How to Select a Patient Skin Prep Solution for Your OR

When selecting a pre-operative skin prepping solution, keep in mind that one size does not fit all, regardless of what manufacturers may have you believe. Here are four tips for selecting the right agents for your facility.

Collaborate
Facilities too often stick with the familiar (traditional scrub-and-paint iodophor prepping) when there may be better options. Or they'll switch because a physician or infection control officer recommends it, without evaluating all the pros and cons, causing less-than-enthusiastic buy-in from nurses.

Physicians and nurses need to express their preferences. The infection control manager needs to look at your facility's infection rates and help interpret the meaning of the products' efficacy data. Finally, the administrator needs to evaluate cost-benefit data.

Ms. Conner ('[email protected]')) is a perioperative nursing specialist in AORN's Center for Nursing Practice.

Evaluate efficacy
Many new surgical skin preparation agents are available. New product formulations and the accompanying manufacturer directions for use often lead to confusion for the perioperative nurse. The new products may require a shorter application procedure, but the objectives of surgical skin preparation remain the same. The product should remove dirt, oils and transient skin microbes. It should reduce the resident microbial count as much as possible, in the shortest time possible. It should cause minimal tissue irritation, and it should prevent rebound growth of bacteria over time.

Many surgeons are requesting new skin preparation products requiring a one-step application, rather than the traditional two-step (scrub-and-paint) process. When considering these products, evaluate the clinical effectiveness. The criteria for measuring the clinical effectiveness of skin preps include:

• Do they rapidly reduce microbial counts?
• Do they irritate the skin?
• Are the agents incompatible or inactivated by organic matter, soaps and detergents or alcohol?
• Are the agents effective throughout the operation?
• Are they compatible with the gloves currently in use?
• Is the product safe for use? Is it flammable?
• What are the indications and contraindications for use?
• Is the product easy and simple to apply?

Few of us believe we are sufficiently expert to thoroughly evaluate and understand manufacturers' testing data. But you should ask for and review the manufacturer's efficacy studies. Compare these study results with other products on the market. Contact colleagues at other facilities and compare notes on their experiences and satisfaction with different preps.

The level of prepping necessary with a given agent does not depend on the type of procedure being performed. You don't a patient having a small lesion biopsied any differently than a patient undergoing major abdominal surgery. That said, it's crucial both from a clinical and quality monitoring perspective to carefully follow the application instructions and indications for every product.

You can't and shouldn't compare the products based on off-label usage. Follow the directions on the manufacturer's package insert to ensure that your patients receive ideal antisepsis with the product.

Different products have different exposure and drying times. Required usage times can be a factor when judging a product's convenience, but you should not deem one product more clinically effective than another because one takes two minutes and another five.

No single product will meet every single patient need. Have an alternative prepping solution available in case a patient is allergic to the agent of your choice, or in case the agent is contraindicated for a specific area. For example, even if you determine that products with chlorhexidine work effectively for the majority of your cases, you'll need an alternative agent if you do any surgery on the face (such as ENT and ophthalmology) because chlorhexidine is contraindicated for the face.

Finally, different products are more popular with certain specialties than others. For example, the iodophor-based gels are often popular with specialties that do large areas and extremities, such as orthopedics.

Consider convenience
Because of the time pressures often experienced in the ambulatory surgery setting, staff and surgeons tend to want to use whichever prep is fastest, easiest and simplest to apply. But no matter what product you use, never take shortcuts in performing the surgical skin prep to save time or money. Hospital-acquired surgical infections are a leading cause of patient morbidity and mortality. Rigorous adherence to the principles of asepsis is the foundation of surgical site infection prevention.

Unlike switching to needle-less products, there are few if any technique adjustments needed with trying out different surgical prepping products. Some products require a two-step process (scrubbing with a detergent and paint with a solution). Some can be done in one step. But the same basic approach recommended in the AORN's "Recommended Practices for Skin Preparation of Patients" holds true for all prepping agents in the actual application - apply the product from the incision site to the periphery, leaving enough area for the surgeon to extend an incision or create new drain sites. Discard the sponge or applicator after the periphery has been reached. Allow sufficient contact time of the product before applying sterile drapes. Allow sufficient time for complete evaporation of flammable agents (alcohol, alcohol-based products). Prevent pooling of the agent beneath the patient, under tourniquet cuffs, electrodes or electrosurgical unit dispersive pads to reduce the risk of chemical burns.

Here's what to ask staff and physicians about convenience:

• Does the product apply easily and quickly (in other words, does the agent drip, pool or run? Does it go on smoothly)?
• Does it dry rapidly?
• Does it stain the patient's skin? Can it be easily removed?
• Does it make a mess, stain the floor or create a clean-up hassle when turning over the case?

Cost-effectiveness
Cost-effectiveness of all surgical supplies is an important consideration in today's competitive healthcare market. Appropriate purchasing decisions are critical not only for safe patient care, but also for the financial health of the organization. Administrators and purchasing agents should educate personnel and surgeons about the cost of supplies (for example, the best price available through a buying group or directly from the manufacturer). If there is no consensus, strong preference or objection to one product over another, cost can make the final choice obvious.

You can't divorce the cost-effectiveness issue from either efficacy or convenience. The cost of a single nosocomial infection can be catastrophic to both the organization and the patient. Ignoring staff's input about their experiences using the product because it costs a bit more or less per case is not only being pennywise and pound foolish, it may jeopardize patient safety and negatively affect the bottom line. If a solution reduces productivity, you'll lose many times over in staffing costs and, eventually, volume and profit margin.

The best way to select prepping products is to do your homework. Review infection control and medical literature and stay current with recommendations and guidelines from the government and professional organizations (CDC, FDA, AORN, APIC). Solicit input from different sources and negotiate the best deal to bring the best skin preparation products to the facility.