Preoperative Skin Preparation: A System Approach
By Nancy B. Bjerke, BSN, MPH, CIC; David W. Hobson, PhD, DABT; Lawton A. Seal, PhD
From the 4th Decennial International Conference on Nosocomial and Healthcare-Associated Infections in March 2000, cutting-edge approaches to infection control, prevention, and reduction were presented. The principal theme was "Prevention is Primary." Yet as the statistics of ever-present morbidity and mortality figures associated with nosocomial surgical site infections (SSI), length of stay for SSI, the economic impact of SSI, and degree of compliance by the perioperative team in basic surgical asepsis are reiterated in publications and from the podium, our progress in prevention seems minimal. Maybe it is time for a different approach--cease the lip service and turn to action!
As RL Nichols, MD, states, "The most critical factors in the prevention of postoperative infections, although difficult to quantify, are the sound judgment and proper technique of the surgeon and surgical team, as well as the general health and disease state of the patient."1 This powerful sentence summarizes the importance of the perioperative team's relationship with the surgical patient. Promoting the prevention theme, the perioperative team enters a partnership with the patient to ensure a SSI-free outcome. Once the patient is informed of his or her options for care, chooses the surgical intervention, and agrees to have the operation, the partnership commences with shared roles and responsibilities.
During the Decennial Conference and subsequent infection control-related conferences that same year, the re-emergence of alcohol as an effective antiseptic in new formations was announced and advocated as an enhancer to hand-hygiene compliance by healthcare workers.2 As with any new technology, healthcare professionals are charged with assessment for the advanced technologies in the diverse practice settings, conducting objective product evaluations, and implementing an informed decision on the best product the facility can afford.
Partnership in Prevention
The patient is identified as endogenous reservoir for infections, especially SSI; however, this same patient is the central focus for a positive perioperative outcome. So what are the role and responsibilities of the patient? How does the patient know them? When does the accountability commence? Who verifies accomplishment of assigned responsibilities, such as preoperative shower and wound care?
Perioperative is the inclusive term of preoperative, intraoperative, and postoperative phases in the continuum of a surgical episode of care. From a patient's perspective, perioperative begins geographically in the surgeon's office, progresses to the surgical facility, continues with discharge to home, and ends in the surgeon's office. In another parallel, the patient encounters an assortment of perioperative team members at each location with varied professional care roles and responsibilities that facilitate a smooth, informative transition for the patient and his support system throughout this surgical episode of care. The patient is provided with oral instructions, forms, and educational materials that explain each step along this perioperative process. The essential element is that the patient knows what to expect, when and how it will happen, where to be or do, and why it is necessary. In other words, the patient's inquiries should be anticipated and answered before the patient verbalizes them. This means the perioperative team must be knowledgeable of each member's role and responsibilities in this continuum; obviously, frequent dialogue by and among the team members is key to a quality-care pathway and positive outcome.
So what are the particular preventive aspects in the purview of the surgical patient? Guidelines and literature reviews cite the following: normal weight for height and age, nutritional status, reduction in addictive substance behaviors, chronic disease control, elimination of remote infections, altered immune response, short preoperative hospitalization stay, multi-resistant organism colonization, preoperative antiseptic showering, compliant postoperative wound care, and reporting complications, to name a few.
While this list contains many aspects for discussion, this article will address the benefits of an antiseptic preoperative shower, describe a product line system, provide a detailed procedure, and offer a study proposal with measurable outcomes.
Patient Preoperative Antiseptic Showering
Based on informal interviews and formal investigative findings, a diversity of patient preoperative cleansings, if any, is occurring throughout the nation. Frequently, no established set, or consensus protocol exists in healthcare practice settings as to whether the ambulatory patient is instructed or accomplishes a preoperative antiseptic shower before the day of surgery or the bedridden patient receives an antiseptic bedbath before going to surgery. The written standard for preoperative antiseptic shower is abbreviated as noted in the most recent guidelines for SSI prevention by the Centers for Disease Control and Prevention (CDC): "Require patients to shower or bathe with an antiseptic agent on at least the night before the operative day."3 A body pre-cleansing that meets the US Food and Drug Administration's (FDA) Tentative Final Monograph for Antiseptic Drug Products testing criteria for Patient Preoperative Skin Preparation is a preventive preparation aimed at reducing the patient's skin colonization before the incision is made. The association that this antiseptic preoperative shower will reduce SSI rates has not been documented in the literature, but has been verbally communicated as a successful recommendation and contributor to lowering SSI rates in outbreak investigations.
