To a surgeon, 30 or so seconds it takes to apply a skin prep can seem like a long time. The 3 minutes he must wait for the prep to dry before you can drape the patient? That must feel like an eternity. The surgeon understands that prepping must occur, but also likes to be time efficient, and may at times ask the OR team to drape earlier than the needed 3-minute wait time.
Of course, we all know that prepping the skin with an antiseptic agent before the first incision is an indispensable step in preventing surgical site infections. We also know it takes time. But the 30-second, back-and-forth friction scrub at the incision site is time well spent (plus, the longer you prep, the better you're able to reach the deeper skin layers). And waiting 3 minutes for an alcohol-based prep to dry before you drape not only helps prevent surgical fires, especially during electrosurgical cases. Equally important is that it is the amount of time that is required to reduce the bacterial load on the skin.
But there's more to prepping the skin than just taking your time. Technique is important, too. For example, you start a chlorhexidine gluconate scrub at the incision site and work your way out in concentric circles. Once you've moved to the periphery, you don't want to reverse your clean-to-dirty course and go back to the incision site, possibly spreading contaminants. Another tactical consideration: How many prepping sticks do you need to cover the body part you're prepping? You want neither too little (insufficient coverage) nor too much (pooling).
In late 2015, our frontline staff reported to us that we didn't always prep the site according to the prep manufacturer's recommendation. (The fact that our nurses were concerned enough to bring this to our attention is a testament to their commitment to safe patient care.) We also observed more and more breaches in proper prepping technique in our 8 ORs. Here's how we shored up the weaknesses in our prepping process.
Patience for our patients
A prepping vendor rep confirmed through an audit what we'd suspected: We were below the national average in prep time and dry time. You could broadly classify the culprits as a lack of education and pressure to go faster. We set out to educate our nurses to perform the surgical prep in the appropriate manner according to the manufacturer's recommendation and decrease the amount of observed inappropriate prepping.
Our reps conducted several on-site educational sessions on proper prepping technique and appropriate coverage area per applicator size. To demonstrate to our nurses how much surface area one stick of prep will cover, reps showed our team a laminated square that a single stick could cover. If the area you're prepping is larger — or if the patient is obese — you'll need a second stick to adequately cover that surface area. To illustrate when it would be appropriate to use a smaller prepping stick, the flip side of the card showed a smaller surface, as if you're prepping for a head and neck procedure. The lesson here: Don't let excess prep pool, and use tuck towels to catch excess prep.
Learning is good, but doing is better. Our nurses used their finger to simulate a prep on our vendor's iPad app. That really gave them the feel for good technique. When new nurses come on board, they go through an internship program and get the same in-service/orientation to prepping. We also reinforce proper technique during staff meetings and daily huddles. "Hey, remember dry time: You have to wait the full 3 minutes. If you have issues, come tell us."
Speaking of dry time, this is where you'll really have to hold your ground with your surgeons. It helps to drive home the point that you're risking a surgical fire if you don't wait the 3 minutes (or however long your prepping agent's dry time is). After we make our final swipe with the prep stick, we look at the clock on the wall and wait 3 minutes. Once your surgeons understand that you're serious and that they'll be held accountable for any breaches, dry time becomes an expectation. You won't have to fight that battle anymore.
But you can still expect pushback. A podiatric surgeon, for example, might tell you he doesn't have to worry about letting the prep dry because he's not going to use a Bovie. Little does he know (until you tell him!) that an electrical instrument such as a drill can spark a fire.
PREP IN PROGRESS
Nurses Wear Pink Gowns to Prep Patients
If you see a nurse wearing a pink gown in our ORs, you know she's there for one reason: to prep the patient. Wearing a different colored gown than what the surgical team wears signals that a critical process is at hand and that the people prepping are not members of the sterile field. The sterile pink gown also helps us prevent infection, as it fully covers the nurse's arms during the prep so that squamous epithelial cells do not fall into the sterile field
Stop the line!
If patient safety is in jeopardy, we want our nurses to say: "You need to stop. We need to make sure we're doing the right thing for the patient. We need clarity." Clarity is the password for Stop the line. In other words, let's stop and figure out if we're about to make a mistake.
One nurse had to stop the line in her room. Since he wasn't using a Bovie, the surgeon didn't understand why he had to wait for the prep to dry. Our director stopped his meeting to talk to the surgeon. He agreed he would wait the 3 minutes on his next case. The nurse felt supported and empowered to do what's right.
New processes are hard to sustain. As the saying goes, what gets measured gets done. Staff nurses perform monthly chart audits to verify we let the prep dry before draping. About 6 months in, we observed prepping practices in 14 random cases and were happy to see our nurses applied the prep from the incision out to the periphery and wore sterile gloves to prep every time. Ongoing education helps a new practice become a standard practice. You don't want staff to think "Oh, this is the flavor of the day. They're going to teach this today and something else tomorrow."
The next phase of our prepping project is to create a standardized prep chart for our facility — a table that lists the suggested skin prep and an alternative for each surgery we perform. We use alcohol-based chlorhexidine gluconate in about 85% of our cases and betadine scrub-and-paint when we can't use CHG (allergies, in open wounds or on any mucous membrane). OSM