Surgical Skin Preparation in the Operating Room Chesapeake Bay Perioperative Consortium In 2009, it was estimated that SSI extended the length of hospital stay on average by 9.7 days and increased costs by $20,842 per admission; this amounts to additional hospital costs exceeding $900 million, with hospital readmission due to SSI accounting for an additional $700 million in health care spending (PMC, 2009). Insurance will not cover these costs & hospitals must absorb these expenses. Add to that the cost of lost wages, the effect on quality of life, or in extreme cases loss of life makes this a very important topic for perioperative nurses and staff.

Objectives Recognize the importance of the surgical skin prep. Differentiate prep solutions and their applications. Demonstrate the application of each prep solution. Review special consideration when performing a surgical skin prep. Correct documentation as per organization process.

Statistics The estimated annual incidence of SSIs in the U.S. ranges from 160,000 to 300,000, and the estimated annual cost ranges from $3.5 billion to $10 billion. On average, a surgical site infection increases the hospital length of stay by 9.7 days.

Background Joseph Lister Complete bacterial antisepsis of skin is not possible A brief historical background should start with Joseph Lister. His name may be slightly recognizable for some – his name is still reflected on a product which can be purchased at any drug store to this day - Listerine. Joseph Lister was the father of antisepsis. As a surgeon, he was concerned about the infection rate & prevalence of gangrene. Lister went of to study wound infection based on Pasteur’s germ theory (Waxman, 2012). Bacterial counts on skin can be reduced with effective surgical preparation however, skin cannot be sterilized. The overarching goal of any surgical prep is to “….remove dirt and transient microbes from the skin, to reduce the resident microbial count as much as possible in the shortest time and with the least amount of tissue irritation, and to prevent rapid rebound growth of microbes.” (Rothcock, p. 101)

Skin an overview The Skin is the body’s largest organ. It serves as the primary protective layer. BUT: it also carries thousands of naturally occurring bacteria, most of which are harmless 80% of skin flora (bacteria and fungi) reside in the first five cell layers. If the skin is not properly cleaned before an incision, microorganisms can lead to an infection.

Very Important! Bacterial counts on skin can be reduced with effective surgical preparation. Skin cannot be sterilized. The goal of any surgical prep is to remove dirt and transient microbes from the skin, to reduce the resident microbial count as much as possible in the shortest time and with the least amount of tissue irritation, and to prevent rapid rebound growth of microbes.

AORN AORN Recommended Practices for Preoperative Patient Skin Antisepsis (2017) AORN provides guidelines with respect to professional practice in the perioperative setting. This reference should be available to staff either in an electronic form or in hard copy, as this contains valuable information for the perioperative staff. Published recommendations are compiled using research to develop an evidence-based practice while allowing for adaptability for each unique setting (AORN, 2017). It is important to note any changes in recommended practices which are noted in the front of this manual, or by visiting the AORN web site. These guidelines are the

Pre-admission Collective evidence supports that preoperative bathing may reduce microbial flora on patients skin More information needs to define optimal peri- operative bathing procedures, including whether antiseptics are more effective than soaps There is a body of evidence supporting the use of 2% CHG- impregnated cloth products for preoperative bathing AORN recommends pts. perform preoperative baths or showers. Additional research is need to define optimal pre-operative bathing procedures (soaps vs antiseptics) optimal timing, number of baths/showers and sites. Patients undergoing surgery to the head are instructed to wash their hair the night before & morning of surgery to decrease microbial counts & resident flora. Patients are instructed to take care & avoid getting the solution in eyes, ears, or any mucous membranes. They are also instructed to rinse thoroughly, dry w/ a fresh clean towel, & wear clean clothing afterward (AORN, 2017).

Pre-admission cont. After preoperative bath or shower, DO NOT USE: alcohol based hair or skin products Lotions Emollients Cosmetics DO NOT APPLY DEODORANT NO HAIR REMOVAL- DO NOT SHAVE OR USE DEPILATORIES

Pre-Op Recommendation IV Hair removal at the surgical site should be performed only in select clinical situations. Patients hair should be removed in a location outside the operating or procedure room. Single-use clipper heads should be used and disposed after each patient use. The reusable clipper handle should be disinfected after each use. Strong evidence suggest that hair should be left in place at surgical site (i.e. braiding with long hair on the head or nonflammable gel) to keep hair out of the surgical site. Patients are instructed to refrain from shaving themselves, and especially from shaving with a razor which can cut skin & result in a higher risk of SSIs. Hair removal should be in a location outside the operating room or procedure room (AORN 2017)

