Proper Skin Prep Reminders

There’s never a wrong time to review processes that prepare the patient’s skin for surgery.

At first blush, skin prep seems like a relatively straightforward process where nothing could go wrong. If compliance with proper practices are lacking, however, problems can propagate over time. And that’s a big problem, because this portion of the episode of care is, in fact, one of the most important tools to reduce surgical site infections (SSIs).

“Skin prep is where you get the biggest bang for your buck as far as preventing SSIs,” notes Benjamin Galvan, MPH, MLS(ASCP), CIC, CPH, infection prevention director at HCA Florida Brandon Hospital.

When a patient is planned for surgery, they’re usually told to shower ahead of time with chlorhexidine gluconate (CHG) for multiple days, says Mr. Galvan. The number of days depends on the type of surgery and the surgeon’s preferences. Regardless of the surgeon’s preference, however, it’s the patients you need to worry about.

Patients’ role in prep

Surgical patients need to understand what they are instructed to do at home regarding their role in skin antisepsis — and then follow those instructions. Sometimes that requires refocusing or retooling patient education. Nurse Manager Racquel Swaby, BSN, BN, CPAN, told Outpatient Surgery Magazine about her former facility’s efforts to bolster patient education and ensure individuals coming in for surgery complied with their at-home skin-prepping requirements.

“We wanted to make sure that every patient was given clear information, based on their procedures, about what they needed to do for skin antisepsis,” says Ms. Swaby.

Specifically, information on whether the surgical procedure warranted CHG cleansing at home on the days leading up to surgery was included in information packets given to patients when their cases were scheduled. The facility paired the beefed-up patient education with a pre-op skin prep assessment tool it developed that allowed nurses use to document what they discovered in the pre-op phase. “We worked with our informatics partners to develop a tool that nurses could use to enter information directly into our EMR,” says Ms. Swaby.

With that combination, the facility was able to track whether the surgical team was compliant with best prepping practices and identify staff members who needed extra education on ensuring patients’ skin is properly treated before surgery.

Essentially, CHG baths are intended to remove as much bacteria as possible off the patient’s skin. Even better, CHG’s effects are persistent, with the agent continuing to kill bacteria after its application. That lowers the amount of bacteria on the patient’s skin in advance of their arrival for surgery. As a final precaution on the day of surgery, pre-op nurses use CHG wipes to coat the patient’s skin before they are rolled into the OR.

Another vital component of skin-related SSI prevention is preoperative antibiotic selection, says Mr. Galvan. Depending on the type of surgery, patients are infused with some type of prophylactic antibiotic. While each type has its own specific guidelines to follow, the antibiotic is generally administered 30 to 60 minutes before incision to ensure it gets in the blood and perfuses into the tissue at the surgical site.

Once in the OR, the next stage of skin prep begins. An alcohol- or CHG-based product is scrubbed into the surgical site to further drive the bacteria level down. “The most important thing to focus on is how the prepping is taking place,” says Mr. Galvan. “Go from cleanest to dirtiest with your single scrub so you don’t pull bacteria from outside of the incision point into the incision point. Start at the incision point and go circumferentially out from the site.”

Providers must make sure to scrub for the appropriate amount of time. The product’s instructions will describe the proper duration of that scrub, as well as how long it needs to stay wet for maximum efficacy in actively killing the bacteria it claims to kill.

Quality control is vital for this activity. An infection preventionist should observe all phases of the skin prepping process to identify opportunities for improvement, from the technique of the scrubbing to ensuring the right amount of product is being used, and ensure that providers are adhering to recommended dry times.

There’s also a fire safety concern that must be observed. Because certain types of applications, particularly alcohol-based ones, are flammable, leaving too much of these products on the skin can increase the chances of an OR fire.

Experts recommend that providers avoid cutting body hair unless absolutely necessary for the procedure. If it must be done, it should be done outside of the OR. Shaving body hair should be avoided when not absolutely necessary because it can result in micro tears of the skin that harm its integrity and increase the risk of infection.

It starts at home

APEX FACTOR Reducing the patient’s own bacteria is at least as important as reducing it from OR surfaces.

“The most important ingredient in the skin prep process is to realize it doesn’t start the day of surgery,” says Frank Edward Myers III, M.A., CIC, FAPIC, director of infection prevention and clinical epidemiology at UC San Diego Health. “We’ve found that doing three CHG baths before the patient arrives at the facility reduces SSIs significantly.”

That even applies to colon surgeries, which Mr. Myers did not anticipate. “We didn’t think CHG prep would make a difference because we thought most of the infections were probably coming from the intestinal tract rather than from the exterior,” says Mr. Myers. “We found it did make a difference in those outcomes.”

Ultimately, says Mr. Myers, skin preparation for surgery is not a minor SSI prevention intervention but, in fact, possibly the most fundamental one. “A good skin prep is more important than reducing the number of bacteria in the surgical environment,” he says. “The patient’s own flora and fauna are far more likely to cause an SSI than the bacteria in the OR.”

Breaking down CHG vs. povidone-iodine

“My interpretation of the data is that CHG preps tend to be more effective, in part because of their persistence,” says Mr. Myers. “And of course things like (povidone-iodine) are deactivated in the presence of blood.” That said, CHG prep has limitations, including the potential for damage if it comes into contact with the patient’s eyes, so it’s generally not used on patients’ faces. It’s also important that CHG not get into an open wound, because it kills cells that should be kept alive.

Because there are different techniques for different agents, every provider at the facility must be made aware when a facility switches skin prep products, says Mr. Myers. Limiting the options is helpful. “I think the standardization of any process always increases compliance and always increases the likelihood that things are done correctly and to the expectation of the surgeon,” he says. OSM