This article appears in the July/August issue of  Surgical Products.

What constitutes proper surgical prepping these days? What are some of the notable misconceptions out there regarding prepping that put hospitals at risk for welcoming surgical-site infections? Surgical Products recently spoke with two industry experts to discuss good prepping practices, key misconceptions, and the products that can help hospitals and other medical facilities in this area.

SP: Do you feel most medical facilities/hospitals are up to par when it comes to their prepping processes? Why or why not?

Shaden Marzouk, MD, Vice President of Clinical Affairs, Cardinal Health: I would say yes. The ease and effectiveness of the one-step preps help make the prepping process a standardized event, which could help decrease process errors and potentially increase case start efficiency.
Moreover, there are commonalities within the overall infection prevention process across institutions. For example, it is common to give a pre-op antibiotic, shave and prep the skin, apply an antimicrobial adhesive drape, care for the skin edges during the case, take the steps to close with healthy tissue, potentially utilize a drain, select certain dressings, and maximize the patient’s systemic factors for wound healing. These steps, in addition to the skin prep itself, help control the surgical site infection rate.

Jodi M. Rohr, MSN, RN, CNOR, Technical Service Specialist 3M Infection Prevention Division: I think there is always a need for education on patient skin preps, including proper prepping practices, protocols, and techniques. It is important to understand the differences in the products and how they are applied. In order to achieve efficacy, skin prep solutions need to be applied per manufacturer’s directions for use.

SP: You mentioned some ways to make improvements in this area. What are some others?
Rohr: Today there are many prepping options available in both scrub and paint and one-step preps. They all have different instructions for use. Even the one-step preps have different directions for use. Some are paint-on products and others require scrubbing to achieve efficacy. It is important to read the label and understand how each product should be applied. Improper technique may diminish the efficacy of the products being used, which may increase the likelihood of a surgical-site infection.
It is also important to understand the surface area being prepped. If a skin prep solution is applied too thin by using it over a surface area larger than recommended by the manufacturer, the efficacy of the product could be compromised, putting the patient at risk for a surgical-site infection.
There is also the misperception that only alcohol-containing prep solutions need to be dry before draping. Much emphasis has been placed on making sure alcohol-containing preps are dry due to flammability issues, which is important, but it may cause the perception that non-alcohol prep solutions do not need to dry prior to draping. All preps need to dry before draping to achieve efficacy and to minimize skin integrity issues.

Marzouk: If I had to select one way, I would stress following a protocol when it comes to the prepping process. If you do something the same way every time, even when the room is in a hurry, steps won’t be skipped or skimped. A standardized approach helps increase efficiencies and promotes patient safety. Also keep in mind that skin prep is important, but there are many factors that relate to surgical site infection. It’s important to consider the systemic factors as well as the local ones.

SP: How can the products that are available today help medical personnel save time and/or become more efficient when it comes to prepping prior to surgery?
Rohr: The one-step applicators on the market allow for quicker application. They also contain alcohol, which is important because alcohol provides rapid bacterial kill. The other active ingredient, either iodine povacrylex or chlorhexidine gluconate, provide persistent activity and keep bacterial counts below baseline for up to 48 hours. Combining two active ingredients provides fast kill and persistent activity in one application.

It is still important to remember that even the one-step applicators have different application techniques based on the manufacturer’s instructions for use; those instructions are based on the ability to achieve proper efficacy. Using a one-step paint-on product is easier and quicker to apply, which maximizes time efficiency in the operating room. 

Marzouk: One of the most helpful changes over time has been the move to one-step skin prep from multi-step prepping practices. Instead of having to do a betadine scrub and paint or other multi-step combinations, you can now do an effective prep in one step, using products that combine iodine and alcohol or CHG and alcohol. Log reduction data has shown the efficacy of one-step preps, and the prep can be uniformly applied by trained OR personnel, increasing room efficiency.

As battery-powered skin shavers have become more ubiquitous, surgeons can closely shave the patient’s skin without nicking it. The battery-powered skin shavers are more convenient than the older versions with power cords. Now you don’t have to find an unoccupied outlet close to the patient or deal with a short cord. Also, improved battery life means that you are grabbing a “dead” shaver less often.

The evolution toward convenience has helped OR personnel save time when it comes to prepping the skin for surgery.

SP: How does some of the technology out there help ensure patient safety, help personnel avoid confusion and error, and increase efficiency?

Marzouk: Technology-enabled, evidence-based medicine can help improve quality, ensure safety, and increase efficiencies. Data analytics that quantify best practices can help hospitals build care pathways and standardize some aspects of patient treatment. It comes down to carrying out aspects of treatment the same way every time. When providers do this, you cut down on errors, become a more efficient team, save money, and improve the quality of care. There is a lot of data being collected through electronic medical records and other specialized software programs. The key is to analyze this data in a way that marries clinical and financial information. Look at what results in better patient care, both on a local and national basis.

Rohr: Educating staff regarding the rationale to why a particular practice or technique is important is the key to compliance in following proper protocol. Prepping practices should be applied consistently by individuals within their surgery department. Standardizing prepping technique and enforcing proper application per the manufacturer’s instructions will provide ease of use and help ensure compliance with protocols. Technology that saves time and is easy to use will certainly help.
Proper surgical skin preparation is a patient safety issue. If it is not being performed correctly, the patient may be at higher risk for surgical-site infection. Reducing the patient’s own bacterial load will reduce the risk of a surgical-site infection because the source of most surgical-site infections is the patient’s own skin flora. There is also evidence that surgical-site infections can come from bacteria in the patient’s nose. Reducing the bacteria in the patient’s nose prior to surgery may help reduce the risk of surgical-site infections.

The idea that surgical skin preparations render the skin sterile is a common misperception. Antiseptics only disinfect the skin. Applying a sterile incise drape over the skin after it has been prepped is the only way to achieve a true sterile surface at the start of surgery. Applying an incise drape that contains an antimicrobial within the adhesive will also continue to kill bacteria remaining on the skin. This technology has been shown to reduce wound contamination, a precursor to surgical-site infections. There are many steps we can take to reduce the risk of surgical site infections. preoperative bathing, disinfecting the nares, prepping the skin, and creating a sterile surface with the use of an incise drape all reduce the patient’s bacterial load and will reduce the risk of surgical site infections.