Proper Preparation is Everything

According to results of a consumer survey conducted by the American College of Surgeons (ACS), the average patient will spend more preparation time before purchasing a big-ticket item for their house than they will spend preparing for a surgical procedure five times as much, in fact.

As upside down as that may sound, it can be easily explained. One word: trust.

The hypothesis is that the majority of patients trust that their physicians and healthcare workers (HCWs) will abide by best practices and keep them safe.

According to the aforementioned survey, 1 in 3 Americans (33 percent) has had a surgical procedure within the past five years. Harkening back to the trust factor, the survey results note that those patients did not check their surgeons credentials before having the procedure.

There are certain protocols that each healthcare entity is expected to follow. One such protocol is that of skin protection protection from the HCW shedding skin onto the patient, and protection of the patient acquiring microbial contamination from their own skin.

The synergy between the appropriate patient skin preparation and adhering to best practices is important in keeping surgical site infections (SSIs) at bay. This is because skin is the most common contributor to microbial contamination. For example, when a patient is severely neutropenic, there is more of a chance that they will contract an infection from their own body than from any other source. This is because skin is the perfect environment for many organisms to reside.

As a double-pronged example of this overall topic, recent research demonstrates how the use of chlorhexidine gluconate (CHG)-based solutions used on human skin helps reduce the rate of infections related to the placement of catheters. This research shows how something as comparatively low risk as catheter placement to say, a major open heart surgery, still can be life-threateningly challenged by microbial-laden skin.

In one such study, culture results from 481 catheters found that the use of a CHG-based solution, when compared with povidone-iodine, was associated with a 50 percent decrease in the incidence of catheter colonization and associated bloodstream infections (BSIs).¹ The researchers in this study concluded that CHG-based solutions should be considered as a replacement for povidone-iodine (including alcohol-based) formulations in efforts to prevent catheter-related infection.

Another like study shows that daily cleansing of medical intensive care unit (MICU) patients with CHG-impregnated cloths is a simple, effective strategy to decrease the rate of infections. A team of hospital-based researchers performed a 52-week, two-arm, crossover clinical trial comprised of 836 MICU patients that over time came through one hospital unit. The results of bathing the patients daily with 2 percent CHG-impregnated washcloths found that patients are significantly less likely to acquire a primary BSI using the CHG cloths (4.1 vs. 10.4 infections per 1,000 patient days). It is interesting to note that the incidence of other infections, including clinical sepsis, were similar. Furthermore, the researchers note that protection against primary BSI by CHG cleansing was apparent after five or more days in the MICU.

To further address this topic, ICT sat down with a few experts in the industry to discuss whats hot on todays market to address these challenges. Our panel also shares some insight on the clinical side of the topic and offers many tips to keep you and your patients safe.

Meet the panel:

John Amat

, vice president of global sales and marketing, Kimberly-Clark Health Care 

Julie Gorog, RN, BSN, CNOR, clinical specialist in the convertors products department of Cardinal Health 

Mardi Bentzen, marketing manager at 3M Health Care 

Sharon Giarrizzo-Wilson, RN, BSN/MS, CNOR, perioperative nurse specialist with the Association of periOperative Registered Nurses (AORN) Center for Nursing Practice

ICT: Is there anything hot or new right now? Any new products our readers should be aware of?

Amat: Wound contamination by the patients endogenous skin flora is a key factor in the development of SSI, and absolute skin sterilization prior to surgery is not possible. Having a solution like InteguSeal that helps to prevent a patients own skin flora from contaminating the wound will bring hospitals one step closer to reducing the risk of SSI. InteguSeal is a filmforming, cyanoacrylate-based microbial sealant that is applied to the skin after pre-op skin prep and prior to making the incision. InteguSeal can be applied quickly and easily, flowing over skin contours, hair follicles and microabrasions.

