While the evidence is strong that pre-op patient skin antisepsis effectively reduces microorganisms on the skin, current research is inconclusive on whether that reduces surgical site infections. “It’s vague,” says AORN Perioperative Nursing Specialist Amber Wood, MSN, RN, CNOR, CIC, CPN. “But we know the patient needs to be clean.”

Even if we don’t know how well pre-op bathing, showering or wiping works, you should still advise patients to do it. That’s the latest recommendation from AORN, which suggests you instruct patients “to bathe or shower before surgery with either soap or a skin antiseptic on at least the night before or the day of surgery.” (Emphasis added.) More than one-third (36%) of the 190 surgical facility leaders that Outpatient Surgery Magazine polled don’t even bother giving patients pre-op bathing instructions (see “What Are Your Pre-Op Bathing Instructions to Patients?”). For those that do, only 13% tell patients to wash or wipe for 2 or more nights.

Keep them compliant
Getting patients to comply with pre-op bathing instructions is challenging when, as Ms. Wood freely admits, “we don’t know what the optimal bathing procedures are.” Among the questions that remain unanswered:

• Which is better: antiseptics or plain or antimicrobial soaps?
• Should patients wash the whole body or just the surgical site?
• How long before surgery should you bathe or shower?
• How many times should you bathe or shower?

Since the potential benefits outweigh the risks, though, AORN recommends that you “develop a mechanism for evaluating and selecting products for pre-operative patient bathing.” A team of physicians, RNs and infection preventionists should standardize your facility’s instructions.

To get your patients to comply with your instructions, you may want to consider partnering with surgeons’ offices to promote the practice to patients early in the process, as well as washing patients while they’re in pre-op. “Then you know they’re clean,” says Ms. Wood.

Pre-op baths and showers frequently take place outside the perioperative environment, so ensuring patient compliance with your instructions is key to getting good results. Researchers from the Medical College of Wisconsin in Milwaukee think that electronic intervention may help.

For a study published in the August issue of the Journal of the American College of Surgeons, they asked 80 volunteers to shower with 4% chlorhexidine gluconate liquid soap over the course of 2 or 3 days. Half of the volunteers were prompted to shower by text messages sent to their mobile phones.

The researchers found that those who’d received the texts had significantly higher skin-surface concentrations of CHG — about two-thirds more — than the unprompted volunteers. They also had less of the soap left over at the end of the study (tinyurl.com/njpwvmz).

“This is a patient-centric process. We have to have a strategy in place to remind them to complete the process,” says Charles E. Edmiston Jr., PhD, CIC, professor of surgery, director of the college’s Surgical Microbiology Research Laboratory and the study’s lead author. Text messaging has previously been used to help patients take medications on time, but “it’s a natural to apply it to pre-surgical preparation.”

While timing and repetition are important, they’re only a part of the compliance that’s necessary. Surgical patients should be provided with the soap or wipes, as well as oral and written directions explaining precisely how much to use and to wait 60 seconds before rinsing it off. “You want to have a high, sustainable concentration on the skin,” says Dr. Edmiston, given CHG’s cumulative effect and residual antimicrobial activity.

Would the use of 2% CHG-impregnated wipes after a shower, which aren’t followed by rinsing, create a more standardized and effective process? “That’s a question I hope to answer in the future,” he says.

Instapoll
What Are Your Pre-Op Bathing Instructions to Patients?

Shower/bathe with CHG scrub the night before surgery and the morning of surgery.	40%
Shower/bathe with CHG scrub once a day for 2 or more days prior to surgery.	11%
Wipe surgical site with antiseptic cloth the night before surgery and the morning of surgery.	11%
Wipe surgical site with antiseptic cloth once a day for 2 or more days prior to surgery.	2%
We don’t give patients pre-op bathing instructions.	36%

Source: Outpatient Surgery InstaPoll, July 2014, n=190

A patient’s responsibility
In the absence of hard scientific evidence, and in light of the potential payoff, experts see pre-op bathing as a clinical responsibility that’s in patients’ hands.

“To me, it’s just common sense. The cleaner you are before we go through the skin, the less likely bacteria will get in,” says Ann Marie Pettis, RN, BSN, CIC, director of infection prevention at the University of Rochester (N.Y.) Medical Center. “And nobody’s more vested in avoiding wound infection than the patient.”