NO ALCOHOL NEEDED? In clean-contaminated surgery, where skin flora is less of a concern, chlorhexidine scrub solution or plain iodophor may be adequate.

Could you defend your facility's choice in skin preps? It's harder than you might think, given the dearth of scientifically proven standards. The CDC has provided some guidelines based on expert consensus, but people are demanding more evidence. Until recently, even AORN shied away from making prep recommendations. Here are 4 evidence-based and common-sense recommendations about skin antisepsis that you can hang your surgical cap on.

1. Use alcohol, but safely
CDC guidelines support using an alcohol-based prep, but do so safely. Free-pouring alcohol is a fire risk because of its fumes and vapors. (Be wary of the doc who says: "I'm going to use some Betadine and then pour some alcohol, and that way, I've met the standards, so I don't have to use a product that contains both.") Let alcohol skin preps dry for 3 minutes; if it gets into really hairy areas, it can take much longer to dry. That's a safety concern, particularly in the presence of a source of ignition, like a cautery or a laser. There can also be a fire hazard if the prep area gets too wet and liquid pools underneath the patient.

2. Chlorhexidine with alcohol vs. povidone-iodine with alcohol
Which is better? Unfortunately, the initial studies haven't really compared them head to head, so this is an ongoing area of debate. I like the fact that the chlorhexidine with alcohol is very effective for a longer period of time than the alcohol-based prep with povidone-iodine. And many would argue that it's superior overall. The Institute for Healthcare Improvement is a huge proponent of chlorhexidine. I expect the new CDC guidelines to recommend a minimum prepping protocol of the night before and morning of a procedure. We probably don't have evidence yet to support beginning the prep 3 days in advance, but it makes some logical sense to do so.

There's a slight drawback with chlorhexidine. Depending on skin color, the prep can be very hard to see. Neither the orange nor the blue colors are really vibrant on the skin. And some physicians ask, what is the sense of a really good skin prep if they can't see it? What we need are clear, randomized studies that address the question of which is more effective.

In choosing between them, the type of surgery may also be a factor. Some surgeons say when you're looking at surgery in which you're particularly concerned about skin flora, alcohol-based preps make a lot of sense. But in other kinds of surgery — procedures in which infections are rarely a result of what's on the skin — you'll hear some surgeons argue against using an alcohol-based prep.

Either way, it's also important to remember that with the chlorhexidine prep, you should use a back-and-forth scrubbing action; with the povidone-iodine based prep, you use a circular motion, starting at the incision site and moving outward.

3. Standardize your skin preps as much as possible
Even in the absence of definitive studies, it makes sense to try to standardize your prep by type of surgery. For instance, for orthopedic procedures, where the No. 1 goal is to keep microorganisms on your skin to a minimum to try to prevent SSIs, there's a lot of information and a fair amount of evidence in favor of chlorhexidine and alcohol prep. So you might decide to use that exclusively, with either wipes or baths, when prepping for orthopedic procedures. Really, with orthopedics, that has become pretty standard — almost a no-brainer.

It's when you look at abdominal and colon and other types of surgery that some disagreement arises. Some doctors do say, it's not the skin flora I'm worried about. And there have been studies in clean-contaminated surgery that show an overall decrease in SSIs with other preps. So depending on the type of surgery, you might decide to just use a chlorhexidine scrub solution, or a plain iodophor absent the alcohol solution.

WHICH IS BETTER? Some experts strongly advocate using chlorhexidine, but there have been no definitive head-to-head studies comparing it with povidone-iodine.

Another consideration: Check to make sure the patient doesn't have any allergies, and that the procedure won't be at a site where alcohol might be contraindicated because it's harmful to the mucous membranes. Be sure to familiarize yourself with the instructions on the alcohol-based preps, because they're contraindicated in certain situations.

Ultimately, you should decide — based on all available evidence — what the appropriate alternatives are for all those cases, and standardize your procedures, so you take the guesswork out of it.

4. Don't shave, use clippers
It's taken years, but the evidence is overwhelming and most people now know that you don't ever shave a patient. If hair has to be removed, and sometimes it does because of the visualization of the site, you clip it and you do so as close to time of surgery as possible. Shaving causes nicks, which let microorganisms enter the body.