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8 Skin Prep Actions to Add to Your SSI Prevention Bundle

Publish Date: July 28, 2021

Surgical site infection remains the deadliest and most costly healthcare-acquired infection. But it’s not impossible to prevent.

We know that careful attention and consistent compliance with SSI prevention bundles that include preoperative patient skin antisepsis can reduce the number of bacteria on the skin near the surgical site that could contaminate the incision.

With AORN’s updated “Guideline for skin antisepsis” published electronically in May, teams now have new skin prep practices to add to their SSI prevention efforts.

New Skin Antisepsis Practices

The updated guideline targets five elements of preoperative skin antisepsis, including: decolonization, preoperative bathing, surgical site hair management, surgical site antiseptic selection and application, and SSI prevention bundles, according to Karen deKay, MSN, RN, CNOR, CIC, AORN perioperative practice specialist and lead author of the guideline update.

“Perioperative nurses play an essential role in ensuring consistent skin antisepsis protocols are followed,” deKay says. “By working with perioperative team members and infection prevention colleagues to adapt updates from the guideline into practice, perioperative nurses can make a difference in reducing SSI rates.”

She suggests that teams updating their skin antisepsis protocols make these important practice changes.

Antiseptic Application

  1. Choose a tinted skin antiseptic and surgical site marker that are visible on the patient’s individual skin tone.
    “One tint color of skin antiseptic will not be visible on all skin tones. Instead choose a tint that is clearly visible on a specific tone,” she notes. The same recommendation also applies to the choice of ink color for the surgical site marker, so that the mark remains visible even after the patient skin antisepsis is applied to ensure that the site may be verified during the time-out.

  2. Don’t use sequential skin antiseptic application.
    Surgeons may ask for double and sometimes triple applications of surgical site antiseptics, but AORN can’t recommend this practice based on limited as well as conflicting evidence regarding these practices and SSI reduction, deKay notes. “Many researchers also raised concerns about the patient’s skin integrity, cost, and time associated with multiple applications of surgical site preparation.”


  1. Use an alcohol-based skin antiseptic unless contraindicated.
    The CDC, World Health Organization and several professionals practice organizations support this recommendation because “a skin antiseptic agent that combines alcohol with another antiseptic is necessary for rapid, persistent, and cumulative action,” deKay explains.


  1. Do not routinely remove hair at the surgical site, unless clinically necessary.
    If hair removal is required, remove as little as possible, as close to start of surgery as possible, and remove hair in an area outside the procedure room.


  1. Consider preoperative bathing for shoulder surgery with a topical benzoyl peroxide gel days before surgery.
    This recommendation is based on evidence that the bacteria found in the sebaceous glands and hair bulbs of the dermis near the shoulder are the main cause of SSIs in shoulder surgery and benzoyl peroxide’s ability to eradicate Cutibacterium acnes.

  2. Consider sending electronic reminders to patients for preoperative bathing.
    One study cited in the updated guideline showed that patients who received a preoperative bathing reminder had significantly higher concentrations of product on their skin compared to those participants who did not receive reminders.

    Instructions for patients should include what product, the amount to be used based on the patient’s BMI, if a pause is necessary before rinsing to ensure adequate binding to the skin for prolonged antimicrobial activity, and how many times the process should be done. “Clear, standardized instructions for patients are key to achieving optimal application,” deKay stresses.

Decolonization (Decolonization recommendations are new to the guideline.)

  1. Create an interdisciplinary team to develop a facility-wide decolonization protocol.
    This team should include infection preventionists, epidemiologists, pharmacists, perioperative RNs, surgeons, microbiology lab personnel and any other stakeholders identified by the organization. They should review the literature and their surgical population to determine the best strategy, protocol, and timing for their facility to cover these important actions:
    • Choose a decolonization strategy: universal (all patients), targeted (specific patients/procedures) or blended.
    • Decide if antibiotic or antiseptic decolonization protocols will be used. (See Table 3 and Table 4 in the guideline for comparisons).
    • Establish a process for continuous access to selected decolonization agent(s). (Remember that a physician order may be necessary for these agents.)


  1. Measure outcomes to improve your SSI bundle.
    The most important outcome to measure the efficacy of patient skin antisepsis are occurrence of SSIs for a specific surgical population, such as total joints or colon surgery.

Some additional measures are wound complications, readmissions, and resistance patterns. For example, when chlorhexidine gluconate and mupirocin are part of decolonization or surgical site preparation, surveillance for emergence of tolerance or resistance to either solution may be evaluated as part of the antibiotic stewardship program.

“Surveillance allows for any increase in resistance to be identified, thereby prompting evaluation and possible revision of bundle elements,” she says.

Access the latest AORN “Guideline for skin antisepsis” in eGuidelines+.

Look for new implementation resources in the Guideline Essentials companion to the guideline, which is available to AORN members only. It includes three tables comparing characteristics of different skin antiseptics, a selection algorithm for antiseptic in different body areas, and an updated guideline presentation slides with speaker notes.