A System Approach
Healthcare is a dynamic field, ever spiraling toward greater improvements and innovative technologies and interventions. The arena of antiseptics is just as progressive. From single-agent predominance to repeated use of the same antiseptic in different formulations (i.e., soap and paint), the concept of special compatibility formulations in product lines presents a system approach to gain an even better response in decreasing colonization of the skin while maintaining skin integrity. With the advent of this concept, healthcare workers (HCWs) may inquire how important is it that the antiseptic chosen for the patient's preoperative shower and the antiseptic employed for the intraoperative skin prep be compatible? Is there a chemical reaction to be concerned about? Is there any science one way or another about this? Should the chosen antiseptic shower agent be compatible with other products, such as body lotions, anionic products, and/or sunscreens? What about the presence of organic debris? Inactivation is common with some currently available antiseptic agents when other formulations are applied to the skin or debris is present, thus, negating the beneficial effect of reducing the number of microorganisms on the skin prior to surgery.
With a system approach to antiseptic product lines, the compatibility issue is engineered into the product development, making applications mutually beneficial to achieve the desired outcome. From a perioperative perspective then, the preoperative antiseptic shower agent would initiate the skin flora reduction and the intraoperative skin prep antiseptic would continue to add persistence, decreasing regrowth of normal flora. The system approach can lead to a best practice when the selection process is objective evaluation with informed decision and intense inservice training for all users during the implementation.
Developing a standardized procedure for the patient's antiseptic preoperative shower involves various aspects to consider.
1. An antiseptic should be selected based on certain criteria/attributes. As to the choice of antiseptic, the FDA under the 1994 Tentative Final Monograph for Antiseptic Drug Products reserves the term "antiseptic" for a product with antimicrobial activity that has been shown to prevent skin infections in a controlled clinical trial. The antiseptic choice is based on data collected in groin and abdomen sites. In the abdominal area, a 2-log 10 reduction of the microbial flora and suppression of bacterial growth within 10 minutes of application and no return to baseline flora count until 6 hours post application. In the groin area, a 3-log 10 reduction of microbial flora from baseline and suppression of bacterial regrowth within 10 minutes of application and no return to baseline flora count until 6 hours post application. The FDA believes that persistence of the antimicrobial effect would suppress the growth of residual skin flora not removed by preoperative prepping as well as transient microorganisms inadvertently added to the operative field during the course of surgery and reduce the risk of SSI. In this same monograph, the FDA further defines "patient preoperative skin preparations" as a fast-acting, broad-spectrum, persistent antiseptic-containing preparation that significantly reduces the number of microorganisms on intact skin.4
An evolution of antiseptics has influenced perioperative practices. Historically, antiseptic agents progressed from the era of alcohol and carbolic acid to hexachlorophene (HCP) and parachlorometaxylenol (PCMX), then povidone iodine (PVP-I), followed by chlorhexidine gluconate (CHG) agents.5 Each agent possesses advantages and cautions, requiring knowledge for proper use. Now newer formulations of these antiseptics as well as advanced technologies offer an enhanced, prolonged, persistent efficacy with low toxicity to the patient when used properly. These products focus on patient safety. Of note is the re-emergence of alcohol products that are waterless and water-aided and are available in rinses and gel media. Also the introduction of compatible antiseptic product lines is being identified and marketed. Thus, HCWs face the importance of reviewing in-vitro and in-vivo product data plus clinical performance of these agents. Product evaluation remains an essential process for selection of an antiseptic.
2. How and when is the antiseptic dispensed to the patient? The selected antiseptic of choice for preoperative cleansing is dispensed to the patient generally in the surgeon's office or at the pre-admission clinic prior to the day of surgery in the quantity and/or media for accomplishing the showering frequency. While an impregnated sponge makes it an economical and easy dispenser of the antiseptic for patient use, 4-ounce liquid containers are given to the patient along with specific multimedia instructions for use.
3. How often should the patient use the antiseptic shower product--once or twice? Because most antiseptics only improve the more they are used, one would conclude "the more, the better." However, patient compliance will suffer if the use instructions are not fully explained and/or demonstrated and realistic. It has been suggested that two to three applications are ideal to reduce colonization of the skin. Note: if the surgical prep agent is the same antimicrobial as the antiseptic shower agent, then the patient will continue the additive and cumulative effect.
4. When are the best times to accomplish preoperative antiseptic showers? At a minimum, the night before and the morning of surgery are the best times.
5. Is the whole body cleaned or just the anticipated incisional site? Protocols should follow the label claims for use. Generally, one should start at the incisional site and work outward, covering the neck down to the feet, paying particular attention to the incisional site, avoiding the head area, and cleansing the highly colonized areas last.