Its mechanical action seals down and protects the incision from pathogens residing deep in the skin and those surviving typical pre-op prep. InteguSeal is effective against common and dangerous bacteria such as methicillin-resistant Staphylococcus aureus (MRSA), Staphylococcus epidermidis and Escherichia coli. InteguSeal is even effective against acinetobacter baumannii, commonly known as the Iraqi bug, a drug-resistant pathogen affecting our military personnel returning to the United States from the Middle East. The amazing part about InteguSeal is that its entirely a mechanical barrier and wont promote bacterial resistance, which is a major concern in healthcare today when using any type of antimicrobial. InteguSeal is a microbial sealant and not a skin prep. This microbial barrier marks the start of a new category and is intended for use after standard skin prep and before incision to lock down the bacteria that survive typical skin prep. InteguSeal is compatible with iodophors, 2 percent CHG and isopropyl alcohol; as well as many common operating room (OR) products such as incise drapes, bovies, etc., so it does not require a significant change in practice. InteguSeal is breathable and remains on the skin throughout surgery and up to five to seven days following surgery. It protects the prep from washing off around the incision site and naturally wears away as the skin exfoliates. It doesnt need to be removed for closure and is compatible with sutures, staples, and wound adhesives. If necessary, InteguSeal can be removed with soapy water, mineral oil or acetone.

Gorog: As of October 2008, the Centers for Medicare and Medicaid Services (CMS) will no longer reimburse for healthcare costs related to healthcare-acquired infections (HAIs), and private insurance companies may follow. CHG has proven more effective than povidone iodine for intravascular catheter-site care and reduction of SSIs.

Bentzen: The United States Adopted Name Council (USAN) has assigned a new chemical name for copolymer iodophors iodine povacrylex.

This name clearly differentiates iodine copolymers from povidone iodine. Iodine povacrylex dries to a water-insoluble film that:

1. resists removal by blood and/or irrigating solutions for at least six hours during the surgical procedure.

2. remains bactericidal after blood and/or saline exposure for at least six hours.

3. improves drape adhesion a. when incise drapes are used, the adhesion is improved to the wound edge b. incise drape edge lift has been associated in some clinical studies with both increased wound edge contamination and surgical site infection 

4. provides the efficacy of a five-minute povidone iodine scrub followed by a paint in a single, painted coat (application).

5. immobilizes bacteria remaining on skin (patient preoperative skin preparations do not sterilize skin, only disinfect, so some bacteria may remain or bacteria may rise to the surface of the skin from deeper levels or hair follicles during the surgical procedure).

ICT: Do you have, or do you know of, any recent case studies we could share with our readers on this topic?

Amat: Were very excited about a recently published clinical study that found a significant reduction in SSI when using InteguSeal compared to just standard skin prep alone. The study compared a prospective group of patients undergoing coronary artery bypass graft (CABG) procedures using InteguSeal microbial sealant versus a historical control rate. The study concluded that the group using InteguSeal had a significantly lower SSI rate than the historical control. (For more on CABG-related infections, see page 16.)

Bentzen: A new infection rate study comparing three different skin preparations will be presented at the Surgical Infection Society meeting in May.

Giarrizzo-Wilson: What follows is a quote from the revised recommended practices related to microbial presence in SSIs (please note: some of the references date back to 1983 as the original supporting investigation):

Staphylococcus aureus (S. aureus) is the most common organism causing SSIs.

^2,3

In 2003, 64.4 percent of healthcare-associated S. aureus infections were from methicillin-resistant

Staphylococcus aureus

(MRSA).

^4,5

Many SSIs result from colonization of the surgical site with the patients own flora; and colonization with S. aureus is a known risk factor for SSI.

2,

^6,7

Clinical trials support the use of preoperative antiseptic showers to reduce the number of microorganisms on the skin, including S. aureus.

^8,9,10,11

ICT: What would you say is the single most important thing to keep in mind when preparing yourself and a patient for surgery?