Razor verses Clipper

Preparation Recommendation III The antiseptic agent used should be selected based on the patient assessment. Identify any contraindications such as allergies, mucous membranes, neonates. The skin marker should be alcohol-based, be visible after the prep, & not facilitate microbial growth. Manufacturer's guidelines Determine the surgical site including the amount of area necessary to be included in the prep. Review allergies & intolerances with patients before sedation or transfer to the operating room. If a patient reports a shellfish allergy, ask if they also react to iodine products on the skin. Ascertain any surgeon preferences and gather the necessary supplies. If you are unsure, please do not hesitate to ask questions either of your preceptor or knowledgeable colleague. Skin markers are used to confirm the surgical site prior to the time out process. It is important to discourage surgeons from using ball point pens. The nurse should clean areas of greater contamination within the prep area (ie, umbilicus, foreskin, under nails, urinary or intestinal stomas) before prepping the surgical site and should isolate areas of high contamination (eg, anus) with a sterile barrier drape

Prep Solutions Recommendation II FDA approved or cleared / approved by the organization’s infection control department MSDS Effective and safe Skin preps must undergo rigorous testing & scrutiny before they are approved & placed into use in a medical setting. The agent used should demonstrate the following qualities: significantly reduce the microbial count on contact with the skin, be non-irritating to the skin, be broad spectrum, fast acting, & have a persistent effect (AORN, 2017. Like any chemical agent found in your organization, information about surgical prep solutions should be readily available in your MSDS notebook. It is important to take the time to read the manufacturers‘ instructions & follow the recommendations therein re. use, handling, and storage.

Betadine 7.5% PVP-I Scrub1 0% PVP-I Paint Solution- Scrub of the operative site should begin at the incision site, working toward the outer parameter in a concentric circular motion for 5 minutes(this time can be broken up between multiple sponges). Blot and apply paint. Paint solution should be applied starting at the site of the incision, working in a circular motion out to the perimeter of the area prepped. Providone iodine is a 2-step prep starting w/ the scrub solution. Remove any surface debris before starting any surgical skin prep. Place absorbent towels on either side of the patient to prevent pooling & prevent any chemical burn or reaction. Start by using winged or flat sponges dipped in scrub solution, starting at the incision & in a circular motion working to the periphery. Repeat this process using all sponges in your kit, taking care not to bring the sponge from dirty to clean (incision). Using a towel in your kit, blot the scrub solution & remove the towel, taking care not to contaminate the prepped skin by dragging your blotting towel across skin. Taking a sponge stick dipped into the prep solution, repeat the process with the iodine soln., leaving the solution in place. Remove any towels placed on the patient’s sides & evaluate for any pooling of solutions.

Duraprep Paint- do not scrub 0.83% Povidone-Iodine 72.5% Isopropyl Application: Apply a thin, even coat starting at the incision site and working outward in a circular motion. Excess solution should not be blotted, but simply allowed to dry. Duraprep is a one step prep which combines the speed of alcohol with the long coverage of betadine. It has a dry time of 3 minutes before draping a patient as fires have been ignited by electro-cautery pencils are used in contact with the highly flammable alcohol content. This prep solution cannot be used on mucous membranes because of the alcohol component but is very popular with orthopedic surgeons as the prep solution remains on the skin after surgery, crating a barrier & long-term microbial protection.

Chloraprep Chlorhexidine gluconate 2% & Isopropyl alcohol 70%. For dry surgical sites (i.e., abdomen or arm): Use repeated back-and-forth strokes of the sponge for approximately 30 seconds on the incision site and outward to the periphery. For moist surgical sites (i.e., inguinal fold or axilla):Use repeated back-and-forth strokes of the sponge for approximately 2 minutes on the incision site and outward to the periphery. Total prep time: 30 seconds/2 minutes followed by 3-minute dry time in non-hairy areas and up to 1 hour for hairy areas when electrocautery is being used. Chloraprep comes in several sizes from the small applicator used to start an IV to the large used to prep skin for surgery. Like Duraprep, the solution is highly flammable & needs to dry for 3 minutes before draping & especially before using an electric cautery. Unlike the Duraprep, prepping begins by swiping the moistened sponge back & forth over the incision site for at least 30 seconds before beginning to prep around the incision site. Remember to have absorbent towels to prevent pooling. Do not blot dry any wet spots. This should not be used in eyes, ears, or in the mouth & can cause permanent damage.

