Infection Control Today - 09/2003: Current Surgical Skin Prep

Current Surgical Skin Prep Standards Due for Review

By John Roark

The Association of periOperative Nurses’ (AORN) Recommended Practices for skin preparation of patients was last updated in January 2002. According to Ramona Conner, RN, MSN, CNOR, perioperative nursing specialist at the Center for Nursing Practice of AORN, the matter is currently in committee.

“Hopefully they will have an updated recommendation for 2004,” she says. “One hot topic is the use of razors — we’re hoping to get people to stop using them. There may be some changes related to the use of razors across the board.”

Conner recommends removing as little hair as possible, and when hair must be removed, using a clipper. “Our recommended practice already says that, but it may be strengthened,” she says.

“Razors damage skin, and it’s been well known for quite a long time. It’s not a good practice, and hopefully we’ll be discussing it more.”

“There probably will be some additional discussion of alcohol-based skin prep products,” continues Conner. “I don’t know what the final language will be, but certainly the alcohol-based skin prep products and surgical hand scrub products are becoming more widely used and appear in the research literature to be safe and efficacious, so there will probably be more discussion on that.”

“I do know that at this moment there is a controversy between the National Fire Protection Association (NFPA) and the Centers for Disease Control and Prevention (CDC) over the use of alcohol-based skin prep products and surgical hand scrub products,” continues Conner. “Because the NFPA standards clearly state that flammable germicides should not be used in a surgical setting.”

“If these sanitizers are to be used effectively, they must be conveniently located in nursing units, and many have suggested that the dispensers be mounted in hospital corridors outside patient rooms,” writes Susan McLaughlin of SBM Consulting in “Alcohol-based hand sanitizers,” posted on NFPA Online. “However, this practice has become controversial because the sanitizers are composed of 60 percent alcohol and have a flash point of 75 degrees F, calling into effect the requirements of NFPA 101, Life Safety Code®, and NFPA 30, Flammable and Combustible Liquids Code.”

“According to these regulations, projections of no more than 3.5 inches are allowed into the corridor of a health care occupancy and not about 38 inches above the floor. While many of the dispensers may comply with the 3.5-inch projection, they would be virtually useless within 38 inches of the floor. Furthermore, the storage or handling of flammable liquids or gases is not permitted in any location where they may compromise egress.”¹

“Some local fire districts are really challenging some of the facilities that are implementing alcohol-based germicides in their operating rooms,” says Conner. “The placement of the dispensers is a bit controversial. We’ve had some reports of some fire marshals not wanting to allow the alcohol-based dispensers in the corridors of the ORs because they are a point of egress. There’s a whole lot of controversy brewing over the conflict between fire safety and infection control. Hopefully the two groups are talking, but at the moment the practitioners are being caught in the middle between these two regulatory standard setting bodies. Stay tuned to that one — it could be ugly! You know how government agencies are—they don’t often play nicely with each other.”

The current recommended practices by AORN for skin preparation of patients are as follows:

RECOMMENDED PRACTICE I

The surgical site should be assessed before skin preparation.

1. Skin should be assessed before skin preparation, and the presence of moles, warts, rashes, or other skin conditions at the surgical site should be noted and documented. Inadvertent removal of lesions traumatizes the skin at the surgical site and provides an opportunity for wound colonization by microorganisms.

RECOMMENDED PRACTICE II

Whenever possible, hair should be left at the surgical site. If it is determined that hair should be removed, removal should be performed according to physicians’ orders and/or according to policies and procedures in the practice setting.

1. An assessment of the amount and degree of hair at the site should be performed. The necessity of hair removal depends on the amount of hair, location of the incision, and type of surgical procedure to be performed. Inappropriate hair removal techniques can traumatize skin and provide an opportunity for colonization of microorganisms at the surgical site.

2. If hair is to be removed at the surgical site, these guidelines should be followed:

• Personnel skilled in hair removal techniques should perform the removal.
• Hair removal should be performed as close to the time of surgery as possible, except when a depilatory is to be used (see number four).
• Hair removal should be performed in an area outside of the room where the procedure will be performed.
• Hair removal should be performed in a manner that preserves skin integrity.

3. Microscopic exudative rashes and skin abrasions can occur during hair removal. These rashes and skin abrasions can provide a portal of entry for microorganisms. When hair removal is necessary, an electric or battery-powered clipper with a disposable or reusable head that can be disinfected between patients should be used, if possible. This is the simplest and least irritating method of hair removal. If hair is removed, removal should take place away from the sterile field, preferably in an area outside of the room where the procedure will be performed. The dispersal of loose hair has the potential to contaminate the surgical site and sterile field.

