When I got my first nursing job as an OR circulator more than 14 years ago, the standard prep was a paint-and-scrub with povidone-iodine unless the patient had a topical iodine allergy. Now there are several specialty products available and many issues to consider, chief among them the prep's ease of use, cost, efficacy, the physician's prep preference and the type of surgery to be performed.

One size doesn't fit all
As my facility's director of both operations and nursing, I'm concerned about controlling costs and preventing infection. An injection for pain requires just an alcohol prep applied with gauze, while an invasive spine procedure such as a microdiscectomy requires a thorough paint-and-scrub job with povidone-iodine to help prevent infection. Because it's sticky, povidone-iodine gel works well for prep jobs on odd-shaped areas — when prepping from the chest all the way down to the fingers before a shoulder arthroscopy, for example. We also use povidone-iodine solutions for cataract procedures by diluting the povidone-iodine 1:1 with saline solution before pouring the mix over a 4-by-4 gauze. The gauze collects the solution like a sponge would and can be used to wipe over the eye area.

It's wasteful to open a pre-packaged surgical povidone-iodine gel kit to prep a patient having a small superficial lesion taken from an arm. In this case, grab a pack of gauze sponges and a bottle of povidone-iodine to save money on a small, relatively non-invasive procedure. Meanwhile, the self-contained applicator prep of iodine-alcohol may not be the best choice when the surgical site requires a large area to be prepped, such as a full leg. You might need more than one applicator and may have trouble prepping properly between the toes because of the applicator's shape.

While we don't have written protocols regarding the use of preps, we do have our house favorites. We order a lot of povidone-iodine and keep it in the sterile storage area. We also stock paint-and-scrub prep trays, trays for povidone-iodine gel, hexachlorophene for patients with iodine allergies and alcohol that we apply with gauze. We keep a few backup prep kits in the ORs so we won't have to run out of the room in case one becomes contaminated. On Fridays the techs restock for the coming week, based on the type and number of procedures scheduled. That way we usually have enough time to order anything that might be missing.

Always consider how easy a prep is to apply. A povidone-iodine gel prep is my preference for an extremity because the gel is a one-step product, eliminating the extra work performed during the paint-and-scrub preparation. This ease-of-use is helpful when holding an extremity, especially the arm or leg of an obese patient — those can get heavy pretty quickly. One drawback with gel is that it's slippery. So when you're prepping an extremity, you may need to ask someone to help you hold it.

While personal preference can be subjective, cost isn't. The prices of preps vary greatly and you can save quite a bit if you pay attention to the preps that you use on specific procedures. A bottle of povidone-iodine solution used with a pack of gauze sponges can cost less than a dollar, while some of the name-brand preparations may cost four times as much. You can also save by buying larger packages, when possible. For example, when doing a lineup of cataracts in a single day, you can use a large 16 ounce bottle of povidone-iodine solution for multiple cases. This creates savings over the individually packaged 4 ounce bottles.

Many studies have compared the available prepping products and their efficacies (you can download many of these from the manufacturers' Web sites). Having read several studies, it's sometimes difficult to see if one product's efficacy is truly superior. Not surprisingly, each manufacturer claims theirs is best. But you can determine the nuances between the products and the best ways to apply individual preps by closely studying the manufacturers' directions.

When reading those directives, be aware of safety issues. Some solutions are safer than others when used on a particular area of the body. Other preps aren't advised for use in specific areas. For example, alcohol and hexachlorophene shouldn't be used around the eyes or the body's mucous membranes because these solutions can cause irritation. And throughout my career, I've only ever used povidone-iodine solution when performing a vaginal prep, whether that prep is used before placing a Foley catheter or for preparing the area before surgery.

Preference cards?
Surgeons' preference cards are often faxed from the main OR of the hospital where he operates. The clinical director of a hospital's main surgical unit often secures better per-unit prices on supplies because she buys in larger quantities than her colleagues in the outpatient arena. For that reason, the staff of a hospital's main OR is sometimes less likely to question a surgeon's preferences. However, those of us in the outpatient setting need to question costs. When preference cards arrive, they're sometimes outdated. It's your responsibility to know. Don't rely on the surgeons — they have other things on their minds.

At our facility, we store physicians' preference cards on a computer. Once a tech is assigned a procedure, she prints out the card and gathers needed supplies, including the preferred surgical prep. At the end of the procedure, the tech looks at what's left over. She notes what was used, what was opened but not used and anything that was requested during the procedure but not found on the card. She then uses this information to update the card in the computer. If during two or three consecutive procedures a surgeon doesn't use something that we've pulled, we remove it from the card. That goes for each supply and prep we pull.

While I'm a stickler when it comes to infection control, I don't hesitate to question a physician before opening a surgical prep on his preference card if another more suitable prep might be substituted. Sometimes the prep requested doesn't match the procedure, such as using a full pre-packaged prep tray for a minimally invasive facet injection in the back. In other cases, the prep requested is more expensive than a similar product that is less expensive. If need be, explain to physicians that staff experience, training and prepping technique are just as effective at preventing infection than the latest name brand. Most physicians understand this. If they don't, you may need to ask for persuasive help from cost-conscious physicians. A few years ago, a surgeon insisted that I prep an entire leg with small prep solution applicators before an ACL procedure. I did it, but it cost 10 times more than it should have. I mentioned this to another surgeon and explained the unneeded cost involved with this overprepping. I asked if he'd be willing to talk to the doctor about his prepping protocol. He was, and we got the surgeon to change his prep preference.