In surgical skin prepping, as in most infection control disciplines, the sacred cows - such as shaving in spite of recommendations to the contrary, or the belief that povidone-iodine is always best - roam freely. The result is great variance in techniques, as you'll see in the answers to a survey of Outpatient Surgery readers' prepping practices. In fact, dominant practices often differ from recommended best practices. Read on to take our eight-question quiz, to view the survey results (we asked 33 readers to take this quiz last month) and to see my recommendations.

1 A 35-year-old male arrives for arthroscopic ACL repair. The operative site is unshaved. How should you proceed?

A. Shave the operative site before the patient arrives in the OR.
B. Shave the operative site in the OR.
C. Clip hair on the operative site just before the procedures
D. Use a depilatory.
E. Don't remove hair.

Survey says: Most respondents to our survey (44 percent) say they clip the hair before ACL repair. Equal numbers - 18 percent each - say they shave the operative site either in the OR or pre-op. Just 12 percent wouldn't remove hair at all; 9 percent take another track; and none use depilatories.

Expert's answer: The recommendation is E. don't remove hair. Hair doesn't need to be removed for arthroscopic ACL repair, and shaving increases the infection risk even in this class I procedure. If the area is particularly hairy, or the surgeon insists the hair be removed, then either clipping right before the procedure or using a depilatory would be best. This holds true for other procedures, such as hernia repair, where hair removal might be needed. If you use a depilatory, test it on patients beforehand to ensure they don't have an allergic reaction or irritation. Even though the data is more than 20 years old, it's been difficult to get healthcare workers to embrace the idea that shaving increases the bacterial load at the operative site, no matter when the shaving is done.

2 A 50-year-old male presents for inguinal hernia repair. It is July, and as you are completing his check-in, he mentions the air conditioning in his home isn't working. What is the best route of action?

A. Do an extra-thorough prep.
B. Send him for a pre-op antiseptic shower.
C. Do nothing.

Survey says: More than four in 10 (44 percent) would take no extra steps. Twenty-four percent would be more thorough with their regular prepping processes, while just 6 percent would order a pre-op antiseptic shower. More than one-fourth (27 percent) say they would proceed with another protocol, such as administering pre-op antibiotics and prescribing a 4% chlorhexidine (Hibiclens) shampoo and scrub for two days before surgery.

Expert's answer: Lack of air conditioning alone doesn't increase the chance of surgical site infection, as some panelists pointed out. It's more important that staff determine if he has been able to keep up with routine hygiene. Pre-op showers have been shown to reduce the skin flora colony count and to reduce the risk of infection. If the patient didn't shower with an antiseptic agent the previous day or the morning of surgery, the answer should be B. send him for a pre-op anti-septic shower.

The Healthcare Infection Control Practices Advis-ory Committee's Guideline for Prevention of SSI requires patients to shower or bathe with an antiseptic agent at least the night before the operative day; it's a Category IB recommendation (viewed as effective by HICPAC and surgical and infection experts). Category IA and IB recommendations should be adopted by healthcare facilities.1

3 Some preps seal abrasions caused by razors, making shaving the surgical site an acceptable practice.

A. True
B. False

Survey says: An overwhelming majority of our panel (94 percent) says the idea that preps seal abrasions caused by razors is false.

Expert's answer: The answer, as indicated by the survey response, is B. false. Abrasions caused by shaving will still be present and can increase the microbial skin flora colony count. Neither the AORN nor the HICPAC SSI guidelines recommend shaving; in fact, they warn against it.

4 Your materials manager says you could save money by switching to exam gloves for patient prepping. From an infection control standpoint, is this a good idea?

A. Yes
B. No

Survey says: Nine in 10 (88 percent) would tell their materials manager it's a no-go because of the potential infection issues such a move would raise.

Expert's answer: It is of primary importance to maintain sterility when you perform a surgical site prep. You could use exam gloves to wash the area to assure that it's clean before the prep if that's necessary, but once the actual prep is begun, you should use sterile gloves; therefore, the answer is B. no. The AORN recommended practices states: "Antiseptic agents used for skin preparation should be applied using sterile supplies."2

5 On her H&P, you note that a 42-year-old female presenting for a carpal tunnel release procedure experienced a hypersensitivity reaction after a past surgery. What prep or preps would be best to avoid potential anaphylaxis?