Abdominal Always begin w/ a visual inspection & remove any surface debris, if necessary. Inspect for any breaks in the skin, rashes, bruises, & document all information – even if the skin is dry & intact. Inspect the umbilicus as this can be a site where debris can collect. If necessary, pour some H2O2 in the umbilicus to soften the debris & then remove with a cotton tip applicator, taking care not to break the skin. Remember to place absorbent towels on both sides tucked under the body to prevent pooling of solutions. Make sure the area prepped is big enough. You can prep too little but never too wide.

Extremities Determine the location of the incision site(s) & follow the instructions for each prep solution. You may need an assistant to hold the limb while you prep so be sure to include the name & title of whoever assists with the prep. Know where the incision will be & prep accordingly. Both the axilla & groin are considered “dirty” areas.

Vaginal / GYN Vaginal preps can be intimidating at first. The vagina is considered “dirty” is prepped last. Start with the exterior area around the pubic symphysis and prep the inside of one leg. Repeat the process but prep out the inside of the other leg, keeping mindful that once prepped to the farthest point you cannot return to already prepped skin. The vagina is the last place prepped & then swipe the sponge stick over the rectum. Once the prep is complete, a Foley catheter can be inserted if need be.

Stomas When possible, stomas should be isolated from the prep with an impervious drape as they are considered dirty. Once isolated, prep the abdomen as usual.

Skin Grafts Donor site is considered a clean site with the recipient site considered dirty. Recipient sites require a separate prep kit. It is necessary to use 2 separate prep kits as the donor site is considered clean while the recipient site is considered dirty. Additionally, the recipient site can be open, as with trauma or burns.

Open Trauma Removal of extraneous material prior to prepping Open trauma are considered dirty. Before prepping the patient’s surgical site, the nurse must remove the patient’s jewelry and may need to clean the incision site with soap if the patient is a trauma patient or did not bathe preoperatively. When the incision site is more highly contaminated then the surrounding skin ( anus, perineum, stoma, open wound, axilla) the area with a lower bacterial count should be prepped first, followed by the area of higher contamination.(AORN 2017)

Cancer Prep gently as to not dislodge cancer cells & possibly migrate to other parts of the body.

DOCUMENATION Recommendation XII Hair removal Skin condition Antiseptic Agent Used Area Prepped Personnel Precautions Removal of Prep Post operative skin condition Follow organization documentation process.

Precautions High Risk Patients Obesity Diabetes Non-compliance Age Skin integrity Alcohol and 2% CHG may cause skin irritation and possible chemical burns on Neonates and burn patients

Questions Which antiseptic should be used for vaginal antisepsis? Should Chlorhexidine (CHG)-impregnated cloths be used for preoperative bathing? Should sterile gloves be worn when performing preoperative patient skin antisepsis? What protective measures should I take to prevent prolonged patient contact with skin antiseptics? Is it necessary to wear long sleeves when performing preoperative patient skin antisepsis? Is it necessary to remove nail polish or artificial nails when performing preoperative patient skin antisepsis on a patient having hand or foot surgery? The collective evidence indicates that povidone-iodine is commonly used for vaginal antisepsis in gynecological procedures There is a growing body of evidence supporting the use of 2% CHG-impregnated cloth products for preoperative bathing. CHG-impregnated cloths may increase the amount of CHG on the skin at the surgical site, which could enhance the activity and residual effect of CHG. Based on the collective evidence, this practice remains an unresolved issue and warrants additional generalizable, high-quality research to confirm the benefit of CHG-impregnated cloths for prevention of surgical site infection. When using an alcohol-based skin antiseptic for procedures involving an ignition source (eg, electro-surgery, laser), hair at the surgical site should be clipped before application of the antiseptic. Hair removal at the surgical site should be performed only in select clinical situations, such as when the presence of hair may contraindicate the use of flammable antiseptics (eg, alcohol-based) according to manufacturer's instructions for use. Sterile gloves should be worn when performing preoperative patient skin antisepsis. Non-sterile gloves may be worn if the antiseptic applicator is of sufficient length to prevent contact of the gloved hand with the antiseptic solution and the patient’s Sheets, padding, positioning equipment, and adhesive tape should be protected from the dripping or pooling of skin antiseptics beneath and around the patient. Yes, the arms should be covered by surgical attire when performing preoperative patient skin antisepsis. The recommendation for nons-scrubbed perioperative personnel to wear long-sleeves has been a part of the AORN “Recommended practices for surgical attire” since 1994. Wearing long-sleeved attire helps contain skin squamous shed from bare arms. If the RN circulator performs the preoperative skin antisepsis without wearing a long-sleeved jacket, skin squamous cells from his or her bare arms may drop onto the area that is being prepped and may increase the patient’s risk for a surgical site infection. Nails on the operative extremity should be clean and natural without artificial nail surfaces or polish. The evidence review for this recommended practices document found no cases of patient incision-site contamination related to wearing artificial nails or nail polish on the operative hand and foot. In two separate studies, researchers found that the amount of potentially pathogenic bacteria cultured from the fingertips of health care personnel wearing artificial nails was greater than for those with natural nails, both before and after hand washing. Artificial nail surfaces or polish may harbor microorganisms, which could contaminate the surgical site or reduce the effectiveness of preoperative patient skin antisepsis.

