PREPPING DEBATE The inexact nature of the science supporting prepping makes for some great debates.

Surgical skin asepsis is like many areas of medicine: fraught with misconceptions that are often in error but seldom in doubt. Want to start a great debate? Ask your surgeons and nurses to defend their skin prepping preferences and beliefs. Should you wear a long-sleeved jacket when you apply a prep? Which antiseptic should you use for vaginal antisepsis? Here are 10 questions to get the discussion going, followed by their AORN-approved answers.

1. Is it necessary to wear a long-sleeved jacket when performing patient skin antisepsis?
Yes. We get this question a lot. Some of us were taught that we should remove our jacket before applying a prep. The thinking was that the sleeve could contaminate the area you're prepping. But if the RN circulator performs the pre-operative skin antisepsis without wearing a long-sleeved jacket, skin squames from her bare arms may drop onto the area that is being prepped and may increase the patient's risk for a surgical site infection. The recommendation for nonscrubbed personnel to wear long-sleeved jackets in the OR or invasive procedure room is not a new recommendation. It has been a part of the AORN "Recommended Practices for Surgical Attire" since 1994. Wearing long-sleeved attire helps contain skin squames shed from bare arms.

2. Should I remove a patient's nail polish or artificial nails before prepping her?
Yes, if the patient is having hand or foot surgery. Nails on the operative extremity should be clean and natural without artificial nail surfaces or polish. The evidence review for AORN's new recommended practices document (Recommended practices for preoperative patient skin antisepsis. [In Press] In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2014. [IVA]) found no cases of patient incision-site contamination related to wearing artificial nails or nail polish on the operative hand and foot. In 2 separate studies, researchers found that the amount of potentially pathogenic bacteria cultured from the fingertips of healthcare personnel wearing artificial nails was greater than for those with natural nails, both before and after hand washing. Artificial nail surfaces or polish may harbor microorganisms, which could contaminate the surgical site or reduce the effectiveness of pre-operative patient skin antisepsis. This is the first time AORN has taken a position on patients' wearing artificial nails. Essentially, we're prescribing the same fingernail precautions for patients having hand or foot surgery as we do for healthcare workers. If a patient's having abdominal surgery, it's OK for her to wear artificial nails or nail polish if permitted by facility policy.

3. May I dilute the skin antiseptic solution when performing preoperative patient skin antisepsis?
No. In a drug safety communication, the FDA recommended that healthcare professionals not dilute antiseptic products after opening them, to reduce the possibility of these products becoming contaminated. Skin antiseptics should be applied according to the manufacturer's instructions for use. Antiseptic manufacturers' instructions for use convey important safety and efficacy instructions to the user. Skin antiseptics are designed and tested by the manufacturer to provide the safest and most effective reduction of skin microbes at specific concentrations. Diluting antiseptic solutions and failing to adhere to the manufacturer's instructions for use may result in patient harm or ineffectiveness of pre-operative patient skin antisepsis. Keep in mind that skin preps have been tested and proven effective at their specific concentrations. If you dilute the product to make it kinder and gentler for the patient or to make a bottle last longer, you may inadvertently make the product ineffective.

SLEEVED OR SLEEVELESS?
Yes, a Long-sleeved Scrub Jacket Is Required

LONG SLEEVES REQUIRED Long sleeves protect against dead skin cells that are constantly sloughing off our skin from falling onto the area you're prepping.

According to AORN's "Recommended Practices for Surgical Attire," you should wear a long-sleeved scrub jacket in the OR while you're prepping a patient. But nearly half (46%) of the 550 surgical facility leaders we polled last month disagree because, they say, the sleeve could contaminate the area you're prepping.

InstaPoll

Should you wear a long-sleeved jacket when prepping patients' skin?
No, the sleeve could contaminate the area you're prepping	46%
Yes, skin squames shed from bare arms may increase the patient's risk for an SSI	54%

Source: Outpatient Surgery Magazine InstaPoll (www.outpatientsurgery.net), May 2014, n=550

4. May I use multiuse containers of skin antiseptic solution when performing preoperative patient skin antisepsis?
No. In November 2013, the FDA issued a Drug Safety Communication requesting that manufacturers package antiseptics indicated for pre-operative skin preparation in single-use containers. The FDA did so in order to reduce the risk of infection from improper antiseptic use and contamination of products during use. In several case reports and non-experimental studies, contaminated skin antiseptics have been linked to patient infections. Simply put: Buy skin antiseptics in single-use containers, discard them after use and don't refill them. Put yourself in the patient's shoes. Do you want a bottle of skin prep that was used on 10 other patients to be used on you, or do you want a brand new bottle?

