No two of our orthopedic skin preps were the same. I know this because I observed the skin prep practices of our orthopedic surgery teams as part of a project to standardize our prepping practices. We'd scrub some patients before painting, but not all. Sometimes we'd wear gloves and use positioning devices and drapes, sometimes not. We'd use betadine on one patient, alcohol and iodine povacrylex on the next. Even who performed the prep varied, with the circulator, attending, scrub tech and fellow each taking a turn.

After gathering this data, I started looking for a fun way to present the not-so-standard practices that I saw in our hospital. I brought my video camera from home and wrote, produced and directed a short video. I enlisted surgical support staff as actors who portrayed a surgeon, patient and the circulator in the OR performing an orthopedic skin prep on a left arm. Using support staff in the video prevented finger pointing among the physicians, who might argue over which of them has the best skin prep methodology and who doesn't follow an established standard for prepping.

I showed my video to the chairman of the department of orthopedic surgery. To minimize resistance to change and encourage the use of a uniform skin prep method, he asked me to place information from the literature and evidence-based research next to the data from my study of our prepping practices. This made my presentation more persuasive. With evidence-based research, changing the way things are done in the OR becomes a no-brainer. Your payors also like it when they know you're using evidence-based practices.

After showing my video and data to the chairman, I got the results I'd hoped for. We were going to make another video, our own reality show. The orthopedic surgeons unanimously agreed to videotape a real patient being prepped (after securing proper consent) and then show the video to the entire orthopedic surgery team and perioperative staff. We'd later present the video to the OR nursing staff to clarify the need for clearer directions for the uniform orthopedic prep.

Our standard routine
Based on my research, here are the standards we now have for orthopedic skin preps:

• Pre-op scrubbing. Perform pre-op surgical hand scrub for at least 2 to 5 minutes using an appropriate antiseptic. Scrub the hands and forearms up to the elbows. Clean under fingernail before performing the first surgical hand scrub of the day.
• Clean and gowned before you begin. It had been common practice to involve an un-scrubbed, un-gowned leg holder. But this practice and the opening of instrument packs during skin preparation and draping places the patient at increased risk of indirect wound contamination. We now insist that a scrubbed and gowned member of the team hold the leg. And we only open instrument packs after we've prepped and draped the skin.
• Write it down. In addition to creating accountability, documenting surgical skin preparation can improve infection control follow-up.
• Take care of the patient's skin. The people prepping should be knowledgeable about the patient and skilled in skin prep techniques. Prepare the surgical site in a manner that preserves skin integrity and prevents injury. Prevent antiseptic agent pooling beneath the patient, pneumatic tourniquet cuffs, electrodes or electrosurgical unit dispersive pads to reduce the risk of chemical burns.
• Use the accepted standard products for prepping. When indicated, prepare the surgical site and surrounding area with an antiseptic agent that has a broad range of germicidal action. Use sterile supplies to do so. Base your choice on data from current research and manufacturers' literature. Adhere to the manufacturer's written instructions.
• Rub, don't dab. The use of sterile supplies alone won't reduce microbial counts and rebound microbial activity. Friction during the cleansing process and application of antimicrobial agents are the primary methods for removing soil and transient organisms. Data from one limited study suggests that a clean prep kit may be as effective as a sterile kit for disinfecting skin. Apply antiseptics that come with applicators with clean gloves per the manufacturers' written recommendations; no published data supports the use of clean as opposed to sterile gloves.
• Wash before you prep. The surgical site and surrounding areas should be clean, and the skin around the surgical site should be free of soil and debris. Removing superficial soil, debris and transient microbes before applying antiseptic agent(s) reduces the risk of wound contamination by decreasing the organic debris on the skin. Wash the surgical site immediately before you apply the antiseptic.

One-two punch
The video was effective because we'd observed actual cases and we were able to show the range of skin prep techniques the orthopedic surgeon group was using. We also supported the video with data. By simply comparing our data side by side with evidence-based research and established AORN standards, we were able to launch a collaborative initiative with a vendor and the infection control department to standardize orthopedic surgical skin prep practices in our organization. As a result, we've eliminated confusion. Everyone in the OR understands the rationale behind our new skin prep routine and we are delivering evidence-based quality care. And the video created such a buzz that we're working on a sequel. Stay tuned.