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A Preview of AORN's New Skin Prepping Guidelines
Let a growing body of evidence govern your bedside practice.
Sharon Van Wicklin
Publish Date: April 29, 2014   |  Tags:   Infection Prevention
colored antiseptics A SIGHT BETTER Evidence supports the use of colored antiseptics, both to ensure complete coverage of the surgical site and to reduce the risk of fire.

Wouldn't it be great to say with 100% certainty exactly which skin preps and practices are going to do the best job of preventing surgical site infections? While that might not always be possible, there's plenty of strong evidence and evidence-based recommendations on which to base your prepping practices. Let's look at the strength and quality of each piece of evidence, along with how they relate to bedside practices, based on new prepping guidelines AORN is scheduled to release in July.

Pre-op showering
The evidence is strong that pre-operative bathing or showering is an effective way to reduce skin flora and that the benefits outweigh the harms (such as possible skin irritation or allergic reactions). Although it's intuitive to suggest that reducing transient and resident microorganisms on the skin reduces the risk that a patient will develop an SSI, there's not enough research to say that for certain.

Nor is there enough strong evidence to say that any one antiseptic is more effective than another for preventing SSIs. We do know that alcohol-based antiseptics may be more effective than those that are water-based, but other than that, the evidence doesn't clearly favor one over another. In fact, a Cochrane review of 13 randomized control trials concluded that the evidence for skin antiseptics is lacking quality, and that no conclusion could be reached as to which is the most effective skin antiseptic. That's not to say that it's impossible that one is more effective than another, but it's an unresolved issue that warrants further research.

As for the ideal number of pre-operative baths or showers, here, too, the evidence is lacking. Until more evidence becomes available, AORN will continue to recommend that patients be instructed to bathe or shower with either soap or a skin antiseptic on the night before or day of surgery. The bulk of available evidence suggests that using 2% chlorhexidine-impregnated wipes is an effective practice, but we also hope to see more high-quality research to confirm that.

Hair removal
The evidence in favor of leaving hair in place at the surgical site is strong. In one landmark study of nearly 24,000 surgical wounds, researchers found that patients who were shaved with a razor had a 2.3% infection rate, patients who had hair clipped had a 1.7% infection rate and those whose hair was left in place had a 0.9% infection rate (tinyurl.com/pvda346).

That and other studies also provide strong evidence that in those instances where hair needs to be removed, it should be done either with clippers or a depilatory method, though there's no evidence to suggest that one should be favored over the other.

We do see strong evidence that clipper heads should be single-use and disposed of after each patient and that clipper handles should be disinfected after each use. Likewise, with depilatories, strong evidence supports testing skin for allergies or other irritation in an area away from the surgical site at least 24 hours before it's to be applied at the surgical site.

Following instructions
One would expect the manufacturers of the various antiseptics to be the experts as far as their own products are concerned, and reasonably strong evidence supports that notion. Strictly adhering to their recommendations is the best way to prevent patient harm in the form of fire, chemical injury or inadequate antisepsis.

Evidence also supports the importance of following their recommendations for handling, storing and disposing of the product. Also important are FDA recommendations that products be purchased in single-use containers and that antiseptic solutions not be diluted.

Evidence and common sense tell us that it's wise for perioperative team members to confirm the surgical site before the time out and before they apply any antiseptic, as failure to do so can set off a cascade of events leading to wrong-site surgery. There's also some evidence that using colored antiseptics results in fewer missed spots. Additionally, clear antiseptics may result in an increased fire hazard, if unseen solution drips or pools near the patient.

8 Prepping Keys Backed by Overwhelming Evidence

follow manufacturers' instructions DON'T GET BURNED Following manufacturers' instructions is crucial, including allowing enough time for flammable antiseptics to dry.

AORN's new skin prepping guidelines will be available for purchase online in July and published in the 2015 edition of Perioperative Standards and Recommended Practices. They include extensive, systematic and recent analysis of evidence related to patient skin preparation, which turned up hundreds of published articles, of which 168 are cited. These are the included recommendations and practices supported by the strongest possible levels of evidence:

  • Patients should bathe or shower with either soap or a skin antiseptic on the night before or the day of surgery.
  • Whenever possible, leave hair at the surgical site in place.
  • When hair at the surgical site has to be removed, use clipping or depilatory methods.
  • Use single-use clipper heads and dispose of them after each patient use. Disinfect reusable clipper handles after each use.
  • When using depilatories, first test the skin for allergy and irritation reactions in an area away from the surgical site.
  • Items touching the patient's skin after skin antisepsis should be sterile.
  • Give flammable skin antiseptics adequate time to dry completely and let any fumes dissipate before you apply surgical drapes or use a potential ignition source.
  • Perioperative team members should communicate that flammable skin antiseptics have been used as part of the fire-risk assessment before beginning a surgical procedure.

— Jim Burger

leave hair in place CLIP, DON'T SHAVE The best option is to leave hair in place at the surgical site. But if you can't, be sure to use either clippers or a depilatory.

Product selection
There are significant variables to consider when selecting skin preps, and the best evidence suggests that such decisions should be made by multidisciplinary teams that include perioperative RNs, physicians and infection-prevention specialists.

For example, CHG shouldn't be used in the ears or near the eyes, and although the American Congress of Obstetricians and Gynecologists recommends the off-label use of 4% CHG as a safe and effective alternative for vaginal preparation when povidone-iodine is contraindicated, manufacturers recommend against using it in the genital area. At the same time, povidone-iodine can be problematic for patients with thyroid issues. So a facility that's doing primarily one type of procedure on a specific patient population might profit from standardizing its approach and using only 1 or 2 skin-prep solutions, but another facility might need a variety of products to meet all the needs of a diverse patient population. Input from team members can be very helpful in reviewing research, clinical guidelines and literature published by manufacturers.

Clinical confidence
The new AORN Recommended Practices for Preoperative Patient Skin Antisepsis cite 168 sources. Perioperative RNs should feel confident when they follow the guidelines, knowing that they're not only evidence-based, but also based on a through search and appraisal of the literature, and a careful rating of the collective body of evidence applied to each recommendation.