6. What kind of multimedia educational materials are available or does the facility need to create their own? This is a facility choice to commercially purchase or create its own educational materials. Clear and concise instructions are imperative for patient safety in use of these agents. Manufacturers should provide a patient education and direction for use program with their products.
7. Is surgeon support key to this initiation, or does this fall into a nursing purview? As a perioperative team, all HCWs should agree to and complete their specific role in this preventive initiative for quality surgical care, SSI free outcome, and patient safety.
8. Who verifies completion of this patient responsibility and how/where is it documented? Generally, the perioperative nurse in pre-admission and the circulator make the inquiries and record the findings on the surgical checklist.
Incorporating the answers to the above inquiries, the following is a suggested antiseptic preoperative shower/bedbath procedure:
1. A perioperative nurse orally instructs the patient and his support system in the rationale for an antiseptic preoperative shower. The rationale is: as a partner of the perioperative team, the patient is asked to reduce the transient and resident colonization of microbes on his skin surface with an antiseptic; and thus, lower the endogenous source for a potential surgical site infection.
2. Written directions with an illustration of a human being are given to the patient as reinforcement to the verbal information and as a reference when the patient is at home performing the shower.
a. This illustration is marked with what anatomical area is to be cleaned with the antiseptic and what anatomy is cleaned normally. Note: chin to toes are generally cleaned with the antiseptic. Some of the antiseptics are counterindicated in eyes, ears, and mucous membranes; read the antiseptic manufacturer's directions and follow accordingly.
b. Unless these are incisional sites, the following directions are appropriate: the hair is shampooed once with the patient's shampoo. The face is washed at night and in the morning with the patient's soap. Oral hygiene is performed at night and in the morning with the patient's toothpaste.
c. The antiseptic preoperative shower/bedbath is performed the night before the operation with the designated antiseptic. A clean washcloth or disposable sponge is used each time to apply the antiseptic. The intended incisional site is cleaned with extra strokes, being careful not to denude the skin resulting in case cancellation. Rinse off the antiseptic. Thoroughly towel dry before donning clean bedtime clothes. Repeat this activity in the morning of the operation, using another clean washcloth or disposable sponge to apply the designated antiseptic. Don't clean street clothes if an ambulatory patient is going to the facility for same day admission or outpatient surgery. Note: If patient is hospitalized and bedridden, perioperative team members perform the antiseptic bedbath the night before and the morning of surgery, using the designated antiseptic and a clean washcloth or disposable sponge each time. Place a clean patient gown on the patient after each bedbath.
3. Upon admission to the OR, the perioperative nurse inquires if the patient accomplished the antiseptic preoperative shower of the designated anatomical area the night before and the morning of surgery. The rationale is to verify accountability that this preventive measure was accomplished as directed.
Research Design with Measurable Outcomes
As a way to challenge the perioperative team to conduct and publish its established and successful protocol with documented outcome measures, the following research design is provided as an initial study for a surgical facility to conduct. Its intent is to offer an objective framework to monitor a change variable to an existing perioperative process while no other change variable is introduced at the same time.
Once the perioperative team is tasked with the responsibility and accountability for this evaluation, simply assess the current perioperative practice for antiseptic preoperative showering. Write this down as the baseline. Initiate the "change" to perioperative practice by stating what specifically will be changed from this point on, such as selection of antiseptic agent or improved patient education or verifying accomplishment, etc. Determine the timeframe for this initiative. Identify the measurable indicators for weighing the pros and cons of this change. Incorporate the indicators into the evaluation form for the users (surgical patients and HCWs). Designate a contact to receive all evaluations. Summarize the evaluations by measurable indicator. Convene the perioperative team to analyze the results. State the conclusion of the initiative and decide if this change will continue or does it need some more refinement to reach a best practice.
While this is primarily an observation study of a changed procedure, some indicators worth considering for measurement include patient satisfaction (in education provided, ease of supply use, communication with the perioperative team, adverse outcome-skin reaction, SSI, etc.); supply support (quantity of product consistently available, delivered to dispensing location, proper storage, etc.); HCW compliance in the enhanced change process; SSI incidences from surveillance activities; and financial impact (cost of change, long term benefit as length of stay or less SSI, fewer deaths, etc.).
Nancy B. Bjerke, BSN, MPH, CIC, is a consultant with Infection Control Associates of San Antonio, Texas; David W. Hobson, PhD, DABT, is vice president of medical product research and development for DFB Pharmaceuticals in San Antonio, Texas; Lawton A. Seal, PhD, is principal research scientist and program manager of research and development for Healthpoint in San Antonio, Texas.