You're probably aware that most surgical site infections are caused by patients' microbial skin flora flaking into surgical wounds. You also know skin prepping eliminates resident and transient microbes on the body's first line of defense against infection and prevents the growth of microorganisms around the incision site. But are you certain your staff applies pre-op skin prep solutions correctly and allows enough time for them to dry? Don't count on it. National statistics show that surgical teams follow proper application instructions and allow for adequate dry times in fewer than half of all cases.

You need to ensure your staff isn't part of that troubling trend, and internal audits are a proven way to identify where gaps in best practices are occurring. There are many competency tools available to help guide observations of your team in prepping action, including AORN's Competency Verification Tool for Skin Antisepsis (osmag.net/VkY7jQ) or the Agency for Healthcare Research and Quality's (AHRQ) Surgical Skin Preparation Audit Tool (osmag.net/jHM3mS). Some tips for effective auditing include:

• Ensure the auditor is familiar with the manufacturer's instructions for the specific prepping product being used.
• Use an auditor who is not assisting with the skin preparation, so she can objectively document each measure.
• Perform audits randomly and across a variety of procedures to achieve a more global assessment of compliance.
• Audit as many procedures as you can. The AHRQ tool recommends auditing at least 10 procedures, although it points out that "the more patients you review, the more likely you are to identify opportunities to improve the adequacy of surgical skin preparation."
• Pay attention to proper prepping of specific body areas. For example, before shoulder surgery, ensure the axilla, an area of higher microbial colonization, is prepped last. In abdominal procedures, ensure the umbilicus is prepped first in order to avoid splashing debris from the umbilicus onto the prepped abdomen.
• Monitor these skin prep variables as well. Among the Association of Surgical Technologists recommendations for proper documentation are patient education and pre-operative instructions, assessment of allergies, removal and handling of jewelry, method of hair removal if applicable, prep parameters and time of prep (including dry time).

Don't hesitate to engage industry professionals to assist with evaluating and improving compliance with best practices. These industry reps are well versed in their products' directions for use and can provide an element of objectivity in the assessment process. In many cases, they will also provide interventions to improve compliance in those areas demonstrating need.

Most experts agree that education is key to improving compliance with best prepping practices. Importantly, discuss the evidence behind dry times and application techniques. For example, studies involving 2% chlorhexidine gluconate (CHG)/70% isopropyl alcohol prep solutions have shown that a back-and-forth application technique, starting with the least contaminated area and moving to the most contaminated area, is the most effective means of working the solution into the outer layer of the skin. This allows for killing of the bacteria that reside there, while minimizing redistribution of bacteria. After observing your staff's prepping techniques, capitalize on all available opportunities to provide them with feedback and education that will improve their techniques:

• Use staff meetings to discuss audit results and to review prepping guidelines.
• Schedule industry professional-led in-services on best practice, including application technique, appropriate maximum and minimum surface area per applicator, proper prep and dry times and variations in application according to body area.
• Educate staff on the evidence and rationale behind each component of best practices, so they fully understand why proper technique matters.
• Conduct one-on-one education sessions with staff members who have trouble putting best practices into action.
• Provide prepping protocol reminders during daily staff huddles.
• Create a standardized prep chart, based on your facility's preferred products, that notes proper application methods and required dry times.

Efforts to improve compliance with best practices might also include limiting the number of skin prep products your facility uses. At the Infectious Disease Society of America's 2018 ID Week conference, researchers from the University of Texas Southwestern Medical Center presented the results of their experience auditing skin prep compliance. After finding that staff applied the appropriate prep in only 3% of cases and followed dry times only 41% of the time, they knew they not only had to educate staff. They also had to limit the skin prep agents available at the institution.

They found that the facility had 9 different product options and that, for povidone-iodine solutions, the scrub and paint directions for use differed between 2 and 3 different manufacturers. As a result, the researchers chose to reduce the number of prep solutions available for use in an effort to limit the variability of appropriate application techniques and dry times. Their efforts worked: Prep time compliance for 2% CHG/70% isopropyl alcohol and aqueous CHG solutions went from 6% to 50% and from 0% to 40%, respectively. Dry time compliance for aqueous CHG and povidone-iodine solutions jumped from 48% to 84% and from 14% to 78%, respectively.