Skin Preps Are Simple. Compliance Is Complex.

Here’s how two facilities keep SSIs at bay by better ensuring this crucial task is properly and consistently performed.

Preoperative skin prepping removes potentially harmful bacteria and microorganisms from the patient’s skin before the surgeon makes an incision.

Sounds simple. Sounds straightforward. And from a clinical perspective, it is. But patient compliance is a significant variable, as they are often instructed to bathe with soap and water or chlorhexidine gluconate (CHG) at home before going to the surgery center. The question is, will they? Or, more to the point for clinicians, did they? Then there are providers who may view proper skin prep as just another box on the pre-op checklist that may or may not be performed or documented properly during a busy day. Do your providers truly understand the reasons why they are expected to do this?

At AORN Expo in March, two posters by OR nurses focused specifically on skin prepping. Here’s what they learned, and what other surgical facilities can apply to their workflows.

Become data-aware

At Nemours Children’s Hospital in Orlando, Fla., an ongoing improvement project for skin preps began in 2019. “We had an increase in SSIs and wanted to know what we were doing well and where our opportunities were for every point that touches the patient — antibiotic use, skin prep, prep solutions, hand hygiene, hand scrubs, essentially every aspect of our care,” says Clinical Nurse IV-OR Yasmin Sookram, RN, BSN, MSN, CNOR-PEDS.

An independent third-party consultant observed the hospital’s perioperative practices and provided a baseline assessment. Skin preps became a primary focus. “We asked them, ‘How are we doing with skin preps? Are we prepping with recommended solutions? What does our technique look like? What does our education look like?’ And we failed across the board,” says Ms. Sookram, who didn’t take it personally. “We were just like the rest of the nation. We knew no one was prepping right, no one was consistently using the recommended solutions or proper technique according to manufacturer’s instructions for use (IFUs).”

Ms. Sookram’s and her poster coauthors — Clinical Nurse Educator Kathryn Farrell, MSN, RN, CNOR, CPN, and Risk and Performance Improvement Analyst Cathryn Gianfalla — acted quickly to correct the most crucial points of failure: a wide variability in skin prep solutions. “We were not using alcohol-based solutions consistently, which are recommended unless it’s contraindicated or if there’s a patient allergy,” says Ms. Sookram. When the team assessed its skin prep inventory, it found solutions not recommended by AORN, CDC, WHO and the American College of Surgeons.

The team first worked to streamline and standardize specific skin prep solutions throughout the system. This high-level process, led by Ms. Farrell, required the involvement and acceptance of administration, leadership and especially the surgeons who ultimately decide which skin preps should be used on their patients. Some were reluctant to change time-honored clinical practices they believed in and found effective and safe, so Ms. Sookram and her team needed to make a compelling case.

“This was all driven by data,” she says. “We showed them the evidence. Kathryn went to multiple meetings with surgeons, leaders and administrators and told these key stakeholders, ‘This is a big change. This is impactful. Here’s how it’s going to impact you. This is the reason why.’”

Surgeons, nurses and techs were then educated on the standardized solutions — CHG with isopropyl alcohol, povidone-iodine with isopropyl alcohol and povidone-iodine scrub and paint solution.

Manufacturers visited to review and demonstrate their IFUs and best practices for proper application with the nurses and surgical techs, who return-demonstrated; this education is reinforced annually. A “train the trainer” program was launched with five OR nurse champions to maintain the sustainability of the changes.

Once education and training was completed, auditing of skin preps began. OR nurses performed 10 skin prep audits per month on peers to encourage and confirm compliance with processes, IFUs and AORN patient skin antisepsis guidelines. “The only way you know a process is working is through direct observation during prepping and giving feedback in the moment,” says Ms. Sookram. She says nurses complied with the audits because the messaging behind them is clear.

“The reason for these preps and why we’re performing the audit is because it impacts patient care,” Ms. Sookram says. “We’re trying to reduce SSIs. We always go back to that. We tell them that this observation is us helping you take great care of your patients. It has been very collegial and professional, in the spirit of wanting to do better, to improve, to work toward excellence.” As compliance improved, audits were reduced to five per nurse per month.

