The Skinny on Skin Prep Standardization

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Consistency in tracking can prevent complacency and bad habits from sneaking into your processes.


When Stamford Health (Conn.) discovered a lack of standardization in its skin antisepsis protocols, the OR leaders at the facility knew they had act. After all, inconsistency is the enemy of an effective prepping process.

Although Stamford did have a policy in place for skin antisepsis, pre-op practices needed to be updated and improved upon. "There was no way of identifying if patients were in compliance with our requirements because there was no uniform policy for documenting it, and no way to validate the process if it was completed," says Racquel Swaby, BSN, BN, CPAN, nurse manager of perioperative services at Stamford Health. "We had long-established pre-op prepping protocols for cardiac patients where every patient would come in, have their hair clipped around the surgical site and receive CHG wipes."

But the inconsistency involved in applying the pre-op protocols to other patients was a major problem. The health system wanted to follow AORN recommendations and ensure that every patient received some form of skin antisepsis before entering the OR, says Ms. Swaby.

With the gap in its skin prep protocols uncovered, Stamford got to work and fixed the problem. First, it changed its policy and required pre-op assessments to include confirmation that all patients prepped their skin at home with either antibacterial soap or 2% chlorhexidine gluconate (CHG) wipes. (The wipes are required for all total joint, spine and cardio patients). If nurses discovered that a patient didn't comply with the antisepsis policy, the prepping process was completed in the pre-op area.

The facility also ramped up its patient education efforts. "We wanted to make sure that every patient was given clear information, based on their procedures, about what they needed to do for skin antisepsis," says Ms. Swaby.

For instance, information on whether the surgical procedure warranted CHG cleansing at home on the days leading up to surgery was included in information packets given to patients when their cases were scheduled. Finally, Stamford developed a pre-op skin prep assessment tool nurses use to document what they discovered in the pre-op phase. "We worked with our informatics partners to develop a tool that nurses could use to enter information directly into our EMR," says Ms. Swaby.

The major benefit of the assessment tool is being able to track whether the surgical team is compliant with best prepping practices and identify staff members who may need extra education on ensuring patients' skin is properly treated before surgery. "It's a way for us to look back at individual charts and say, 'OK, was this patient assessed for pre-op prep, yes or no?'" explains Ms. Swaby.

Deviation remediation

REPEAT AFTER ME The more standardized your skin prep protocols, the fewer opportunities there are for staff to create their own deviations from proper practice.   |  Pamela Bevelhymer

Whether it's your pre-op antisepsis protocols or the prep that takes place just prior to the surgical incision, standardization is what you're ultimately striving for with skin prepping practices.

"The more standardized you are in your approach, the more it becomes a habit and the fewer opportunities there are for staff members to question practices that lead to their own deviations," says Linda R. Greene, RN, MPS, CIC, infection prevention manager at the University of Rochester (N.Y.) Medical Center's Highland Hospital.

Of course, there are plenty of obstacles that can impact the consistency of a standardized skin prepping process: surgeon preference, supply issues related to purchasing and the pressure staff feel to cut corners in an effort to begin cases on time and keep the case schedule on track.

Although Ms. Greene is quick to point out that everyone in the healthcare industry is always committed to doing everything as safely and as thoroughly as possible, there is a tremendous amount pressure, particularly in the outpatient surgery world, to move quickly. "Oftentimes in the OR, it's about speed and it's about room turnover," says Ms. Greene. "That can lead to variation, and that variation can impact how effectively you prep the skin."

Variation and the subsequent improper prepping techniques can increase the risk of patients acquiring an SSI. So, what can facility leaders do to promote standardization? "Monitor staff's practices in real time," says Ms. Greene. "To make sure everyone is aware of the policy, go around and ask people, 'OK, show me how you perform a skin prep.'" By observing everyone's practices, you may be able to catch problematic deviations or shortcuts before they become ingrained habits.

Ms. Greene believes the most common prepping mistake among surgical teams is not allowing solution to fully dry after application. "In order for the solution to do the work that it's supposed to do, it needs to dry completely, and sometimes that takes several minutes," says Ms. Greene. She points out busy surgeons in high-volume facilities often don't want to wait for the full dry time to elapse.

Another common mistake — one that surgical leaders must do everything in their power to prevent — is not following a prep manufacturer's application instructions. "You really need to follow exactly what the manufacturer says in terms of how long the solution needs to dry and how it gets applied," says Ms. Greene.

Picking the right prep

SPOT CHECK By routinely observing staff's skin prepping techniques, you'll be able to catch issues or shortcuts before they become ingrained habits.   |  David Reidy/CHOC

By far, the two most common skin prepping solutions used by facilities are CHG and povidone iodine. Both have advantages, disadvantages and different application methods, but is either product clearly superior? Not according to the research, says Ms. Greene: "Studies demonstrate that CHG and povidone iodine are equally effective."

  • CHG. One of the advantages of chlorhexidine is that it's not inactivated when it comes in contact with blood and organic matter, says Ms. Greene. That makes it an extremely effective antiseptic and often preferrable option for surgical skin prep before surgery. The downside, says Ms. Greene, is that CHG isn't as visible on the skin as povidone iodine. The solution also shouldn't be used near certain areas, such mucous membranes. For application, CHG requires a back-and-forth scrubbing technique — from the least contaminated area to the most contaminated (clean to dirty) — over the prep site.
  • Povidone Iodine. Though visibility on the skin is excellent, organic matter decreases the activity of povidone iodine, which can be drawback, according to Ms. Greene. However, it's an effective choice for prepping around the eyes and mucous membranes, and on patients who are sensitive to chlorhexidine solutions. In terms of familiarity, clinicians may be more comfortable with the application technique, which focuses on concentric circles as opposed to CHG's back-and-forth scrub. "You begin at the incision site, carry the prep to the periphery and use an ever-winding circular motion — always progressing from clean to dirty," says Ms. Greene.

While many surgeons have their preferred skin prep solution, there's no reason you can't have both CHG and povidone iodine at the ready and ensure your staff is well-trained in using both. In fact, Ms. Greene says many healthcare organizations will provide both in order to account for surgeon preference. But regardless of whether your facility offers many options for solutions or just one or two, the most important thing is ensuring skin prepping protocols are standardized and consistently applied. OSM

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