Questions Cont. Is it acceptable to dilute the skin antiseptic solution when performing preoperative patient skin antisepsis? Is it acceptable to use multi-use containers of skin antiseptic solution when performing preoperative patient skin antisepsis? Are there special methods that should be used when performing preoperative patient skin antisepsis of the hand or foot? Why do we remove cosmetics before the preoperative skin prep? What precautions should providers take when removing hair at the surgical site? How can I minimize the fire risk when using flammable patient skin antiseptic products? Which patient skin antiseptic products are flammable? For a procedure that involves the genitalia, should a urinary catheter be inserted before or after preoperative patient skin antisepsis? In a drug safety communication, the FDA recommended that health care professionals do not dilute antiseptic products after opening them to reduce the possibility of these products becoming contaminated. Skin antiseptics should be applied according to the manufacturer’s instructions for use. Antiseptic manufacturers’ instructions for use convey important safety and efficacy instructions to the user. In November 2013, the FDA issued a Drug Safety Communication requesting that manufacturers’ package antiseptics indicated for preoperative skin preparation in single-use containers to reduce the risk of infection from improper antiseptic use and contamination of products during use. In several case reports and non-experimental studies, contaminated skin antiseptics have been linked to patient infections. Skin antiseptics should be purchased in single-use when performing preoperative patient skin antisepsis of the hand or foot, perioperative team members should take care to apply the antiseptic to all surfaces between fingers or toes. Antisepsis may be difficult in the areas between the fingers and toes due to reaching all surfaces of the skin. containers, discarded after use (one patient, one time), and not refilled. Cosmetics may contribute to increased soil and contamination and impede the effectiveness of the antiseptic agent. The removal of facial cosmetics also may be indicated to prevent debris from irritating the eyes, to facilitate securing the endotracheal tube, or for other reasons identified by the surgical team. If the presence of hair will interfere with the surgical procedure and removal is in the best interest of the patient, the provider should take the following precautions: Hair removal should be performed the day of the surgery, in a location outside the operating or procedure room. Only hair interfering with the surgical procedure should be removed. Hair should be clipped using a single-use electric or battery-operated clipper Allow sufficient drying time, including time for the vapors to dissipate, before applying surgical drapes, using a potential ignition source. Flammable skin antiseptics should be prevented from pooling or soaking into linens or the patient’s hair. Communicate use of flammable skin antiseptics as part of the fire risk assessment involving the entire perioperative team before beginning a surgical procedure. When the surgical area involves the genitalia and the patient requires a urinary catheter, the nurse should insert the catheter after performing the preoperative patient skin antisepsis.

Discussion

References AORN-Perioperative Standards and Recommended Practices. 2017. Denver, CO. Alexander, J. W., Solomkin, J., & Edwards, M. Updated Recommendations for Control of Surgical Site Infections. (2011). Annals of Surgery253(6):1082-1093. Retrieved from Medscape Nurses website:http://www.medscape.com.

References Dizer, B., Hatipoglu, S., Kaymakcioglu, N., Tufan, T., Yava, A., Iyigun, E., & Senses, Z. (2009). The effect of nurse-performed preoperative skin preparation on postoperative surgical site infections in abdominal surgery. Journal Of Clinical Nursing, 18(23), 3325-3332. doi:10.1111/j.1365-2702.2009.02885.x Medical Press. January 19, 2017. Surgical site infections are the most common and costly of hospital infections. https://medicalxpress.com/news/2017-01-surgical-site-infections- common-costly.html#jCp

References Reichman, D., & Greenberg, J. Reducing Surgical Site Infections: A Review. (2009). Reviews in Obstetrics & Gynecology 2(4): 212 – 221. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC28 12878 Rothcock, J. Care of the Patient in Surgery. (14th Ed.). (2010). St. Louis, MO: Elsevier. Waxman, B. P. (2012). Medicine in small doses. ANZ Journal Of Surgery, 82(10), 668. doi:10.1111/j.1445- 2197.2012.06226.x