A Clearer Protocol: Streamlining Skin Prep for Safer Surgery

Selecting the right prep is just the beginning — standardization is the key.

Failure to prioritize the prevention of surgical site infections (SSIs) may result in your facility incurring hundreds of thousands of dollars in costs. Treatment of SSIs is not only time-consuming and costly, but can be deadly for the patient.

According to the CDC, approximately 100,000 SSIs occur annually, costing on average $3,300 more per patient to treat after discharge than a patient who does not incur an SSI.

This number does not yet reflect procedures performed in an outpatient setting, as the CDC reporting system has only recently been updated to include an ability to report an SSI with an outpatient procedure component. However, with the trend of increasing volume in outpatient surgical procedures, we can assume a greater majority of SSIs will be reported with an outpatient procedure component.

Proper skin prep is the first line of defense against SSIs, especially in outpatient settings where high volume meets high expectations. Standardization of your skin prep practices can help improve outcomes, prevent variability and streamline your SSI prevention process.

“By standardizing the process for preoperative skin preparation, there is less variability among the surgical team members,” says Marianne McAuliffe, DNP, RN, CPAN, nurse manager at Boston Out-Patient Surgical Suites in Waltham, Mass.

How to standardize

PREPPED FOR SUCCESS Consistent education on efficient skin prep across surgical teams is the key to success.

The building of policies and procedures around the standardization of skin preparation should be a team effort. Unfortunately, however, the choice of skin prep product often falls to the surgeon. While surgeons should certainly be involved in the discussion, a facility-wide policy takes the guesswork out of how to properly prep the patient. Standardization starts by knowing the research behind the recommendations from organizations like the CDC, the World Health Organization (WHO), and the National Institutes of Health (NIH).

• Bathing. CDC recommends that every patient shower or bathe with soap at least the day before surgery. The research has proven bathing to be a highly effective, cost-conscious and simple SSI prevention strategy.

The soap does not need to be antimicrobial to be effective. Non-antimicrobial soaps work just as well in preventing SSIs as chlorhexidine gluconate (CHG) soap and other antibacterial washes.

Bathing can be recommended to pediatric patients, a population that cannot always tolerate the use of antiseptics such as CHG, as well as populations with surgical sites that are sensitive, such as mucosal membranes. In areas where antimicrobial solutions are contraindicated, it is useful to know that non-antimicrobial soap is equally effective at preventing SSIs.

• CHG wipes. While the use of these wipes is common, the CDC does not recommend their routine use. CHG wipes are high-waste, single-use items, and the research on their effectiveness remains mixed. For facilities serving under-resourced communities, adopting CHG wipes as a standard protocol may not be practical. CHG wipes are often utilized as an extra layer of protection against high infection-risk surgeries, such as those involving surgical implants and abdominal surgeries. Leadership should take all factors into consideration when deciding if CHG wipes are right for their facility.

• Hair clipping. This is a standard of prep before many surgeries. Hair should only be removed when necessary, however, as any excessive hair removal can cause skin trauma.

Instruct patients to avoid hair removal at home to minimize the risk of microabrasions and the introduction of bacteria from unsanitized tools. Hair should be removed outside of the operating room or procedure room when possible to reduce the risk of stray hairs ending up in the surgical incision. When hair needs to be removed in the OR or procedure room, ultilize a vacuum device or wet clipping system.

• CHG vs. iodophor vs. alcohol. The current recommendations from the WHO, CDC and NIH are to use an alcohol-based skin prep in the operating room prior to surgery. CHG in an alcohol-based formula is the first choice for broad-spectrum antiseptic surgical skin prep, as it is highly effective against a variety of organisms.

If a patient is allergic to CHG, or if CHG is contraindicated for that population or surgical area, then an iodophor (stabilized iodine) — most commonly povidone-iodine with an alcohol base — is the next preferred skin prep.

If a patient has a sensitivity to alcohol, an aqueous-based solution can be used that contains CHG or an iodophor, although these solutions are proven to be less effective. While alcohol alone is fast-acting and broad-spectrum, it requires a long dry time and does not have the residual antimicrobial effect that combination agents have, making it the least ideal skin prep solution to use.

