IS ROUND RIGHT? Make sure your staff are well versed in the proper application techniques of each prepping agent your facility stocks.

Pre-operative skin antisepsis is a critical component of your surgical site infection prevention efforts. But are you clear on the currently accepted practices? Quiz yourself and your staff with the following 5 true-or-false questions.

False. The clinical debate over the effectiveness of different antiseptic solutions continues, with neither the Centers for Disease Control and Prevention nor the Association of periOperative Registered Nurses nor other agencies or organizations definitively recommending chlorhexidine gluconate (CHG) or povidone-iodine products for all cases.

"No studies have adequately assessed the comparative effects of these pre-operative skin antiseptics on SSI risk in well-controlled, operation-specific studies," says the evidence-based recommendations endorsed by the CDC in its Healthcare Infection Control Practices Advisory Committee's 1999 surgical site infection prevention guidelines (tinyurl.com/ocxokoo), still considered the standard in the field.

False. A multi-center study published in the Jan. 7, 2010, issue of the New England Journal of Medicine (tinyurl.com/3alrol3) gained much clinical attention by demonstrating a CHG product's impressive anti-SSI results in comparison to povidone-iodine. But it hasn't ruled out the need to stock the latter agent.

"The Darouiche study, that's the one we make sure our physicians are aware of," says Lucille Hanus, MSN, MEd, RN, CNOR, a clinical education specialist at the Phoenix (Ariz.) Children's Hospital, who presented a poster on improving compliance with evidence-based skin prepping techniques at the 2013 AORN Congress. "It's the most up-to-date and well-known research" among a recent wealth of studies backing CHG's antiseptic power.

Although infection preventionists pointed out that the study pitted a 2% CHG, 70% isopropyl alcohol product against an aqueous solution of 10% povidone-iodine, this may not have been an uneven match, considering what ORs generally have on hand. "A Betadine soap-and-paint is what most people are using," if they're not using CHG, says Ms. Hanus. "The study compared the 2 most commonly used skin preps."

The Darouiche study may not have provided an apples-to-apples appraisal of skin-prepping agents, says Gwenda Felizardo, RN, BSN, CIC, an infection preventionist for Group Health Cooperative in Seattle, Wash. The preps' differing uses and abilities make such a matchup difficult to study, "so we don't have any overall comparison."

But, there's no disputing that there's still a place for povidone-iodine in pre-op preparations. Skin preps are not interchangeable for any surgeries or sites. For example, CHG (with or without alcohol) mustn't be used near a patient's eyes, ears or mucous membranes, while povidone-iodine can be. An iodine-alcohol prep might be better for general and abdominal surgery, where the chief bacterial risk is gram-negative bowel flora, while CHG is more effective against the gram-positive skin flora that bedevils orthopedic cases. Povidone-iodine also serves as an inexpensive alternative in the event a patient is allergic or sensitive to CHG.

ONE OR THE OTHER The appropriate prepping agent is determined by the surgical site location, the prep's effectiveness against SSI risks and patient sensitivities, among other factors.

True. Isopropyl alcohol has an immediate antimicrobial impact, but it doesn't last long. Coupled with the residual effects of CHG, though, it makes a strong contribution. Povidone-iodine has a fast, broad-spectrum antimicrobial activity, but it's easily inactivated through contact with blood, bodily fluids, tissue proteins or other organic matter. "Even after letting Betadine dry, once blood enters the scene, it's going to be ineffective," says Ms. Hanus. Alcohol, however, isn't and can boost iodine's effects. As a result, there is a general consensus, recently emphasized by the Institute for Healthcare Improvement's Project JOINTS (tinyurl.com/otmkt4w), that no matter which type of prep you're using, alcohol should be a part of it. Unless, of course, you're prepping an area where alcohol is not tolerated, such as around the eyes or mucous membranes.

Because alcohol is a flammable substance, it's also imperative that it's completely dry before the patient is draped and surgery begins, and that it not pool on or beneath the patient.

As evidenced by the Darouiche study, the iodine-and-alcohol combination might not be used as widely or as frequently as other prepping solutions, but Ms. Felizardo suggests that the time may be right for a re-evaluation, noting that its effects are similar to those of CHG-and-alcohol products, and particularly practical for abdominal surgery.

False. Just as different skin-prepping agents are intended for different parts of the anatomy and have different antimicrobial effects, they also have different application techniques.

A circular application, starting at the incision site and spiraling outward, has traditionally been recommended for a povidone-iodine paint. But CHG formulations benefit from a back-and-forth scrub over the site, starting at the least contaminated area and moving to the most contaminated. "Friction is what does it," says Ms. Hanus.

PREP IN PRACTICE CHG is often combined with isopropyl alcohol for a rapidly effective prep with lasting microbial action.

One iodine-alcohol product, on the other hand, recommends a single-stroke motion to cover the site, not a back-and-forth one, before letting the solution dry completely. "Application is basically the biggest mishap in skin prepping," says Nicholas Wade, RN, MPH, the director of infection prevention at Forest Hills (N.Y.) Hospital. "People don't apply the product for the correct amount of time for it to be effective." And, adds Ms. Felizardo, "if your staff isn't educated on the requirements for each type of prep, they may default to a circular motion, which is not effective for some of them."

In the clinical environment, "education must be part of anything you're doing," says Ms. Hanus, who recommends in-servicing staff with a hands-on skills lab demonstrating how each product is to be used.

True. Infection preventionists have promoted showering or bathing with antimicrobial soap on the night before and the day of surgery as a way for patients to lend a hand in their surgical safety. The IHI's Project JOINTS now suggests that patients who shower with CHG for 3 days before their surgeries will benefit from the agent's cumulative effect against skin-based bacteria.

"We can't say that CHG showers definitely will prevent SSIs," says Ms. Felizardo, "but plenty of studies support CHG as a preferred pre-op shower regimen to reduce the bacterial load, and the risk of SSIs."

She further notes that instructing patients to cleanse their surgical sites with 2% CHG-impregnated wipes after they shower may provide a greater effect than having them shower with 4% CHG-containing liquid soap. Used in the shower, she explains, the soap is lathered on, and then rinsed off. The compound still retains some of its antimicrobial effect, but not as much as that delivered by a cloth vigorously wiped over the area and not rinsed off.

Regulations requiring the public reporting of healthcare-associated infections have given a big push to patients' pre-op showering in the name of SSI prevention, says Mr. Wade. But because this practice necessarily takes place in patients' homes, outside of the perioperative environment, providing patients with adequate instructions is a must for pre-op showering to be effective.

The packaging for CHG soap or wipes will include the manufacturers' directions for use, says Ms. Hanus, but it's advisable for surgeons and staff to explain the products' uses to patients themselves. Most notably, patients should thoroughly wash their bodies, including their surgical sites, from the neck down and avoid their genitals. After washing, they should don clean clothes and sleep on clean bed sheets.