PROBLEM WITH PREPPING Where protocol recommendations conflict and products abound, there's sure to be practice confusion.

We can all agree that skin prepping is a key early step to reducing surgical site infections. After that, let the debates begin. Which skin prep is the most effective — povidone-iodine, chlorhexidine or iodophor? How best to apply it? Is pre-op hair removal necessary? And what about pre-op showers? Let's have a look at the questions — and attempt to arrive at answers — for each step of the prepping process.

1. Are pre-op showers necessary?
Practice recommendations from professional organizations sometimes differ due to a lack of definitive evidence regarding SSI reduction. There is, however, evidence to show that pre-op showering decreases bacterial colonization of the skin. Further, chlorhexidine gluconate (CHG) in particular has been shown to reduce bacterial colonization of the skin.

Bathing or showering with or applying a CHG liquid (4% in bottle) or cloth (2% in cloths) twice before surgery makes good sense for most surgical procedures, says Ann Marie Pettis, RN, BSN, CIC, the director of infection prevention at the University of Rochester (N.Y.) Medical Center.

"To gain the maximum antiseptic effect of CHG, it must be allowed to dry completely and not be washed off," says Linda R. Greene, RN, MPS, CIC, the director of infection prevention for Rochester (N.Y.) Health System. Those 2 showers recommended before surgery are for Class 1 surgical procedures below the neck. For procedures on the neck or head, 2 pre-op shampoos with CHG are recommended, says Ms. Pettis.

"Although existing guidelines don't address Class 2 procedures, which make up a greater proportion of outpatient surgeries, it's reasonable to think the microorganism reduction would in turn reduce SSI risk," says Ms. Greene.

If you choose to have patients shower with CHG (or less effective povidone-iodine soap, if they have a skin condition that could be exacerbated by CHG), have patients do so the night before the surgical day. (Be sure to instruct patients to keep the solution out of their eyes, ears and nose, says Ms. Pettis.) Then, apply the second dose in the pre-op area on the day of surgery. Ms. Pettis says one way to document that patients followed instructions is to require that they bring their bottles or packages along to the facility.

2. What are ideal uses of alcohol-based prep, CHG and povidone-iodine?
As yet, no professional body has officially recommended one prep over another, since studies have been conflicting. (That could change with the CDC/HICPAC revised SSI-prevention guidelines, slated for release in 2013, says Ms. Pettis.) The 2 most commonly used prep solutions are povidone-iodine (P-I) and CHG, the latter of which has "excellent persistent activity," says Ms. Greene.

It's also been gaining favor over traditional P-I after one often-cited study found fewer SSIs with CHG use, says Ms. Pettis.1 That study, however, was limited, as it didn't compare CHG with a P-I/alcohol combination product. Because of this, "some lingering controversy exists over which prep solution is most effective," says Ms. Greene. "Also, some surgeons feel that the iodine preparation gives greater visibility of the prep site, which they may prefer."

MULTIPLE BENEFITS Single-use chlorhexidine units can apply faster, dry quicker on skin, increase drape adhesion and reduce cross-contamination risk.

Further, despite the increased acceptance for CHG, it's contraindicated in a number of procedures, including those involving mucous membranes.

"[CHG] must not be used for ophthalmic, ENT and some plastic surgery cases," reminds Ms. Pettis. "It's also off-label for neurosurgical cases involving the meninges, nor would it be prudent for use on patients with sensitive skin, such as those with known allergies."

Iodine solutions are tried and true and can be used in procedures involving mucous membranes. Just to confuse the issue more, a 2009 study found iodine povacrylex and isopropyl alcohol to be more effective at decreasing SSIs than either betadine or CHG/alcohol. Contraindications include irritation and toxicity, says Ms. Greene. "And, if left on the skin for extended periods, it can cause 'burning' of tissue, which is something to keep in mind if a procedure is delayed for some reason after the patient has been prepped."

Both P-I and CHG are generally combined with an alcohol base, though P-I is available on its own for procedures in which there's no mucous membrane contact. (If a patient's allergic to iodine, parachlorometaxylenol [PCMX] is indicated.)

"The rapid bactericidal activity of alcohol makes it an excellent prep when used in combination with other active ingredients," says Ms. Greene. That's why "the National Quality Forum has recommended use of an antiseptic combination product. But alcohol should never be used on its own."