Educating your staff on why certain products are chosen and the research behind them can empower them to use products appropriately and consistently. Remember to utilize your vendors for help maintaining staff education, up-to-date regulations, standardization of care and advice on reaction treatments.

Trial and compare products

Each type of skin prep comes in multiple forms, including pre-saturated swab sticks, wipes/towelettes and pour bottles. Using a multidisciplinary approach, your facility should trial different products in different forms and collect feedback on preferences. Depending on the types of surgeries performed at your facility, certain formulations and formats may work better than others.

Pay attention to criteria such as ease of use, dry time, drape adhesion, flammability risk and skin compatibility in your evaluation tool. Extra emphasis should be placed on feedback received from end users such as OR nurses, scrub techs and those surgeons who like to prep their patients themselves. Practical user experience feedback may include storage and shelf life, packaging types, low-waste impact and time of application.

“With all of the shortages affecting medical products, consistency of availability should be considered as well,” says Dr. McAuliffe. “Pricing, of course, is part of the process, and even carefully considering reviews on social media may be a quick way to consider feedback on a specific product.”

Create a standardized protocol

Using a combination of the results of the product trials and evidence-based practices from leading governing bodies, leaders must implement protocols. Set up a clear set of standards for your facility to help take the guesswork out of which product will be used for each surgical prep.

Education should expand outside of the OR to pre-op nurses, as they can educate patients prior to surgery. This is especially helpful in the patient population that has experienced a reaction in the past and may have questions regarding which skin prep will be used this time.

Skin prep products should be chosen based on what works at your facility. Paring down the options can help eliminate variability. The products should be organized based on surgery types.

For example, all surgeries can be prepped with an alcohol-based CHG solution unless the patient is a pediatric patient, allergic to the solution, or is having surgery where the solution could come into contact with the eyes, ears and other mucosal membranes. In these cases, an alcohol-based povidone-iodine solution should be used. Making the policy concise with a step-by-step algorithm can help streamline your skin prep system.

“Skin prep products should be chosen based on what works at your facility.”

Standardized patient education for preoperative washing should be a priority. Make it clear, concise and accessible to individuals at all reading levels. Instructions should explain when to bathe or shower using regular or antimicrobial soap, emphasize the importance of avoiding hair removal at home and advise patients not to apply any creams, lotions or oils after washing. If a CHG solution is prescribed, patients should receive specific guidance on how to use it properly. They should also be informed that certain products such as shampoo, conditioner or body lotion can interfere with CHG’s effectiveness and should be avoided. SSI prevention practices should be standardized across the surgical team.

Collaborate with surgeons, nursing staff and leadership to create a unified patient education strategy that reflects both evidence-based guidelines and facility policy.

Triaging a potential reaction in the skin prep protocol can increase patient satisfaction and timely management of skin irritation. Post-op phone calls are a helpful way to ensure recovery at home is going well for patients, and it is essential that triage advice be consistent across staff members and aligned with policy. Whether the reaction happens in the facility or during recovery at home, your staff should be educated on the steps to take when a patient complains of skin irritation from the skin prep solution. Vendors should be able to assist in best practices for their particular products.

Reevaluate regularly

Along with standardization, facilities should have an easy way to track compliance with skin prep protocols. Nursing should be able to easily document if and when patients perform pre-op bathing with or without CHG or antibacterial soap. Collecting this data can help continually improve policies.

Periodic protocol review should be done at least annually. Vendors can provide excellent support by supplying staff education about changes in product formulations and updated clinical recommendations.

If an SSI does arise, it’s important to show the prevention efforts that were made. Knowing if something in the prevention pathway is not working can help leaders determine where improvements are needed. The data can be used to show that your facility is using the best evidence-based practices to prevent SSIs and why your facility is an excellent choice for surgeons and patients regarding patient safety.

Choosing the right skin prep product is a critical step to protect patients and streamline workflows. By thoughtfully evaluating products based on clinical performance, ease of use and compatibility with evidence-based regulatory recommendations, ASCs can help prevent SSIs. Standardization simplifies staff training, ensures compliance, supports operational efficiency and improves patient satisfaction. OSM