OSM