The Essentials: Peerless Skin Prep: Here’s How

Practical, evidence-based strategies decrease the microbial load on patient skin and reduce surgery-related infection.

Skin antisepsis practices that destroy microorganisms and inhibit the microbial load on your patients’ skin should be the cornerstone of every surgical procedure involving a skin incision.

Making it happen requires total team buy-in. “Standardization, specific team actions and information sharing must align to ensure effective skin antisepsis for every patient,” says Karen deKay, MSN, RN, CNOR, CIC, lead author of AORN’s Guideline for Preoperative Patient Skin Antisepsis.

Perioperative consultant Peter Graves, BSN, RN, CNOR, agrees, adding, “If we are really serious about reducing infection rates, every member of the team has to be both intentional and deliberate with following evidence-based practices for safe and effective skin antisepsis.” Ms. deKay and Mr. Graves break down the basics of effective surgical skin antisepsis by standardizing your skin prep solutions, protocols and tools, and share tips for auditing your staff’s performance through the entire perioperative process.

1. Standardize skin prep solutions for all patients and train.

The goal of surgical site preparation is to rapidly remove transient microorganisms and maintain resident microorganisms at subpathogenic levels. This decreases the microbial load — and the risk of a surgical site infection developing.

The basic approach to achieving this subpathogenic microbial state starts with assessing the patient to ensure the correct skin prep solution is chosen, one that is both safe and effective for the individual patient and for the procedure, according to Ms. deKay. “Skin microbiota varies depending on body site location. Consequently, each body part may have different responses to the same skin antiseptic,” she says.

She highlighted these key skin prep assessment factors from the AORN guideline:

• Site of surgical incision
• Proximity to eyes, ears and mucosa
• Skin integrity
• Skin tone to ensure the prep solution is visible
• Allergies and sensitivities, such as susceptibility to iodism
• Patient age, such as neonates who have increased sensitivity to skin agents, and
• Amount and thickness of hair near surgical site and area where drapes will be placed.

Several prep solutions are FDA approved and on the market for preoperative patient skin antisepsis, including alcohol-based products with either iodine povacrylex, iodophor or chlorhexidine gluconate (CHG) as a secondary agent. A new alcohol-based skin antiseptic with functional excipients is projected to be released later this year.

No matter which skin prep product you choose, Mr. Graves stresses the importance of standardizing it for the majority of surgeries when not contraindicated to support correct use. “Reducing variability with products and having the antiseptic vendor come in to do staff in-services on the proper application per manufacturer instructions for use is important to help team members follow specific requirements for actions such as drying time,” he says.

Once a skin antiseptic product is implemented and staff are trained to use it correctly, Mr. Graves says practices need to be validated with regular spot checks to make sure skin prep is being done correctly. “With the understanding of how practices are lacking or providing examples, ASC leaders can use these findings to establish constant feedback focused on antiseptic application.”

GRAVE ADVICE Peter Graves (pictured) consistently reminds surgical leaders that one of the best deterrents against bad prepping habits is simply speaking up in real time or, as he puts it, “if you see something, say something to encourage best practices.”

2. View skin antisepsis as a part of wound care.

While selecting an evidence-based alcohol-based skin prep product is often the easiest step in achieving standardized skin antisepsis, evidence-based behaviors must also be put in place to minimalize the bacterial burden that could risk infection, says Mr. Graves. He suggests ASC staff and leadership view skin antisepsis as one action in the larger effort to care for the surgical wound throughout perioperative care, whether preparing the surgical site, using sterile technique in applying an antiseptic and managing sterile draping, or observing the surgical incision throughout the surgery and maintaining the sterile field.

The AORN Guideline supports this focus on standardized wound protection through the course of surgical care by zeroing in on three main actions: site preparation before application of the skin antiseptic, application of the skin antiseptic using sterile technique and safety measures to prevent patient skin injury related to skin antiseptic use, according to Ms. deKay.

• Prepare for skin antisepsis. Hair management is critical to get right to ensure effective skin antisepsis. Best practice is leaving patient hair in place unless it interferes with vision of the surgical field, makes wound closure difficult, would cause the drape or dressing not to adhere, or creates a fire risk with the use of alcohol-based prep.

It’s important to evaluate the amount and thickness of a patient’s hair because this can impact drying time and may require an alternative to an alcohol-based prep, particularly in cases when it might not be feasible or desired to remove large amounts of hair.

“Do not remove any more hair than is needed, remove hair as close to start of surgery as possible and remove hair in an area outside the procedure room,” says Ms. deKay.

