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Infection Prevention
How Long Should You Scrub Before You Prep?
Dan Mayworm
Publish Date: October 10, 2007   |  Tags:   Infection Prevention

Dan Mayworm Q I'm trying to re-write our policy and procedure on surgical scrubs for patient skin prepping to include how long we should scrub with povidone-iodine scrub solution before switching to the P-I prep solution. I've found literature that states how long you should scrub hands before gowning and gloving, but I can't find anything to support how long you should scrub the patient's skin before painting it with the P-I prep. Please help.

Dan Mayworm\ A The CDC's Guideline for the Prevention of Surgical Site Infection (writeOutLink("www.cdc.gov/ncidod/hip/SSI/SSI_guideline.htm",1)) and page 339 of the 2003 edition of the AORN's Standards, Recommended Practices and Guidelines are thorough, comprehensive resources. However, neither lists time frames because of the variability of the choices of agents.

Berry and Kohns, Ninth Edition1, states: "The recommended minimum time [for scrubbing] may be two to five minutes, but consideration should be given to the extent of the area being prepped."

I'd like to point out that there is a shorter way, time-wise, of approaching skin prep. Depending on the product, such as a film-forming iodophor prep, you may be looking at a 30-second paint.

A study published in the December 2001 American Journal of Infection Control2, found that "one-step, film-forming iodophor preparation is as effective as a povidone-iodine scrub and application of solution used in the traditional two-step process." Read more at writeOutLink("www.apic.org/ajic",1). You can also check out the CDC SSI guidelines for alternate methods.

My best suggestion, though, is to call the manufacturer of your P-I products. Contact the technical (not sales or marketing) department and insist on getting an answer in writing on how to properly use the product. If necessary, go to the president of the company.

Q Our ASC is used mostly for pre-op staging of same-day surgical patients and their Stage 2 PACU before discharge. We also use this area, which has four patient areas separated only by curtains, for giving injections (for example, epogen) and transfusions for outpatients, and for administering IV therapy to outpatients. Our manager is concerned because some patients receiving transfusions are oncology patients with lowered immune resistance. Is it OK for potentially infectious patients to receive antibiotic therapy in the same area as day-surgery patients?

A Your problem is that your manager thinks you need to separate "clean" and "dirty" with regard to different stages of patient immunity and susceptibilities. The Universal Precautions (UP) and the CDC isolation guidelines were established to deal with these types of situations and are based on the theory that all patients are uniformly susceptible to infections. To wit, the UP's introduction says it emphasizes, "applying Blood and Body Fluid Precautions universally to all persons regardless of their presumed infection status."

If you follow these precautions with all patients (all facilities should), there shouldn't be any real issue of patient-to-patient infection.

Unsterilized Hip Reamer Forces Recall of Patients

Nearly 1,150 hip-surgery patients in Quebec will be tested for hepatitis and HIV after an acetabular reamer was improperly sterilized at 12 hospitals, according to the provincial Health Department. A department spokeswoman says the recall could be expanded as the province continues its investigation into the handling of the instrument used during hip-replacement surgery.

The problem first came to light in January when a hospital employee discovered the instrument could be taken apart and cleaned more thoroughly. The surgical drill has a cheese-grater-like ball at the end that is used to grind the hip cavity so the hip ball can fit in to it. Techs failed to disassemble a small metal collar on the shaft of the reamer before they sterilized it, apparently not realizing it was removable or that debris may be hidden under the moveable ring. "We washed and sterilized it without separating it," says Sheila Moore, the director of public relations and communications at Montreal General Hospital, which is recalling 179 hip replacement patients. "There may be a risk of contamination if it's sterilized as one part. But our microbiologists tell us that the risk is very minimal."

"The chances are incredibly small that anyone was hurt in any way by this," says Brian Ward, a microbiologist at the hospital. "Even if it was not completely sterilized, the risks involved in using this instrument are minimal." Since March, the instrument in question is being properly sterilized, says Mr. Ward.

- Dan O'Connor

  • Wash your hands. Do so after contact with blood, body fluids, secretions, excretions and contaminated items, regardless of whether gloves are worn, according to the UP.
  • Wear gloves. Gloves provide a protective barrier, prevent cross-contamination and reduce transmission of microbes from healthcare workers' hands to patients.
  • Handle with care. Handle used, soiled patient-care equipment (anything that comes in contact with a patient, including IVs, linens and blood-pressure cuffs) so as to avoid contact with patients; such equipment should be either reprocessed according to accepted methods before the next use or disposed of properly.
  • Clean well. Routinely clean and disinfect all surfaces, especially the beds, chairs and other surfaces touched often by patients.
  • Implement safety sharps and techniques. Preventing potential injuries helps prevent potential resultant infections.
  • Use common sense. If a patient is contaminating the environment (for example, with bodily fluids), can't help by following simple infection control practices (for example, a pediatric patient) or has a highly transmissible microorganism, find a separate room for him.
  • Protect patients in transport. When moving a patient to another room, issue him barrier protection (such as a mask) to avoid his infecting staff and other patients he may come into contact with during the move, which should be as direct a route as possible.
  • Issue gowns, masks and eye protection. Wear these to protect you from potential infection (and therefore potentially infecting patients) and remove soiled protective wear as soon as possible.

References
1. Fortunato, N. Berry and Kohn's Operating Room Technique, Ninth Edition. Mosby; 2000:506-7.
2. Jeng, David K. "A new, water-resistant, film-forming, 30-second, one-step application iodophor preoperative skin preparation." Am J Infect Control 2001;29:370-6.

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