Infection Control Today - 09/2003: Surgical Prep

Surgical Prep: The Right Product for the Right Function
Minor changes bring major improvements in efficiency, safetyand costs

By Rosaline Parson, RN, BSN, CEN, CCRN

As hospitals seek new ways to increaseefficiency and safety while reducing costs, surgical services are findingthemselves under the microscope, charged with identifying areas for improvement.

And while its not easy, given the unique needs of eachsurgical procedure, our experience has been that a comprehensive assessment one that includes an examination of the efficacy of surgical products used, aswell as staff productivity, overall safety and associated costs will oftenreveal areas where a few relatively minor adjustments can have significantresults. This is particularly true with surgical prep processes.

In fact, recent evaluations have consistently identified twokey aspects of the surgical prep where a slight change in practice or productcan result in higher productivity, lower costs and improved safety.

Surgical Prep Solutions

While the process of surgical site preparation has remainedvirtually unchanged over the years, the variety and delivery of solutions hasnot. Todays solutions range from aqueous/non-aqueous isdophor and isopropylalcohol to iodine, chlorhexidine and chloroxylenol and gel compounds, all ofwhich come in multi-use bottles, or pre-measured single-use applications.

In addition to meeting the primary goal of surgical skinpreparation to remove dirt, oil and reduce microbial count as quickly aspossible with as little irritation as possible the selection of scrubsolutions should also be based on:

• Compatibility with the items it comes in contact with, including gloves and draping materials

• Flammability

• Whether or not it is inactivated by organic material

• How easily it can be removed from the skin surface

• The area being prepped, procedure being performed and the patients condition

Interestingly enough, in spite of all those variables, the choice of scrub solutions or more accurately the delivery method of solutions actually plays a fairly significant role in the efficiency of surgical prep. In fact, if you factor in the safety and productivity benefits of utilizing scrub solutions in pre-measured applicators, these individual, single-use applications are attractive in spite of their slightly higher price tag when compared to multi-use bottles. Among their key benefits are:

• They are faster to apply, less messy, cleanse more effectively, dry faster and enhance drape adhesion, thus preventing the sterile surface from being compromised while speeding prep time.

• They reduce cross-contamination.

• Pooling between patient and equipment is reduced since application is controlled, thereby reducing the risk of skin irritation and providing for a quicker post-procedure clean-up.

While they may cost a bit more (an obstacle that can often beeliminated by appropriate product utilization based on procedures), theirbenefits in terms of speedier preps, enhanced drape adhesion and reduction ofother risks outweighs the cost. Thus, pre-measured applicators can have apositive impact on the bottom line.

Updating Outdated Practices

The second area of surgical prep that can be streamlined toimprove efficiencies without affecting safety is to eliminate the waste createdby outdated practices, such as discarding sterile exam gloves in favor ofsurgical gloves when prepping patients. Exam gloves, which cost 10 to 20 timesless, provide more than adequate protection and wont degrade during the fewminutes it takes to prep a patient.

Its also important to note that the exam gloves found inmost prep kits are latex-free, while surgical gloves often are not. Therefore,discarding exam gloves in favor of surgical gloves can unknowingly expose staffand patients to latex. Since sensitivities can be unknown (many patients haventcome into contact with latex prior to the gloves used for surgical prep),unnecessary exposure to latex should be eliminated.

This practice also undermines the goal of standard and customprocedure trays and leads us to our next target for waste elimination. When these trays are dismantled, any cost and productivitysavings realized through their use is tossed out with the unused contents. Ifthis is happening, its time to re-evaluate the contents.

According to a survey by the California Integrated WasteManagement Board, a five-hospital system in Portland, Ore. reported a netsavings of more than $30,000 per year and a total waste prevention of 11,000pounds per year just by removing items from their custom surgical packs thatwere not routinely used.

Finally, its time to stop excessive layering of surgicaldrapes. In the past, when cloth (reusable) drapes were utilized, it wasnecessary to create multiple layers to foster absorption and prevent fluids frompooling. But advances in the materials used for disposable and reusable drapeseliminate that problem, along with the need for multiple layers. In fact, it isnow possible to square off and then use one key drape and/or universal drape ofthe appropriate reinforcement.

In summary, by using the appropriate products made from theappropriate materials, it is possible to improve the safety and speed of thesurgical prep process and cut costs by eliminating waste, increasingproductivity and reducing inventory costs.

Rosaline Parson, RN, BSN, CEN, CCRN, is vice president ofClinical Resources, the consulting arm of Maxxim Medical, a leading manufacturerof custom procedure trays, medical gloves, vascular access and critical careproducts. Clinical Resources is comprised of RNs skilled in providing clientswith inservice education, CEUs, product utilization studies, procedure costingapplication and clinical support during product conversions.

Evaluating the True Cost of Surgical Prep Trends

By Rosaline Parson, RN, BSN, CEN, CCRN

When it comes to assessing some of the recent trends insurgical prep materials and practices, its important to look not only at theproduct efficacy, productivity and safety, but also associated costs. Threeexamples of overkill or waste in surgical prep include:

• Discarding the sterile exam gloves in favor of sterile surgical gloves when prepping a patient for surgery. The exam glove, which is far less expensive, provides more than adequate protection and wont degrade during the few minutes theyre in use while prepping the patient.

• Using layers of drapes after prep instead of one drape of the appropriate reinforcement for the procedure. Excessive layering is an unnecessary expense that takes longer and costs more without enhancing safety or preventing infections.

• Dismantling custom procedure trays and using only a portion of the contents, and then discarding the rest. If this is happening in your facility, its time to re-evaluate the contents of those procedure trays.

Two examples of where the purchase price doesnt alwaysreflect actual value:

• Not using scrub solutions in pre-measured applicators. They may cost a bit more than multi-use bottles, but they actually save money inthe long run because they are less messy, faster to apply, cleanse moreeffectively and enhance drape adhesion, thus preventing the sterile surface frombeing compromised. Too, by standardizing prep solutions throughout a facility,savings is realized through bulk purchases. Date labels and excess waste is alsoavoided with pre-measured applicators.

• Using materials that contain latex. Even if latex-freecosts more, the risk isnt worth the pennies saved. With the proliferation oflatex-free products on the market today, there is no reason to risk exposingpatients and staff to latex reactions because your surgical supplies rangingfrom gloves and gowns, to drapes and trays arent latex free. For many, the prep may be the first latex (gloves) contact thepatient will have, and it could easily be avoided with use of the right glovepackaged with the prep process.