Preoperative Skin Preparation: A System Approach

October 1, 2001

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 andHealthcare-Associated Infections in March 2000, cutting-edge approaches toinfection control, prevention, and reduction were presented. The principal themewas "Prevention is Primary." Yet as the statistics of ever-presentmorbidity and mortality figures associated with nosocomial surgical siteinfections (SSI), length of stay for SSI, the economic impact of SSI, and degreeof compliance by the perioperative team in basic surgical asepsis are reiteratedin 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 toaction!

As RL Nichols, MD, states, "The most critical factors in the preventionof postoperative infections, although difficult to quantify, are the soundjudgment and proper technique of the surgeon and surgical team, as well as thegeneral health and disease state of the patient."1 This powerfulsentence summarizes the importance of the perioperative team's relationship withthe surgical patient. Promoting the prevention theme, the perioperative teamenters a partnership with the patient to ensure a SSI-free outcome. Once thepatient is informed of his or her options for care, chooses the surgicalintervention, and agrees to have the operation, the partnership commences withshared roles and responsibilities.

During the Decennial Conference and subsequent infection control-relatedconferences that same year, the re-emergence of alcohol as an effectiveantiseptic in new formations was announced and advocated as an enhancer tohand-hygiene compliance by healthcare workers.2 As with any newtechnology, healthcare professionals are charged with assessment for theadvanced technologies in the diverse practice settings, conducting objectiveproduct evaluations, and implementing an informed decision on the best productthe facility can afford.

Partnership in Prevention

The patient is identified as endogenous reservoir for infections, especiallySSI; however, this same patient is the central focus for a positiveperioperative outcome. So what are the role and responsibilities of the patient?How does the patient know them? When does the accountability commence? Whoverifies accomplishment of assigned responsibilities, such as preoperativeshower and wound care?

Perioperative is the inclusive term of preoperative, intraoperative, andpostoperative phases in the continuum of a surgical episode of care. From apatient's perspective, perioperative begins geographically in the surgeon'soffice, progresses to the surgical facility, continues with discharge to home,and ends in the surgeon's office. In another parallel, the patient encounters anassortment of perioperative team members at each location with variedprofessional care roles and responsibilities that facilitate a smooth,informative transition for the patient and his support system throughout thissurgical episode of care. The patient is provided with oral instructions, forms,and educational materials that explain each step along this perioperativeprocess. The essential element is that the patient knows what to expect, whenand how it will happen, where to be or do, and why it is necessary. In otherwords, the patient's inquiries should be anticipated and answered before thepatient verbalizes them. This means the perioperative team must be knowledgeableof each member's role and responsibilities in this continuum; obviously,frequent dialogue by and among the team members is key to a quality-care pathwayand positive outcome.

So what are the particular preventive aspects in the purview of the surgicalpatient? Guidelines and literature reviews cite the following: normal weight forheight and age, nutritional status, reduction in addictive substance behaviors,chronic disease control, elimination of remote infections, altered immuneresponse, short preoperative hospitalization stay, multi-resistant organismcolonization, preoperative antiseptic showering, compliant postoperative woundcare, and reporting complications, to name a few.

While this list contains many aspects for discussion, this article willaddress the benefits of an antiseptic preoperative shower, describe a productline system, provide a detailed procedure, and offer a study proposal withmeasurable outcomes.

Patient Preoperative Antiseptic Showering

Based on informal interviews and formal investigative findings, a diversityof patient preoperative cleansings, if any, is occurring throughout the nation.Frequently, no established set, or consensus protocol exists in healthcarepractice settings as to whether the ambulatory patient is instructed oraccomplishes a preoperative antiseptic shower before the day of surgery or thebedridden patient receives an antiseptic bedbath before going to surgery. Thewritten standard for preoperative antiseptic shower is abbreviated as noted inthe most recent guidelines for SSI prevention by the Centers for Disease Controland Prevention (CDC): "Require patients to shower or bathe with anantiseptic agent on at least the night before the operative day."3A body pre-cleansing that meets the US Food and Drug Administration's (FDA)Tentative Final Monograph for Antiseptic Drug Products testing criteria forPatient Preoperative Skin Preparation is a preventive preparation aimed atreducing the patient's skin colonization before the incision is made. Theassociation that this antiseptic preoperative shower will reduce SSI rates hasnot been documented in the literature, but has been verbally communicated as asuccessful recommendation and contributor to lowering SSI rates in outbreakinvestigations.

