HANDS ON Standardizing skin preps is a way to empower pre-op personnel who are responsible for patient safety.

We prepare more than 3,000 patients a year for surgery, and one byproduct of all that activity was that some patients weren't having their skin prepped before they entered the OR. In other cases, they were prepped, but not as our physicians preferred. That was 2 years ago, before we volunteered to take part in the Institute for Healthcare Improvement Project JOINTS initiative. Now we're seeing the benefits that come from standardizing the skin-prepping process. Not that our infection rates were ever high — they weren't — but we wanted to get the rate as close to zero as possible. And when we looked closely at what we thought the obstacles toward achieving that goal might be, a lack of standardization was one that was high on the list. Now, in part because of the changes we've implemented, our infection rate is below 1% and we're seeing other benefits, as well.

Making the switch
We were fortunate that agreeing to a standard prep wasn't as difficult as it might have been. We're primarily an orthopedic facility (more than 80% of our surgical procedures are orthopedic) and naturally there was some back-and-forth, but most of our surgeons were already believers in chlorhexidine gluconate (CHG). Still, there were a few that we needed to find a way to convince. We'd asked our healthcare librarian to do a literature search of relevant randomized trials and meta-analyses, and when we showed the more reluctant surgeons the data and told them we were going to be participating in the Project JOINTS initiative, they all agreed to give it a shot.

Since then the feedback has all been positive. In fact, one of our surgeons was frustrated at the time because he'd been having some infections with the preps he'd been using. When we shared with him the evidence-based literature suggesting that CHG was better, he agreed to try it. Now, he's a CHG convert.

Committing ourselves to the project also meant educating and enlisting the cooperation of patients, since the initiative calls for them to pre-wash surgical sites with CHG wipes for at least 3 days before their scheduled surgeries. Our chief spine surgeon wanted them to use the wipes for 5 days. With the availability of pre-filled/soaked single-use CHG wipes, getting patients to carry out the task is fairly easy and inexpensive. For patients who come to our pre-surgical planning meetings, we have a basket of wipes that we make sure they take home with them. And when we have out-of-towners planning to come in for surgery, we just instruct them to go to their local pharmacies and pick up the wipes.

To monitor compliance, when patients show up for their procedures, we ask them in the pre-op holding area whether they used the wipes, and if so, for how many days. About 80% report using them for at least 2 days, if not the 3 to 5 that we recommend.

PROCESS IMPROVEMENT
Standardizing Skin Preps is
the First Step Toward Reducing SSIs

HOW TO What steps should you take to standardize preps?

In 2012, Mercy Medical Center in Canton, Ohio, adopted a standardized skin-prepping regimen that reduced the incidence of infection from 3.7% to 0.6% (3 infections in 498 orthopedic procedures). Lead author Melissa Lingle, RN, CNOR, the facility's clinical manager of surgical services, spells out the 6 steps the facility took:

• Educate OR staff on the fundamentals of aseptic technique, followed by ongoing reinforcement.
• Provide chlorhexidine wipes for patients, educate them on SSI prevention and instruct them to scrub operative sites daily for the 3 days immediately preceding their surgeries. Screen patients, via nasal swabs, for MRSA.
• Scrub operative sites again with chlorhexidine wipes in pre-op before transporting patients to the OR.
• Emphasize strict adherence to aseptic technique by all staff before, during and after surgery.
• Apply silver-impregnated absorbent dressings to incision sites immediately post-closure.
• Apply a new silver-impregnated dressing on the third day after surgery, and keep it in place for an additional 7 days (unless there is excessive bleeding, in which case the wound is examined and the dressing is changed immediately). Goal is to maintain incision coverage for a full 10 days.

— Jim Burger

Final steps
From there it's up to our pre-op nurses. They take care of any clipping that needs to be done, and we make sure they all understand the proper procedure for applying the preps as a last step before the patient goes into the operating room.

ALL FOR ONE A few of our physicians had to be convinced to standardize preps, but they came around when we showed them the data.

Having a standardized approach is a big plus when it comes to training, too. Before we made everything uniform, there was always the possibility that new employees would be taught to do something a certain way one day, only to be told just the opposite the next day. This way everyone is on the same page, which helps us achieve another of our goals: increasing our percentage of on-time starts. The CHG has short application and drying times, which helps us stick to our schedule. The fact that we don't have to worry about stocking as many supplies is another boost to the bottom line.

We're trying to standardize our work practices across the board and this was an area where we felt doing so would also help provide better care for our patients. With an infection rate close to zero, we feel as if we've accomplished that. Has our life gotten a little easier since we standardized our skin-prepping regimen? Absolutely. We've eliminated the extra work and bottlenecks that occurred when surgeons forgot to order skin preps, and we've empowered the people who are responsible for patient safety in the pre-op department to implement an evidence-based infection-prevention process on every patient, every time.