5. Should I use special methods when performing pre-op patient skin antisepsis of the hand or foot?
Yes. When performing pre-op patient skin antisepsis of the hand or foot, perioperative team members should take care to apply the antiseptic to all surfaces between fingers or toes. Antisepsis may be difficult in the areas between the fingers and toes, as it's difficult to reach all surfaces of the skin. In a randomized controlled trial of 50 patients undergoing foot surgery, researchers reported a significant reduction in bacterial recolonization of the foot with additional cleaning of the area between the toes. International studies from England, Australia and New Zealand describe a novel technique for skin antisepsis of the hand or foot that involves using a sterile bag. Researchers have found the bag technique to be effective in reducing bacterial counts and application time. This bag technique is similar to Shake 'n Bake, a flavored bread crumb-style coating for chicken and pork. You fill a gallon-sized plastic bag with a couple of inches of prep and then place the foot or hand inside the bag.

PROPER PREPPING ATTIRE Nurses should wear gloves and long sleeves when applying skin preps.

6. Which antiseptic should I use for vaginal antisepsis? Which antiseptic should be used if the patient is allergic to povidone-iodine?
This is a one of the most common questions we field. The collective evidence indicates that povidone-iodine is commonly used for vaginal antisepsis in gynecological procedures.¹

There are currently no FDA-approved (Category I, New Drug Application) antiseptic alternatives on the market for use in the vaginal vault when povidone-iodine is contraindicated (for example, a patient allergy).¹ The perioperative team members should collaboratively evaluate the risks and benefits of using Class II or III FDA-approved antiseptics or other alternative solutions (soaps or saline, for example).¹ (See "FDA Categories of Patient Pre-operative Skin Preparations" below.) Two alternatives to vaginal povidone-iodine, sterile saline² and baby shampoo,³ were discussed in the literature. Both studies suggest that these alternatives are as effective as povidone-iodine for pre-op vaginal antisepsis. In a position statement from the American Congress of Obstetricians and Gynecologists (ACOG), the committee recommends off-label use of 4% CHG with low alcohol content (4%) as a safe and effective alternative for vaginal preparation when povidone-iodine is contraindicated or CHG is preferred by the surgeon.⁴

7. Should chlorhexidine (CHG)-impregnated cloths be used for pre-operative bathing?
Undecided. A growing body of evidence supports the use of 2% CHG-impregnated cloth products for pre-operative bathing. CHG-impregnated cloths may increase the amount of CHG on the skin at the surgical site, which could enhance the activity and residual effect of CHG. Based on the collective evidence, this practice remains an unresolved issue and warrants additional generalizable, high-quality research to confirm the benefit of CHG-impregnated cloths for prevention of surgical site infection.¹

8. Our organization's protocol for pre-operative skin antisepsis is to use an alcohol-based antiseptic, but the dry time for the antiseptic in hair is 60 minutes which is not feasible. This conflicts with our protocol not to remove hair at the surgical site. What is the best practice?
It depends. When using an alcohol-based skin antiseptic for procedures involving an ignition source (electrosurgery or laser, for example), you should clip hair at the surgical site before application of the antiseptic.¹ Hair removal at the surgical site should be performed only in select clinical situations, such as when the presence of hair may contraindicate the use of flammable (alcohol-based) antiseptics, according to manufacturer's instructions for use. There was no evidence found that describes the length or amount of hair that constitutes a fire risk when using alcohol-based skin antiseptics. When hair removal is necessary, clipping the hair may be associated with a lower risk of developing an SSI than hair removal with a razor.¹

9. Should you wear sterile gloves when performing pre-op patient skin antisepsis?
Yes, you should wear sterile gloves when performing pre-op patient skin antisepsis.¹ You can wear nonsterile gloves if the antiseptic applicator is of sufficient length to prevent contact of the gloved hand with the antiseptic solution and the patient's skin.¹

10. What protective measures should I take to prevent prolonged contact with skin antiseptics?

• Protect sheets, padding, positioning equipment and adhesive tape from the dripping or pooling of skin antiseptics beneath and around the patient.¹
• Protect electrodes (electrocardiogram [ECG], electrosurgical unit [ESU] dispersive electrode) and tourniquets from contact with skin antiseptics.¹
• Place a fluid-resistant pad under the patient's buttocks during pre-op patient skin antisepsis for patients in the lithotomy position. Remove the pad after the antiseptic is dry and before you apply sterile drapes.
• As necessary, remove and replace any material near the patient that is in contact with the skin antiseptic solution, including electrodes (ECG or ESU) and tourniquet materials (cuff, padding).¹

Standardization
The answers to these 10 questions come from the newest AORN recommended practices, but most of the studies we found are conflicting. They don't really show that one kind of skin antiseptic is better than another. There's also no consensus on the best application techniques. With that in mind, it helps to standardize your prepping products and practices. The bedside nurses can then select an approved product for each individual patient based on their assessments.

Whichever prepping product you're using, a multidisciplinary team at your facility should have selected it and provided education for nurses on its application and use. Nurses and others who perform skin preps should apply the antiseptic according to the manufacturer's instructions for use. When prep manufacturers test their products, they do so using a particular protocol. For example, most surgical nurses have been taught to prep in a circular motion, moving outward from the incision. However, if you're using a product that should be applied using a back-and-forth motion, your staff must change their habits — and maybe their beliefs, too.