Surgical site infections are the third most common healthcare-acquired infection (surpassed only by urinary tract infections and pneumonia), and prepping the skin before making the incision is a key to reducing their incidence. Here are tips for enhancing your skin prep protocol to reduce the potential for SSIs.

On The Web
Need help evaluating skin preps? Go to writeOutLink("www.outpatientsurgery.net/forms",1) to download a PDF that makes it easy to compare preps.

Cleaning the skin
Microorganisms found on the skin are the source of most SSIs. When you perform surgery, the incision disrupts the integrity of the skin and creates a perfect portal for microorganisms to enter the wound. The first step in prepping the skin, then, is to remove dirt and debris from around the surgical site to help reduce the number of resident and transient microorganisms on the skin.

Here are two ways to ensure the skin is cleaned properly before applying prepping solutions.

• Require showers. A shower/shampoo is an effective way to reduce the number of microorganisms on the skin; however, I have found that many facilities don't follow this protocol. In one study of 700 patients who took two pre-op showers, researchers found a nine-fold reduction in skin bacterial count. This practice is especially easy to implement in an outpatient setting. Have your patients shower/shampoo the night before their procedure and again on the morning of surgery. Using the proper soap is also essential. Repeated showers with chlorhexidine gluconate produce the maximum benefit, but povidone-iodine or triclosan products also reduce skin bacteria.
• Avoid shaving. It is well known that removing hair around the surgical site 24 hours before surgery increases the potential risk for infection, and that chance for infection increases the further out from surgery you shave a patient. No matter how smooth a shave looks, the razor creates tiny nicks in the skin, breaking the body's first defense against entry and colonization of bacteria. According to current literature, shaving before surgery is not necessary and should actually be avoided unless the hair is in the way of the surgery itself.

So why are preoperative shaves still performed? Because old habits are difficult to break. Shaving only when hair interferes with the procedure is not a new concept, yet always shaving a surgical site is engrained in clinicians' minds and changing that mindset is difficult. A no-shave-unless-absolutely- necessary mandate is an excellent quality improvement initiative. When a shave is necessary, keep these guidelines in mind. Shave as close to the time of surgery as possible (in the pre-op holding area just before surgery) use electric clippers as opposed to a standard razor; be sure the head of the clippers is disposable or can be cleaned between patients; and never shave in the OR.

Picking the product
Your first priority when choosing a prepping product is to contact your center's infection control practitioner to make sure the product is efficacious. Once you've determined that, work with the materials manager to determine if the product is cost effective. Most prepping products come in a pack with a sponge containing the cleansing product and another containing the prepping solution. Other prepping packs include sterile gloves or come with the prepping solution already mixed. Find the product that works best for you within your budgetary constraints. Remember, though, that safety always comes before price in the case of skin preps.

Only use products that are recommended for skin prep and are identified by the Food and Drug Administration as appropriate for this activity. Also make sure you have the right product for the right patient. Work closely with your infection control practitioner to avoid mistakes ' such as putting chlorhexidine on a mucous membrane. Is your patient allergic to shellfish? If he is, you may need to consider using a prep that doesn't contain iodine. Even if a patient's allergy is to something ingested, you don't want to take a chance. It is critical to refer to the product literature and instructions for use. Some prep solutions may not be suitable for use around the eyes or on neonates and may be harmful to the fetus if used on pregnant women. Facilities write their own policies for solution selection, but think through contingency plans and consult your infection control practitioner.

Once you establish a policy for choosing a product and assigning prepping solutions to specific cases, stay on top of research and industry developments. There is a great deal of recent research on antiseptic skin agents, and the products you currently use may not be the best choice. Your policy should reference backing scientific data. Read periodicals and journals, but also work the exhibit halls at trade shows to gauge the market. Company reps will have literature on their products, but they'll also have clinical data about the prepping solution they offer.

Prepping protocol
Once you choose a product, how should you apply it? AORN guidelines state that antiseptic agents used for skin prep should be applied using sterile supplies. Data from one limited study, however, suggest a clean kit is as effective as a sterile kit. You also don't have to use have sterile gloves to handle the applicator stick; clean gloves may be used. But again, when determining the best procedure for prep application, it's critical that you follow the written recommendations of the product.

Different facilities have variations in prepping protocol. Individual preferences have not been shown to make an improvement, but here's some basic guidelines to follow.

• Work outward. Begin at the incision site and move out in concentric circles. Discard the sponge applicator when the periphery is reached and do not return a sponge/applicator to the incision site once it has been applied to that area. Every area that will be exposed during surgery requires an antiseptic prep application. When using a drape, anticipate the fenestration over the incision and extend the prep far enough so the entire exposed area and beyond will be prepped.
• Prep problem areas last. Certain areas within the incision site with the potential to house excess bacteria need particular attention during the prepping process. The umbilicus typically has a high microbial count and needs to be cleaned with a Q-tip prior to prepping. Open wounds, and perineal areas should be prepped last. If the patient has a colostomy, cover it with a sponge containing the antiseptic solution while the rest of the surgical area is prepped, and then prep this area last.
• Be careful with drapes. When applying a drape, it is critical you follow the drape's individual product instructions. Certain preps need to remain in contact with the skin for a specified amount of time to be fully effective. Placing a drape before the solution dries could interfere with this time requirement, so check the product's package label for special instructions.
• Avoid pooling. Applying excess amounts will cause the prep solution to pool under the patient. Pooled prep solution in contact with the patient's skin can cause irritation or burn and can compromise the adhesive of a dispersive electrode. Be especially careful to prevent pooling under a tourniquet cuff. If a flammable agent, such as alcohol, is used, allow the solution to dry to reduce the possibility of fire. Use of an active electrode in the presence of a flammable agent could result in fire.
• Document action. Performing a skin assessment, documenting the assessment, prepping and observing the condition of the skin after surgery are other key components of a successful infection control strategy. Look at the condition of the skin before the prep. Is there a rash? Do you notice a break in skin integrity? Written documentation of your assessment will create a baseline record and will let staff in the recovery unit determine if a later skin reaction was the result of the prep.

The written record of the prepping process should also include a report on hair that is removed, the method used for removal, when the hair was removed, the cleansing and prepping solutions used, the name of the clinician(s) who performed the prep and any noted skin reactions that occur during the process. Most intraoperative forms have space allocated for this information; if yours does not, make that addition. Check-box formats are an efficient way to record prepping results.

Promoting your preps
With more states moving toward mandated public reports on incidence of surgical infections, documenting your prepping procedures is a great opportunity to promote the precautions you take on every patient. Although time consuming, periodic auditing of skin preps is an excellent way to measure your success in performing surgical skin preps correctly and protecting your patients from possible surgical site infection.