Procedures for skin preparation vary based on patient and surgical procedure factors. Of the 21,000 SSIs reported to the National Healthcare Safety Network (NHSN) in 2009-2010, 30.4% were attributed to Staphylococcus aureus, a bacteria that is commonly found on the skin.2 Close to half of these S. aureus infections are methicillin-resistant S. aureus.2 Because not all hospitals reported data to NHSN in 2009 and 2010, these figures are likely to increase with the advent of federal pay-for-reporting programs in 2011-2013. A number of other pathogens are associated with SSIs, some of which are normal flora based on the site of surgery.
The Association of periOperative Registered Nurses (AORN) Recommended Practices Committee describes the goals of preoperative skin preparation as:
* The removal of soil and transient microbes from the skin.
* The rapid reduction of resident microbes without tissue irritation.
* The inhibition of rapid, rebound growth of these microbes.3
For the patient with a planned procedure, skin preparation begins at home. Patient education is essential. For patients undergoing Class I/clean procedures below the chin, AORN recommends two showers using chlorhexidine gluconate before surgery to decrease the number of microorganisms on the skin (see Surgical wound classifications). Although the act of showering or bathing with regular soap will reduce skin flora, using 4% chlorhexidine gluconate doubles the reduction. The CDC also supports patients showering with an antiseptic agent at least on the night before surgery.4
Chlorhexidine gluconate has been shown to be an effective skin prep agent, but needs to be used properly and cautiously by the patient at home. Important teaching points include achieving a contact time of 2 minutes and thorough rinsing to remove residual chlorhexidine (which can cause skin irritation), followed by drying with a clean towel. The patient shouldn't apply powders or lotions following the shower, and should don fresh clothing.3
Patients should be told to use chlorhexidine 4% carefully and to avoid contact with the eyes, insides of the ears, and other mucous membranes because of the risk of corneal damage and deafness.3 Chlorhexidine gluconate also can have a drying effect on the skin.5 Explain to patients that chlorhexidine gluconate comes in different concentrations based on intended use; the oral rinse, for example, is a 0.12% concentration.
Some facilities provide patients with enough chlorhexidine gluconate for two applications; others provide a list of local pharmacies and a list of alternate names for the product. If your facility suggests brand names, confirm that the product is FDA- approved for general cleansing. When the patient arrives for surgery, confirm that he or she has taken the preoperative showers as instructed; if the patient hasn't performed them, wash the surgical site in the preoperative area according to the facility's policy and procedure.3
The days of shaving hair from the operative site with a razor before surgery are long gone. Advise patients not to shave operative sites before arriving for surgery. To keep hair out of the way for surgery on the head, try creative strategies like braiding or nonflammable hair gel.
Evidence-based research has demonstrated that the best practice is to leave the hair in the operative area in place.3,4 If hair must be removed, use a clipper or depilatory on the day of surgery.3,4 Hair clipping should take place outside the OR and the clipper should be disinfected if it's not disposable. Use depilatories cautiously, due to the potential for sensitivity and skin reactions. Facility compliance with appropriate hair removal is publically available as part of the Surgical Care Improvement Project and used by the Centers for Medicare and Medicaid Services and The Joint Commission as a measure of quality.3
The final stage in skin preparation is to apply an antiseptic to the site. The preparation selected should be FDA-approved, broad-spectrum, fast-acting, nonirritating, and persistent in reducing microorganisms on the skin.3 Because skin preparation solutions are flammable and can cause chemical burns when not allowed to dry, AORN emphasizes the importance of education and annual competency assessment for healthcare providers involved in skin preparation.3
In addition to chlorhexidine gluconate (alone or in combination with alcohol), other commonly used skin preparation solutions are povidone-iodine, parachoroxylenol (PCMX), and iodine povacrylex (0.7% available iodine) in 74% isopropyl alcohol. No empirical evidence has shown that one product is superior to the others for all procedures. Rather than endorsing a specific product, AORN and CDC focus on the importance of the process of skin preparation as well as consideration of patient factors such as location of the surgical site and allergies (avoid using a solution in a patient who has an allergy or sensitivity to chlorhexidine gluco- nate, iodine, or any other product component).3,5
Surgical wound classifications
Class I-clean wound
An uninfected surgical wound without inflammation in which the respiratory, gastrointestinal (GI), or genitourinary tract hasn't been entered, for example, surgical wounds from total knee replacement or breast biopsy.
Class II-clean-contaminated wound
A surgical wound with no sign of infection in which the respiratory, GI, or genitourinary tract has been entered, for example, surgical wounds associated with thoracotomy and abdominal hysterectomy.
Class III-contaminated wound
An open, fresh traumatic wound or a surgical wound involving spillage from the GI tract or a break in surgical asepsis, for example, open fractures and wounds associated with surgery to remove a ruptured appendix.
Class IV-dirty wound
An infected wound, perforated viscera, or old traumatic wound with retained devitalized tissue, for example, wounds caused by debridement or incision and drainage of an abscess.
Source: Surgical Care made Incredibly Visual! Ambler, Pa: Lippincott Williams & Wilkins; 2007.
Povidone-iodine has been around since the days before Joseph Lister, and has been used as an antiseptic agent since the 1950s. Broad-spectrum with minimal persistence, povidone-iodine acts by releasing the free iodine that binds to bacteria. Unfortunately, the free iodine also binds with organic matter, which makes povidone-iodine less effective in the presence of blood, pus, or fat.5 Povidone-iodine can cause skin irritation.3
PCMX has been introduced as a safe skin preparation solution for mucous membranes, but is less effective than the other products. Nontoxic, it blocks the uptake of amino acids, disrupting cell membranes, and its effectiveness isn't hampered by blood, organic matter, or saline solution. Although more research is needed, the absence of tissue contraindications and moderate persistence make PCMX a suitable alternative in some situations.5
Iodine povacrylex with alcohol combines the residual actions of iodine with the immediate ability of alcohol to denature proteins.5 As with any solution containing alcohol, take care to let it dry completely on the skin to prevent surgical fires and patient burns.
No matter which skin preparation solution you choose, follow the manufacturer's instructions for using it. Also, AORN recommends that nonscrubbed personnel apply the skin preparation solutions after performing hand hygiene and donning sterile gloves. Sterile gowns and gloves may be contaminated if scrubbed personnel apply the skin preparation solution.3 The skin preparation solution itself should be applied using sterile supplies as well as sterile gloves unless the prep applicator is long enough to prevent contact with nonsterile gloves.
The skin preparation solution should be applied from the site of the planned incision to the periphery and extend far enough out to accommodate the potential for additional incisions and drains.3
By taking appropriate preoperative skin preparations, you can set the stage to prevent SSIs. OR
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