Amat: We know from the research that most SSIs are caused by pathogens from the patients own endogenous flora. These pathogens can enter the surgical incision by way of irrigation fluids, gloves, instruments, sponges or implants. And while skin can never be sterile, the healthcare community has recognized the importance of minimizing the opportunity for bacteria to find its way into the incision. A microbial sealant is designed with this effort in mind: it seals and immobilizes the bacteria on the skin to protect the incision from contamination.

Gorog: Factors that help reduce the incidence of HAIs and SSIs include routine handwashing, CHG skin prep for intravascular catheter site care, use of clippers for hair removal if necessary, and maximal barrier precautions with insertion of central lines.

Bentzen: The most important thing to keep in mind when using a topical antimicrobial is to follow the manufacturers directions for use. If these are not followed, the efficacy and/or safety of the product may be compromised.

Giarrizzo-Wilson: The single most important action to protect a surgical patient or yourself is to thoroughly wash and rinse the skin (e.g., surgical site, hands) to remove surface microorganisms (normal flora). By reducing the number of surface microbes on the skin there is reduced risk of introducing microbial contaminants into a surgical wound or to other individuals and onto inanimate surfaces.

ICT: What is the most overlooked single practice? How can better compliance be addressed?

Amat: There are many practices and techniques in place in todays OR to combat skin flora, but despite these practices SSI remains a growing issue. It is most important for us all to realize that regardless of the skin prep used, there is still bacteria present and able to regrow throughout the surgery, putting our patients at risk for SSI. We have also found that bacteria can regrow under antimicrobial incise drapes, so despite all of the techniques used today there is still a risk for infection among our patients. As we consider the growing amount of risk factors each patient now has (obesity, diabetes, age, etc.), the role of skin flora becomes even more important.

Gorog: Handwashing. Most important to be done before and after patient contact and before and after donning gloves. Hospitals should educate staff, provide adequate supplies, place reminders in patient rooms and encourage patients and families to remind staff. (These are all suggestions from the Institute for Healthcare Improvements 5 Million Lives Campaign for reduction in transmission of MRSA.) Alcohol-based hand rubs make handwashing easier and caregivers tend to be more compliant. Alcohol-based rubs should not be used with patients with Clostridium difficile.

Bentzen: Following manufacturers directions for use. Better compliance can be addressed by selecting products that: a) have directions for use that do not require variation from established best practices, and b) have directions for use that do not vary regardless of the area of the patients body to be prepped.

Giarrizzo-Wilson: The single best practice to implement, as supported by the Centers for Disease Control and Prevention (CDC), for reduction of surgical patient surface microbial load, is to instruct or assist the patient to perform two preoperative baths or showers with CHG before surgery. The text below is an excerpt from the revised recommended practices (same references as above):

Unless contraindicated, patients should be instructed or assisted to perform two preoperative baths or showers with CHG before surgery, to reduce the number of microorganisms on the skin and reduce the risk of subsequent contamination of the surgical wound.

Clinical trials support the use of preoperative antiseptic showers to reduce the number of microorganisms on the skin, including

S. aureus

.

^8,9,10,11

In 1999, the CDC recommend requiring patients to shower or bathe with an antiseptic agent at least the night before the operative day (Category IB).

²

ICT: Is there any bundle or checklist that may cover these very important steps in a surgical patients care?

Amat: SSI risk depends upon a number of patient factors, including pre-existing medical conditions, amount and type of resident skin bacteria, perioperative glucose levels, core body temperature fluctuations as well as pre-, intra- and post-operative care; therefore, it is difficult to predict which wounds will become infected.

For that reason, caregivers should strive for early identification of patients with risk factors amenable to intervention, to minimize the risk of wound contamination in all surgical cases, and to support host defenses throughout the continuum of care. These, and other well-researched interventions, should be bundled together and considered integral components of the care we must provide our patients every day.