At first, nurses documented the audits on paper, which made data collection, aggregation and analysis difficult. “I was the person who collated all the data, which was very cumbersome,” says Ms. Sookram. “Paper gets lost, people don’t turn in audit papers, and collating the data took hours of time.” Audit data collection was shifted to a mobile phone app using a REDCap survey containing all of the audit’s compliance fields. Resulting data at first was retrieved, aggregated and analyzed by Ms. Gianfalla using a spreadsheet, which created a one-month time lag in the data shared with OR leadership and staff. Now Ms. Sookram can see and interact with real-time audit data via a computer dashboard, which enables quicker corrective action. “It’s helpful to not have to wait a month to get the data back, and it helps to improve our sustainability for excellent skin prep,” she says.

Education and reinforcement continue in perpetuity, driven by the data insights Ms. Sookram now enjoys. “During our 10-minute huddle every morning, a couple seconds is devoted to talking about skin preps, about where we’re not meeting our standards and also where we’re excelling,” she says.

Because of this ongoing intervention along with other infection prevention initiatives, Nemours’ SSI rate has declined. Ms. Sookram says success starts with educating staff on the basic facts of why alcohol-based preps should be used, and what a proper prep looks like. “Give them the evidence, the facts, the data,” she says.

Ensure patient compliance

At Phoenix Children’s Hospital, the neurosurgery division’s SSI rate was trending up. A common cause analysis of SSI data revealed organizational inconsistencies and documentation variations surrounding the preoperative bathing process. An improvement project was launched, with a focus on educating clinicians and parents about the importance of preoperative bathing, developing a more effective protocol and better assuring compliance.

The improvement team included Karen Johnson, MSN, RN, CNOR, perioperative clinical education specialist, Martina Lisi, MBA, MHA, BSN, RN, CPN, director of perioperative nursing services, and Kelli Teal, MPH, CIC, senior infection preventionist. They focused on a two-step pre-op bathing process: a bath or shower with soap and water at home within 24 hours of surgery, and then a CHG wipe down in pre-op. If the family didn’t perform the first step, nurses used hospital-approved bathing wipes on the patient before the CHG wipe down. Such a system was already considered evidence-based best practice but wasn’t standardized throughout the organization, and often wasn’t performed or documented properly. “Some patients just got the CHG wipes, some just got the baths,” says Ms. Lisi. System-wide auditing and documentation issues also needed to be addressed. “Everybody was charting the wipes or bath or CHG in different places,” she says.

The team succeeded in making the two-step process required as part of hospital policy, and standardized auditing and documentation in the electronic health record. Nurses now use radio buttons to check off elements of the two-step bathing process as part of their charting flow. A pop-up window reminds nurses to ask parents if the at-home bath was performed. Audits are regularly performed.

The biggest component for success, says Ms. Lisi, is education — of providers and of patients and their caregivers. For staff, a culture change was necessary. “It had been just another task added on to their daily grind in the morning, which is really fast and furious sometimes, especially in the outpatient world,” says Ms. Lisi. “It’s about education — saying, ‘We’re doing this to reduce risks of infection after surgery, and these are the reasons why,’ telling a story about a patient who had an infection and how long it took them to heal, the prolonged appointments and therapies and everything afterward. It’s about being an advocate for our patients. Telling the stories, I think, helps them realize, ‘Okay, this is not just another task. There is a reason we’re doing this. We may not be able to see it, but we know it’s going to be helpful.’ And I think now it’s just second nature to them.”

Ms. Lisi preaches patience when trying to transform organizational culture. “Be persistent, collect the data and adjust every month,” she says. “It’s hard when you go a beyond a month to try to change habits. It took us about a year to establish this. Celebrate the little wins, keep at it and you’ll see a difference.”

Patients and caregivers, meanwhile, must understand the importance of cleanliness to prevent infection. Parents receive written and verbal bathing instructions from nurses during pre-op phone calls, clinic visits and testing, as well as with forms and questionnaires sent via text message. “Every touchpoint where we talk to the family or a nurse interacts with the family, they get that education,” says Ms. Lisi.

Staff and patient compliance with the two-step bathing process has increased as SSIs have declined, and the policy is now implemented beyond neurosurgery to all divisions and surgical service lines systemwide at Phoenix Children’s. Compliance, which had been in the 80% to 85% range, is now consistently at 95% or better. OSM