A. Alcohol/isopropyl alcohol
B. Chlorhexidine gluconate
C. Povidone-iodine
D. Chlorhexidine gluconate plus isopropyl alcohol
E. Chloroxylenol

Survey says: There are several correct answers, so respondents were allowed more than one response. As such, 75 percent say chlorhexidine gluconate would be a good choice; 21 percent tagged CHG plus isopropyl alcohol; and 14 percent would use alcohol. About 11 percent each say chloroxylenol and povidone-iodine are acceptable.

Expert's answer: When you have access only to limited information, as you do in this hypothetical situation, it's best to err on the side of caution.

Preferably, you'd be able to get to the extremely important task of determining what caused her reaction. Was it the prep that caused the hypersensitivity reaction after the last surgery? If yes, which one? Some patients are iodine-sensitive, which would eliminate povidone-iodine as an option.

Other substances, such as latex, can cause hypersensitivity reactions, so it would be very important to understand the exact source of her hypersensitivity. If the old records aren't available, then the surgeon should consider allergy testing before surgery to determine the best alternative.

If that isn't possible, I'd suggest that you use A. an alcohol/isopropyl alcohol prep, because relatively few hypersensitivity reactions to alcohol have been reported. Low allergic reaction ratios are also noted for B. chlorhexidine gluconate, D. chlorhexidine gluconate plus isopropyl alcohol and E. chloroxylenol.

6 When prepping a patient for endometrial ablation, what types of surgical prep or preps would be best to choose?

A. Alcohol/isopropyl alcohol
B. Clorhexidine gluconate
C. Povidone-iodine
D. Chlorhexidine gluconate plus isopropyl alcohol
E. Chloroxylenol

Survey says: Nearly two-thirds of our panel (63 percent) say povidone-iodine would be a good selection. CHG is the next most popular, at 37 percent, while 10 percent say chloroxylenol and 3 percent say CHG plus isopropyl alcohol are potential options. No respondents would use alcohol. More than one choice was again allowed.

Expert's answer: The AORN standards caution about using CHG or alcohol-based products on mucous membranes because of the potential for irritation.2 However, it must be noted that, in the dental setting, CHG products are often used to reduce flora. Some GYN practices will use the soap form of CHG to wash the vaginal area. You should select the prep with the surgeon. But without that discussion, you would usually want to select C. povidone-iodine or E. chloroxylenol.

7 Your inguinal hernia repair patient has now made it to the OR, and has been prepped using a povidone-iodine solution. After prepping, you should

A. Immediately proceed with draping.
B. Dry the area with a sterile towel, then drape.
C. Let the site air-dry before draping.

Survey says: Four in 10 (44.1 percent) would dry the area with a towel; 24 percent would immediately drape; 21 percent would let the site air-dry; and 12 percent would follow another protocol.

Expert's answer: The key to any povidone-iodine solution's effectiveness is letting the product dry completely; therefore, you should C. let the site air-dry before draping. Wiping or draping before drying will remove the product before it can kill the skin flora. In addition, povidone-iodine products are bacteriostatic as long as they're on the skin, and premature removal would negate this.

8 A 23-year-old female tennis player is admitted for arthroscopic shoulder repair, with possibility of open repair. The patient has been prepped with a povidone-iodine solution. At the end of the procedure, you should

A. Apply the dressing, leaving the remaining prep in place.
B. Remove all traces of the prep using sterile saline.
IC. Remove all traces of the prep using soap and water.
D. Apply dressing and remove prep solution from the area around the dressing.

Survey says: No respondents would leave the prep in place. Fifty-two percent would remove all prep with sterile saline; 6 percent would do so using soap and water; and 27 percent say they would only remove the prep outside the dressing. Fifteen percent say they would follow another protocol.

Expert's answer: No guidelines indicate a clear answer. When you apply a dressing, follow the principle of maintaining sterility of the incisional site for one or two days for incisions that have had primary closure. If irritation is a concern, then you would B. remove all traces of the prep using sterile saline from around the incision. But remember that povidone-iodine and CHG products have residual effectiveness, and removing them would negate that protection.

References
1. Guideline for the Prevention of Surgical Site Infection, 1999. "CDC Recommendations for Prevention of Surgical Site Infection." Appendix J;J-1.
2. AORN, 2003 Standards, Recommended Practices and Guidelines; "Recommended Practice IV, Recommended Practice for Skin Preparation of Patients":340-1.