Preoperatively, there are at least five distinct interventions used to minimize patient skin flora contamination of the surgical site:

1. whole body disinfection or showering with antiseptic soap 
2. if deemed necessary, non-razor surgical site hair removal immediately prior to surgery 
3. skin scrub with antiseptic soap 
4. skin paint with antiseptic solution 
5. application of barrier drapes or skin sealants 

Gorog: Central Line Insertion Bundle:

• hand hygiene 
• maximal barrier precautions upon insertion 
• chlorhexidine skin antisepsis 
• optimal catheter site selection, with subclavian vein as the preferred site for non-tunneled catheters 
• daily review of line necessity with prompt removal of unnecessary lines 

Surgical Site Prevention: CATS 

• Clippers: Use of clippers instead of razors if hair removal is necessary. Make sure to educate staff on proper use of clippers. Inappropriate technique can lead to skin abrasions.
• Antibiotics: Administered within one hour of surgical incision time 
• Temperature: Maintain normothermia (96.8 degrees to 100.4 degrees) one hour postoperative 
• Sugar: Maintain glucose control < 200mg/dl on postoperative day one and two 
• Preoperative cleansing of surgical incision site for removal of dirt before antiseptic skin prep in OR 

Giarrizzo-Wilson: AORN does not provide a bundle or checklist on this process. Individual facilities may have established policies or protocols outlining preoperative skin antisepsis processes. With regard to preoperative showering guidelines, the surgeons office or the healthcare facility may be providing written instructions for the patient but there is no way to monitor patient implementation of the guidelines. 

References 

1. Mimoz O, et al. Chlorhexidine-based antiseptic solution vs. alcoholbased povidone-iodine for central venous catheter care. Arch Intern Med. 2007;167(19):2066-2072.

2. Bleasdale S.C., et al. Effectiveness of chlorhexidine bathing to reduce catheter-associated bloodstream infections in medical intensive care unit patients. Arch Intern Med. 2007;167(19):2073-2079.

References for AORN responses 2. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999. Infect Control Hosp Epidemiol. 1999;20:250-278.

3. Centers for Disease Control and Prevention. Management of multi-drug-resistant organisms in healthcare settings. 2006. Clin Infect Dis. 2006; 42, 389-391.2. Also available at http://www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006.pdf.  Accessed October 5, 2007.

4. Centers for Disease Control and Prevention. MRSA in Healthcare Settings, 2007. http://www.cdc.gov/ncidod/dhqp/ar_MRSA_spotlight_2006.html. Accessed Nov. 5, 2007.

5. Klevens RM, Edwards JR, Tenover FC, McDonald LC, Horan T, Gaynes R. Changes in the epidemiology of methicillin-resistant Staphylococcus aureus in intensive care units in U.S. hospitals. 2992-2003. Clin Infect Dis. 2006:42:389-91.

6. Kluytmans JA, Mouton JW, Ijzerman EP, et al. Nasal carriage of Staphylococcus aureus as a major risk factor for wound infections after cardiac surgery. J Infectious Disease. 1995;171:216-219.

7. Leigh DA, Stronge JL, Marriner J, Sedgwick J. Total body bathing with hibiscrub (chlorhexidine) in surgical patients: a controlled trial. J Hosp Infect. 1983;4:229-235.

8. Garibaldi RA. Prevention of intraoperative wound contamination with chlorhexidine shower and scrub. J Hosp Infect. 1988;11(Suppl B):5-9.

9. Hayek L, Emerson JM, Gardner AMN. A placebo-controlled trial of the effect of two preoperative baths or showers with chlorhexidine detergent on postoperative wound infection rates. J Hosp Infect. 1987;10:165-72.

10. Byrne DJ, Napier A, Phillips G, Cuschieri A. Effects of whole body disinfection on skin flora in patients undergoing elective surgery. J Hosp Infect. 1991;17:217-222.

11. Kaiser AB, Kernodle DS, Barg NL, Petracek MR. Influence of preoperative showers on staphylococcal skin colonization: a comparative trial of antiseptic skin cleansers. Ann Thorac Surg. 1988;45:35-38.