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Surgical Skin Antisepsis Done Right
10 tips for ensuring that patients begin their surgical procedure with an aseptic surgical site.
Dan O'Connor
Publish Date: January 9, 2017   |  Tags:   Infection Prevention
basis for preventing surgical site infections SCRUB AND PAINT The fundamental basis for preventing surgical site infections is the antiseptic preparation of the skin at the surgical site.

So devoted was a spine surgeon to his skin prep that he was moved to say: "You can cheat on your spouse, but you can't cheat on your 6-minute prep." Don't misunderstand. He brought up infidelity only to show how faithful he was to his prep.

"He was very particular," says Margaret Sherman, RN, BSN, clinical director of the Hamilton (N.J.) Endoscopy & Surgery Center. "Six minutes of scrubbing and prepping: That's how he was taught."

Couple that with the surgeon's superstitious streak and the fact that he'd never had an infection with his 6-minute prep and, yes, you guessed it, that spine surgery was wed to his prep.

"Every surgeon has his preference and it rarely changes," says Ms. Sherman. "It's a waste of time, effort and money to try."

Skin prepping is hardly complex, but it is by no means a simple process. There's a right way — and there are many wrong ways — to safely prepare your patient's skin. As Sheila Tesiny, RN, CNOR, the clinical coordinator of outpatient surgery at Henry Mayo Newhall Hospital in Valencia Calif., says, "The prep is the start to a successful case. Never underestimate the importance of it." As you'll see in these 10 tips, there's more to safe prepping than starting at the incision site and spiraling outward.

1. Don't assume your nurses know the proper application technique. Review prep manufacturers' directions and compare them to what's actually being performed in the ORs. If necessary, conduct in-service training to ensure consistent technique in all cases. "You'd be surprised at how many variations people put into their own practices," says Jesse Hixson, MSN, RN, CNOR, an OR manager at West Virginia University Health Care. "If someone has bad technique, they're bringing a breach in sterility to the surgical table."

gloves and long sleeves PROPER ATTIRE Don gloves and wear long sleeves when applying a prep.

2. Don't default to a circular motion. A circular application has traditionally been recommended for a povidone-iodine paint, moving from clean to dirty. Chlor-hexidine gluconate (CHG) formulations require a back-and-forth scrubbing motion over the site, starting at the least contaminated area and moving to the most contaminated. One iodine-alcohol product recommends a single-stroke motion to cover the site, not a back-and-forth one, before letting the solution dry completely. When prepping an incision site that is more highly contaminated than the surrounding skin (anus, axilla or open wound, for example), prep the area of lower bacterial contamination first and then the areas of higher contamination, says AORN. Regardless of technique, apply the prep in an area that is large enough to allow for an extension of the incision, additional incisions, drain placement or shifting of the drapes, says AORN.

3. Don't wing it. When you stray from antiseptic manufacturers' instructions for use, you compromise the prep's effectiveness. For example, don't dilute antiseptic products after opening them.

4. Ensure prep dry time. Let the antiseptic solution dry for the full time recommended by the manufacturer. Draping sooner than that minimizes the effectiveness of the prep and risks OR fires from not having a dry prep. But waiting the 3 minutes it takes for most alcohol-based skin preps to dry can seem like an eternity to an anxious surgeon who's ready to drape the patient and begin the case. One solution: Place store-bought timers in each OR and magnetically attach them to your whiteboards. "We set the timers for 3 minutes. We prep the patient, start the timer and then perform the time out. The rule is that you can't drape the patient until the timer goes off," says Heather Schimmers, RN, BSN, of Mercy Medical Center in Oshkosh, Wis.

5. Dress the part. What to wear when prepping the skin? Don sterile gloves (you may wear nonsterile gloves if the antiseptic applicator is long enough to prevent your hand from touching the solution or the patient's skin), says AORN. Wear a long-sleeved scrub top or jacket to cover your arms while prepping. Wearing long-sleeved attire helps contain skin squames shed from bare arms, says AORN.

6. Don't remove hair. Don't remove the patient's hair at the surgical site — unless the hair interferes with the procedure, says AORN. When you remove hair, there's the potential for trauma to the skin, increasing the risk for an SSI. If hair removal is necessary for the procedure, remove it by using a clipper or a depilatory, outside of the OR or procedure area.

7. Prevent fires. Yes, "a messy prep is a good prep!" as Tara Flanagan, RN, director of nursing at the Ardmore (Okla.) Regional Surgery Center, points out, but don't let flammable skin antiseptics pool or soak into linens or the patient's hair. Communicate use of flammable skin antiseptics as part of the fire risk assessment involving the entire perioperative team before beginning a surgical procedure.

8. Keep it clean. To protect patients from invariable dripping and staining when using prep solutions in hand-held applicators, use cloth towels or chux pads to cover linens, gowns, tourniquets and the patient's hair, says Anthony Pierini, RN, charge nurse at Clark Fork Valley Hospital in Plains, Mont. "After prepping, ensure that towels are removed without contaminating the sterile field," he adds. Also protect electrodes and tourniquets from the dripping or pooling of skin antiseptics beneath and around the patient, says AORN.

9. Prevent skin irritation. Remove the antiseptic from the patient's skin following the procedure (unless otherwise indicated by the manufacturer's instructions), says AORN.

"The prep is the start to a successful case. Never underestimate the importance of it."

10. Pick the right prep. The clinical debate over the effectiveness of different antiseptic solutions continues, with neither the Centers for Disease Control and Prevention nor AORN definitively recommending CHG or povidone-iodine products for all cases. How do you determine the appropriate prepping agent? By the surgical site location (different skin-prepping agents are intended for different parts of the anatomy), the prep's effectiveness against SSI risks and patient sensitivities, among other factors.

Variability is the enemy of standardization
The literature is filled with evidence that says you should standardize your skin prep, both the solution you use and the technique you use to apply it. If you don't have a uniform process, you could be introducing infection. The thinking goes: When you standardize, you simplify and enhance protocol compliance and therefore solidify your surgical site infection prevention efforts.

Easier said than done, right? Many surgeons have very strong feelings about skin preps. Like the doc at Volunteer Community Hospital in Martin, Tenn., who'd berate the RN circulator for using the newfangled wand-type scrub instead of old-school betadine, his prep of choice.

"He wanted his own prep, his own way, and he was mad she wouldn't change for him," says Mike Morel, CRNA, the hospital's director of anesthesia services. "He always had a problem with the prep: the length of the prep and letting it dry completely before he started."

Mr. Morel politely informed the surgeon, who's no longer operating at the hospital, of 3 things. First, the scrub nurse doesn't decide which prep to use; she was following hospital protocol. Second, the hospital abides by AORN antisepsis guidelines. And third, it's not feasible to let every surgeon on staff pick his favorite prep — there's no way the circulator who preps patients can keep all of their orders and requested methods straight.

Mr. Morel's advice? Stick to your guns. "Follow the evidence-based standards and guidelines no matter what the surgeon says." OSM

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