FREE RESOURCES

Tools for Standardizing Skin Antisepsis

In coordination with AORN releasing an update to the Guideline for Preoperative Patient Skin Antisepsis, a number of complementary resources for AORN members will be released soon to help any team standardize their skin prep, according to AORN’s Karen deKay, MSN, RN, CNOR, CIC.

Here are a few helpful resources she recommends:

• In Guideline Essentials for Patient Skin Antisepsis: Find a Gap Analysis Tool to support auditing, a Policy and Procedure Template to standardize practices and antiseptic selection tools, including an Analysis of CHG vs. Povidone-Iodine, Selection Algorithms and a Surgical Skin Antisepsis Chart to help with patient assessment.

• In the AORN Journal: Find “Skin Prep-at-a-Glance” articles first published in July 2021 in the Periop Briefing section. Using product IFUs, these articles outline the recommended procedures, along with illustrations for a variety of anatomical areas, such as lower extremity, upper extremity, hip, shoulder, eye, scalp and vagina.

• In the eGuidelines+ subscription: Find “At a Glance: Skin Prep Sheets” that can be viewed electronically covering many different anatomical areas and look for “Pocket Surgical Site Prep” cards free to AORN members slated for release later this year.

—Carina Stanton

“There are times when patient dignity may require hair to be removed in the OR, such as for OB/GYN or urology procedures,” adds Mr. Graves. In these situations, he reminds staff that vacuum-assisted clippers should be used to suction hair upon removal to prevent infection risk in the OR.

Another skin tip: Don’t forget to have your patients degerm before surgery, not just through pre-op bathing and nasal decolonization, but also “by simply having them wash their hands before surgery because they will likely touch their wound or dressings after surgery.”

• Apply skin antiseptic following IFUs and using sterile technique. Remember that strict adherence to sterile technique applies to preoperative skin antisepsis, says Ms. deKay, adding that employing single-use antiseptic dosing and drip towels before prepping and removing them after prepping is paramount. “More solution is not necessarily better, so use only what each antiseptic applicator identifies as the area it will cover,” she says. “Although, if a skin surface area is larger than indicated by the products, another applicator may be necessary.”

Pay attention to your application movement — back and forth or in circular motion — and specific drying time that includes checking the prepped area is dry, such as a change in solution appearance from shiny to dull.

“Staff should constantly monitor the prepped wound area in order to maintain the sterile field,” says Mr. Graves. “Drapes should be left in place until the wound is sealed and the dressing is in place. If dressing changes are needed after a wound has been dressed in the OR, make sure to use sterile technique.”

• Reduce the risk of patient injury. It’s important to recognize specific patient safety dangers that can occur during antisepsis, including skin damage for multiple reasons, says Ms. deKay.

For example, excessive friction during application can damage skin. Prolonged exposure to skin antiseptic can also be a problem, particularly if sheets, padding or positioning equipment become saturated with the antiseptic. Plus, this could increase the risk for surgical fire, especially if antiseptic doesn’t dry before surgical drapes are placed.

3. Use surveillance and data analysis to audit skin prep compliance.

Mr. Graves and Ms. deKay agree that collecting compliance data through audits, and analyzing and sharing infection rate data, are key to monitoring and improving skin antisepsis. They each offer several tips to help in this area.

Ms. deKay recommends convening an interdisciplinary team that includes frontline staff, ASC leaders and infection prevention experts to evaluate antiseptic products for your specific patient population and coordinate staff training with product vendors. “When a new antiseptic product or process is introduced, this team should be proactive in providing staff-wide education for correct use,” she says.

Once an antiseptic product is implemented, she suggests creating an audit tool with key elements of performance and to develop a plan to train auditors, complete audits and report findings.

If you are using electronic health record (EHR) documentation, which permits data collection on skin antisepsis practices, it can be beneficial for auditing compliance on the type and location of the skin prep chosen, Mr. Graves suggests. “Some EHR systems support reports that recognize when a skin antisepsis-related practice has been missed,” he says. “This allows leaders to ensure facility-approved skin antiseptic practices are being followed and monitored.”

EHR systems can also make it easier to monitor SSI rates — data that should be shared with frontline staff so they understand if there is a need for practice improvement.

Don’t underestimate the value of simple actions such as encouraging peer-to-peer communication and self-monitoring around skin antisepsis practices. “If you see something, say something to encourage best practices,” says Mr. Graves. “And remember, this communication goes both ways — encourage feedback from ASC staff because sometimes the best-laid plans are not achievable, and you want to encourage staff to tell you when something with your skin prep process is not working.” OSM