4. Depilatories have caused skin reactions in some individuals, causing surgeries to be cancelled. If a depilatory is to be used, manufacturers’ written instructions regarding pre-application skin testing should be followed. Depending on the manufacturers’ instructions, some depilatories may require use before the patient’s arrival in the practice setting.

5. Hair removal with a razor can disrupt skin integrity. If the physician orders shaving with a razor, hair and skin should be wet before shaving. Wetting hair with soapy water makes it softer and easier to remove and results in fewer microabrasions to the skin’s surface. Wet shaving also controls dispersal of loose hair.

6. All items used in hair removal should be disposed of or disinfected between surgical procedures.

RECOMMENDED PRACTICE III

The surgical site and surrounding areas should be clean.

1. The skin around the surgical site should be free of soil and debris. Removal of superficial soil, debris, and transient microbes before applying antiseptic agent(s) reduces the risk of wound contamination by decreasing the organic debris on the skin.

2. Cleansing should be accomplished before surgical skin preparation by any of the following methods:

• patient showering and/or shampooing before arrival in the practice setting,
• washing the surgical site before arrival in the practice setting, or
• washing the surgical site immediately before applying the antiseptic agent in the practice setting.

RECOMMENDED PRACTICE IV

When indicated, the surgical site and surrounding area should be prepared with an antiseptic agent.

1. Antiseptic agent(s) should be selected according to AORN’s “Recommended practices for the evaluation and selection of products and medical devices used in perioperative practice settings” and used in accordance with the manufacturers’ written instructions. Antiseptic agent(s) should have a broad range of germicidal action.

2. Data from current research, manufacturers’ literature, the Association for Professionals in Infection Control and Epidemiology (APIC), and the US Food and Drug Administration should be consulted when selecting an antiseptic agent for skin preparation.

3. Products for skin antisepsis should be chosen carefully according to the patient’s condition. Antiseptic agents used on the skin of patients with known hypersensitivity reactions may cause adverse outcomes (e.g., blisters, rashes). Some antiseptic agents may be absorbed by the skin or mucous membranes and become neurotoxic or ototoxic. Certain antiseptic agents are believed to be potentially harmful to fetuses or neonates if used on pregnant women and/or nursing mothers.

4. Antiseptic agents used for skin preparation should be applied using sterile supplies. Infection can occur due to a high microbial count at the incision site; therefore, skin preparation should progress from the incision site to the periphery using a sponge/applicator, which should be discarded after the periphery has been reached.

The use of sterile supplies alone does not reduce microbial counts and rebound microbial activity. Friction during the cleansing process and application of antimicrobial agents are the primary methods for removing soil and transient organisms. Data from one limited study suggest that a clean prep kit may be as effective as a sterile kit for disinfecting skin. Additional research is needed to establish definitive patient outcomes and/or support for a change in practice. Antiseptic products that are marketed with applicators may be applied with clean gloves per the manufacturers’ written recommendations; however, there presently are no published data that support the use of clean, as opposed to sterile, gloves.

5. The prepared area of skin and the drape fenestration should be large enough to accommodate extension of the incision, the need for additional incisions, and all potential drain sites. Enlarging the drape fenestration or inadvertent shifting of the drapes can result in contamination, as an unprepared area may be exposed.

RECOMMENDED PRACTICE V

Personnel who are knowledgeable about the patient and skilled in skin preparation techniques should prepare the surgical site in a manner that preserves skin integrity and prevents injury to the skin.

1. When preparing the skin for a surgical procedure, special considerations should include:

• preparing areas of high microbial counts (e.g., umbilicus, pubis, open wounds) within the prepared areas last;
• isolating the colostomy site(s) from the prepared area, covering the site(s) with an antiseptic-soaked sponge, and preparing the colostomy site(s) last;
• using normal saline to prepare burned, denuded, or traumatized skin;
• avoiding the use of chlorhexidine gluconate and/or alcohol or alcohol-based products on mucous membranes;
• using gentle preparation techniques when preparing skin of patients with certain medical conditions (e.g., diabetes, skin ulcerations);
• allowing sufficient contact time of antiseptic agents before applying sterile drapes to achieve maximum effectiveness of the agent;
• allowing sufficient time for complete evaporation of any flammable antiseptic agent (e.g., alcohol, alcohol-based preparations) to reduce the possibility of fire; and
• preventing antiseptic agent pooling beneath patients, pneumatic tourniquet cuffs, electrodes, or electrosurgical unit dispersive pads to reduce the risk of chemical burns.²