A System Approach

Healthcare is a dynamic field, ever spiraling toward greater improvements andinnovative technologies and interventions. The arena of antiseptics is just asprogressive. From single-agent predominance to repeated use of the sameantiseptic in different formulations (i.e., soap and paint), the conceptof special compatibility formulations in product lines presents a systemapproach to gain an even better response in decreasing colonization of the skinwhile maintaining skin integrity. With the advent of this concept, healthcareworkers (HCWs) may inquire how important is it that the antiseptic chosen forthe patient's preoperative shower and the antiseptic employed for theintraoperative skin prep be compatible? Is there a chemical reaction to beconcerned about? Is there any science one way or another about this? Should thechosen antiseptic shower agent be compatible with other products, such as bodylotions, anionic products, and/or sunscreens? What about the presence of organicdebris? Inactivation is common with some currently available antiseptic agentswhen other formulations are applied to the skin or debris is present, thus,negating the beneficial effect of reducing the number of microorganisms on theskin prior to surgery.

With a system approach to antiseptic product lines, the compatibility issueis engineered into the product development, making applications mutuallybeneficial to achieve the desired outcome. From a perioperative perspectivethen, the preoperative antiseptic shower agent would initiate the skin florareduction and the intraoperative skin prep antiseptic would continue to addpersistence, decreasing regrowth of normal flora. The system approach can leadto a best practice when the selection process is objective evaluation withinformed decision and intense inservice training for all users during theimplementation.

Proposed Procedure

Developing a standardized procedure for the patient's antiseptic preoperativeshower involves various aspects to consider.

1. An antiseptic should be selected based on certain criteria/attributes. Asto the choice of antiseptic, the FDA under the 1994 Tentative Final Monographfor Antiseptic Drug Products reserves the term "antiseptic" for aproduct with antimicrobial activity that has been shown to prevent skininfections in a controlled clinical trial. The antiseptic choice is based ondata collected in groin and abdomen sites. In the abdominal area, a 2-log 10reduction of the microbial flora and suppression of bacterial growth within 10minutes of application and no return to baseline flora count until 6 hours postapplication. In the groin area, a 3-log 10 reduction of microbial flora frombaseline and suppression of bacterial regrowth within 10 minutes of applicationand no return to baseline flora count until 6 hours post application. The FDAbelieves that persistence of the antimicrobial effect would suppress the growthof residual skin flora not removed by preoperative prepping as well as transientmicroorganisms inadvertently added to the operative field during the course ofsurgery and reduce the risk of SSI. In this same monograph, the FDA furtherdefines "patient preoperative skin preparations" as a fast-acting,broad-spectrum, persistent antiseptic-containing preparation that significantlyreduces 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 carbolicacid to hexachlorophene (HCP) and parachlorometaxylenol (PCMX), then povidoneiodine (PVP-I), followed by chlorhexidine gluconate (CHG) agents.5Each agent possesses advantages and cautions, requiring knowledge for properuse. Now newer formulations of these antiseptics as well as advancedtechnologies offer an enhanced, prolonged, persistent efficacy with low toxicityto the patient when used properly. These products focus on patient safety. Ofnote is the re-emergence of alcohol products that are waterless and water-aidedand are available in rinses and gel media. Also the introduction of compatibleantiseptic product lines is being identified and marketed. Thus, HCWs face theimportance of reviewing in-vitro and in-vivo product data plus clinicalperformance of these agents. Product evaluation remains an essential process forselection of an antiseptic.

2. How and when is the antiseptic dispensed to the patient? The selectedantiseptic of choice for preoperative cleansing is dispensed to the patientgenerally in the surgeon's office or at the pre-admission clinic prior to theday of surgery in the quantity and/or media for accomplishing the showeringfrequency. While an impregnated sponge makes it an economical and easy dispenserof the antiseptic for patient use, 4-ounce liquid containers are given to thepatient along with specific multimedia instructions for use.

3. How often should the patient use the antiseptic shower product--once ortwice? Because most antiseptics only improve the more they are used, one wouldconclude "the more, the better." However, patient compliance willsuffer if the use instructions are not fully explained and/or demonstrated andrealistic. It has been suggested that two to three applications are ideal toreduce colonization of the skin. Note: if the surgical prep agent is the sameantimicrobial as the antiseptic shower agent, then the patient will continue theadditive and cumulative effect.

4. When are the best times to accomplish preoperative antiseptic showers? Ata 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 atthe incisional site and work outward, covering the neck down to the feet, payingparticular attention to the incisional site, avoiding the head area, andcleansing the highly colonized areas last.

