Skin Prepping Done Right

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Implement standardized protocols based on best practices to prevent wound contamination.


Last May, the Association of periOperative Registered Nurses (AORN) revised its guideline for patient skin antisepsis to provide evidence-based practices that reduce the risk of surgical site infections (SSIs). Karen deKay, MSN, RN, CNOR, CIC, a senior perioperative practice specialist at AORN in Denver and lead author of the updated guideline, says surgical nurses can work closely with an interdisciplinary team of providers to apply the latest recommendations. Here are several that deserve your attention.

Decolonization. Staphylococcus aureus (S. aureus) colonizes the skin and nares of about 30% of the general patient population, according to the guideline. Facilities can decide to implement universal decolonization, which involves treating all patients with interventions such as nasal decolonization and bathing with chlorhexidine gluconate (CHG) before surgery. This method avoids the time and resources needed to screen every patient and ensures carriers of S. aureus are treated. However, it raises concerns of patients developing a resistance to the decolonizing agents and increases the costs associated with prescribing the treatments to all patients.

A targeted approach involves screening all patients before surgery and treating only carriers of S. aureus. This practice decreases the risk of resistance to decolonizing agents and optimizes the use of prophylactic antimicrobial treatments. However, screening and surveillance before surgery increase the overall cost of care and could miss patients who are carriers at other body sites.

AORN’s guideline suggests that a blended method involving universal decolonization for high-risk cases in the ambulatory setting — orthopedic, urologic, neurologic, cardiovascular and general surgeries — and targeted decolonization for other procedures might be the most practical approach.

“There’s not enough clinical evidence to support decolonizing all patients,” says Ms. deKay. “It goes back to weighing the risks against the benefits. A facility’s interdisciplinary committee comprised of surgeons, nurses, infection preventionists, microbiology lab personnel and pharmacists can evaluate the rate of S. aureus infection and colonization in their facility and community to determine which patient group needs to be decolonized before surgery. It should be a risk-based decision.”

Preoperative bathing. Patients should bathe at least once with soap or an antiseptic before surgery to reduce microbial flora on their skin, according to the guideline. The guideline acknowledges more research is needed to determine whether soap or an antiseptic is best to use, the optimal timing of the bathing before procedures, the number of times patients should bathe and whether they should clean their entire body or focus on the area around the planned surgical site.

The guideline says a standardized application method is best and patients should be provided with clear instructions on how to apply antiseptics to ensure maximal skin concentration — repeated application and pausing before rinsing allows CHG to bind to the skin, for example. Electronic reminders are effective ways to ensure patients comply with pre-op bathing requirements and the antiseptic manufacturer’s instructions for use.

Hair removal. Keeping hair in place around the surgical site eliminates skin trauma, which could increase the risk for SSIs, and increases patient satisfaction. Hair should therefore only be removed if it will interfere with visualization of the surgical site or wound closure, prevent the surgical drapes from adhering to the patient or before the application of an alcohol-based skin prep that includes hair, which takes longer to dry and therefore increases the risk of a surgical fire.

Use disposable clipper heads or depilatory cream to remove hair outside of ORs or procedure areas, says the guideline. It also recommends removing a minimal amount of hair as necessary and as close to the start of surgery as possible — instruct patients to not remove hair at home — to limit possible bacterial contamination of the skin before the incision is made. If hair must be removed in the OR or procedure room, minimize dispersal with wet clipping or a vacuum device.

Antiseptic application. Prep selection is a complex process based on knowledge of current research, clinical guidelines and information provided by prep manufacturers — as well as feedback from frontline staff about how the products are used in practice. Facilities should rely on their interdisciplinary committee to identify and standardize the prepping agents used for procedure types based on clinical research about the efficacy of each agent against the bacteria at specific surgical sites.

One of the more significant updates in the AORN guideline is the recommended use of an alcohol-based antiseptic unless it is contraindicated. Alcohol has a broad spectrum of effective bactericidal activity, but it lacks persistence. Combining it with another agent such as CHG or povidone-iodine provides a rapid, persistent and cumulative effect, notes the guideline.

AORN recommends selecting an alcohol-based prepping agent based on the patient assessment and anatomical location of the surgical site. The guideline suggests assessing the surgical site for skin integrity, the presence of hair and proximity to mucosa, eyes or ears. Alcohol-based preps should not be used on the mucosa or eyes, and studies have found that iodine-based, non-alcoholic products are safest for use in the ear when applied with caution.

Ms. deKay points to the importance of allowing enough time for staff to apply prepping agents correctly and ensure they dry completely after application. “Some facilities use timers to ensure nurses perform both steps correctly,” she says.

When applying a prep with proper sterile technique, start at the incision site and move outward toward the periphery of the surgical site, applying the solution according to the manufacturer’s instructions for use. Discard applicators that contact contaminated areas of the patient’s skin. There is limited evidence to support the efficacy of applying multiple layers of different prepping agents, according to Ms. deKay. In fact, she says, the practice raises concerns about damaging the patient’s skin and is a time-consuming process that has not been shown to reduce the risk of SSIs.

Select the tint of antiseptic that will be most visible on the patient’s skin, recommends the guideline, which also states the color of the marker used to mark the surgical site should remain visible after the prepping agent is applied.

Constant monitoring

CRITICAL COUNTDOWN A handheld timer can be used to ensure staff apply prepping agents correctly and allow them to dry completely before surgery begins.

Jennifer Schacherer, BSN, RN, CNOR, manager of perioperative services at the University of Texas at Tyler College of Nursing and Health Sciences, has seen plenty of patients being prepped in hospitals and outpatient facilities throughout the course of her career. All too often, she says, nurses who applied the preps didn’t follow a standardized technique. “The method a nurse would use was based on how they were trained or what they saw others doing — and some of the techniques were flat out wrong,” says Ms. Schacherer. “That’s when I became interested in assessing the various ways nurses were prepping surgical sites and ensuring that part of the skin antisepsis process is standardized.”

She launched a quality improvement project a couple years ago that involved observing staff in prepping action, correcting improper techniques, assigning education modules on proper practice and making skin antisepsis an annual competency staff must complete. Her efforts worked. “We began to see more consistent application of the preps that were used,” says Ms. Schacherer.

Time pressures can also prevent nurses from applying preps correctly or ensuring they dry completely before procedures begin. “It helps to have a surgical leader present to explain the proper process to surgeons, who might push back because they want to start operating as soon as possible,” says Ms. Schacherer.

Some prepping vendors will send reps to facilities to educate and train staff on application practices and monitor their performance, points out Ms. deKay. “Making change happen isn’t easy,” she says. “It takes time and constant monitoring to prevent drifting back into old habits.”

Tell members of the surgical team that you’re going to conduct random audits of their prepping practices, says Ms. Schacherer. She suggests correcting staff members who use improper techniques and asking those who are prepping correctly to describe the steps to reinforce positive performance.

“You have to stay on top of the practice,” says Ms. Schacherer. “Consistency is key or all the progress you made to improve how staff prep patients will begin to fade. Their best bet is to do it right every time because they’ll never know when you’ll be watching them through the OR window.” OSM

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