3. What are the rules on pre-op hair removal?
"Hair should be removed only if it will interfere with the procedure or is in the best interest of the patient," says Ms. Pettis. And if you're going to do it, use "a single-use disposable electric or battery-operated clipper or a reusable head that can be adequately disinfected between patients."

Depilatories are also appropriate, but can irritate the skin. Whatever method you choose, remove hair "as close as possible to the surgery — no more than 2 hours before," says Ms. Pettis. "And it should be performed outside the OR, in a private area. Wet the skin and hair, as water softens the hair and skin surface, reducing the risk for skin injury."

Razors are inappropriate under all circumstances, says Ms. Greene, even when the skin will ostensibly have a chance to heal before surgery.

"Pre-op shaving of the surgical site, even the night before the procedure, is associated with a significantly higher SSI risk," she says. "It creates microscopic cuts that provide entry for bacteria to enter and a place for them to then multiply."

To ensure compliance, remove razors from the OR and instruct patients not to shave at home before surgery, says Ms. Greene.

4. Should you warm prep solutions?
In your efforts to maintain perioperative normothermia, it might be tempting to warm prep solution so as not to actively cool the patient's skin in the OR. However, doing so can lead to fires or burns with some solutions, warns Ms. Pettis.

"The alcohol solutions in particular are flammable and shouldn't be warmed due to risk of fire," she says. "Heat can change the chemical properties of the active ingredients of some prep solutions, resulting in reduced effectiveness or skin burns. The solution might feel fine to you, but the warmth can creep up on the patient, who can't communicate that to you."

She recommends that you check all manufacturers' instructions to confirm whether warming is allowed. For example, PCMX specifically states, "Do not heat."

STERILE SPONGE? Use of sterile versus nonsterile products in prep application, such as sponges for povidone-iodine, remains an unresolved issue.

5. What's the current thinking in methods of prep application?
Before you begin, says Ms. Pettis, make sure the patient's skin is clean, with no residual cosmetics or lotions. Remove all body jewelry. Use the no-touch technique to apply the prep, starting at the incision site and moving outward — in concentric circles with P-I solutions or in a back-and-forth motion with a prep containing CHG.

Whichever applicator type you're using, it should be discarded after use in a "highly contaminated area," such as the groin, feet, axilla or rectum, "regardless of whether there's still solution remaining," she says.

The use of sterile versus nonsterile products (such as a sponge for P-I) in prepping remains an unresolved issue per the CDC guidelines. "One potential advantage of all-in-one applicators is that everything is sterile out of the package," says Ms. Pettis. "It's just another potential assurance."

Although all-in-one products can be more costly on an individual basis, clinicians may find that they're cost-effective in the long run, because appropriate application and product use are keys to the effectiveness of the prepping process.

Whatever you choose, remove any wet items after prepping, and let the solution dry to maximize efficacy. And don't let preps collect on or pool underneath the skin, especially when using alcohol-based products. This lets any vapors dissipate before applying surgical drapes, using electrodes or lasers, or activating a fiber-optic light cable, which helps prevent fire, says Ms. Pettis. "Avoid getting the prep too close to the patient's hair, as hair damp from prep solution can be flammable, too." Finally, use an approved site marker to ensure the surgical site isn't damaged or sensitized by this key step before the procedure begins, says Ms. Pettis.

6. When should patients be instructed to shower post-op?
Although there's no standard regarding post-op showering, instruct patients to gently remove the prep solution around the incision site with warm water or saline solution, says Ms. Greene. "Care must be taken to keep the incisional area dry for the period instructed by the physician. Depending on the type of surgery (for example, if an extremity is involved), the surgeon may instruct the patient to shower provided they do not get the operative area wet."

One advantage of CHG is that it has residual activity on the skin for several days after application, notes Ms. Pettis. When that prep has been used, "most surgeons seem to recommend that the patient not shower for at least several days," she says.

References
1. Farouche RO, Wall Jr MJ, Itani KMF, et al. Chlorhexidine-alcohol versus povidone-iodine for site antispesis. N Engl J Med. 2010;362(1):18—26. Available at http://www.nejm.org/doi/full/10.1056/NEJMoa0810988
2. Swenson BR, Hedrick TL, Metzger R, et al. Effects of preoperative skin preparation on postoperative wound infection rates: a prospective study of 3 skin preparation protocols. Infect Control Hosp Epidemiol. 2009;30(10):964—971.