6. What kind of multimedia educational materials are available or does thefacility need to create their own? This is a facility choice to commerciallypurchase or create its own educational materials. Clear and concise instructionsare imperative for patient safety in use of these agents. Manufacturers shouldprovide a patient education and direction for use program with their products.

7. Is surgeon support key to this initiation, or does this fall into anursing purview? As a perioperative team, all HCWs should agree to and completetheir specific role in this preventive initiative for quality surgical care, SSIfree outcome, and patient safety.

8. Who verifies completion of this patient responsibility and how/where is itdocumented? Generally, the perioperative nurse in pre-admission and thecirculator make the inquiries and record the findings on the surgical checklist.

Incorporating the answers to the above inquiries, the following is asuggested antiseptic preoperative shower/bedbath procedure:

1. A perioperative nurse orally instructs the patient and his support systemin the rationale for an antiseptic preoperative shower. The rationale is: as apartner of the perioperative team, the patient is asked to reduce the transientand 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 thepatient as reinforcement to the verbal information and as a reference when thepatient is at home performing the shower.

a. This illustration is marked with what anatomical area is to be cleanedwith the antiseptic and what anatomy is cleaned normally. Note: chin to toes aregenerally cleaned with the antiseptic. Some of the antiseptics arecounterindicated in eyes, ears, and mucous membranes; read the antisepticmanufacturer's directions and follow accordingly.

b. Unless these are incisional sites, the following directions areappropriate: the hair is shampooed once with the patient's shampoo. The face iswashed at night and in the morning with the patient's soap. Oral hygiene isperformed at night and in the morning with the patient's toothpaste.

c. The antiseptic preoperative shower/bedbath is performed the night beforethe operation with the designated antiseptic. A clean washcloth or disposablesponge is used each time to apply the antiseptic. The intended incisional siteis cleaned with extra strokes, being careful not to denude the skin resulting incase cancellation. Rinse off the antiseptic. Thoroughly towel dry before donningclean bedtime clothes. Repeat this activity in the morning of the operation,using another clean washcloth or disposable sponge to apply the designatedantiseptic. Don't clean street clothes if an ambulatory patient is going to thefacility for same day admission or outpatient surgery. Note: If patient ishospitalized and bedridden, perioperative team members perform the antisepticbedbath the night before and the morning of surgery, using the designatedantiseptic and a clean washcloth or disposable sponge each time. Place a cleanpatient gown on the patient after each bedbath.

3. Upon admission to the OR, the perioperative nurse inquires if the patientaccomplished the antiseptic preoperative shower of the designated anatomicalarea the night before and the morning of surgery. The rationale is to verifyaccountability 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 itsestablished and successful protocol with documented outcome measures, thefollowing research design is provided as an initial study for a surgicalfacility to conduct. Its intent is to offer an objective framework to monitor achange variable to an existing perioperative process while no other changevariable is introduced at the same time.

Once the perioperative team is tasked with the responsibility andaccountability for this evaluation, simply assess the current perioperativepractice for antiseptic preoperative showering. Write this down as the baseline.Initiate the "change" to perioperative practice by stating whatspecifically will be changed from this point on, such as selection of antisepticagent or improved patient education or verifying accomplishment, etc. Determinethe timeframe for this initiative. Identify the measurable indicators forweighing the pros and cons of this change. Incorporate the indicators into theevaluation form for the users (surgical patients and HCWs). Designate a contactto receive all evaluations. Summarize the evaluations by measurable indicator.Convene the perioperative team to analyze the results. State the conclusion ofthe initiative and decide if this change will continue or does it need some morerefinement to reach a best practice.

While this is primarily an observation study of a changed procedure, someindicators worth considering for measurement include patient satisfaction (ineducation provided, ease of supply use, communication with the perioperativeteam, adverse outcome-skin reaction, SSI, etc.); supply support (quantity ofproduct consistently available, delivered to dispensing location, properstorage, etc.); HCW compliance in the enhanced change process; SSI incidencesfrom surveillance activities; and financial impact (cost of change, long termbenefit as length of stay or less SSI, fewer deaths, etc.).

Nancy B. Bjerke, BSN, MPH, CIC, is a consultant with Infection ControlAssociates of San Antonio, Texas; David W. Hobson, PhD, DABT, is vice presidentof medical product research and development for DFB Pharmaceuticals in SanAntonio, Texas; Lawton A. Seal, PhD, is principal research scientist and programmanager of research and development for Healthpoint in San Antonio, Texas.