- Email: [email protected]
Back to Basics: Surgical Skin Antisepsis
CONTINUING EDUCATION
Back to Basics: Surgical Skin Antisepsis 1.0 www.aornjournal.org/content/cme
LISA SPRUCE, DNP, RN, CNS-CP, CNOR, ACNS, ACNP, FAAN Continuing Education Contact Hours
Approvals
indicates that continuing education (CE) contact hours are available for this activity. Earn the CE contact hours by reading this article, reviewing the purpose/goal and objectives, and completing the online Examination and Learner Evaluation at http://www.aornjournal.org/content/cme. A score of 70% correct on the examination is required for credit. Participants receive feedback on incorrect answers. Each applicant who successfully completes this program can immediately print a certificate of completion.
This program meets criteria for CNOR and CRNFA recertification, as well as other CE requirements.
Event: #16503 Session: #0001 Fee: For current pricing, please go to: http://www.aornjournal .org/content/cme.
Conflict-of-Interest Disclosures
The contact hours for this article expire January 31, 2019. Pricing is subject to change.
Purpose/Goal To provide the learner with knowledge of best practices related to surgical skin antisepsis and prepping.
AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this activity for relicensure.
Lisa Spruce, DNP, RN, CNS-CP, CNOR, ACNS, ACNP, FAAN, has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. The behavioral objectives for this program were created by Helen Starbuck Pashley, MA, BSN, CNOR, clinical editor, with consultation from Susan Bakewell, MS, RN-BC, director, Perioperative Education. Ms Starbuck Pashley and Ms Bakewell have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article.
Objectives 1. Discuss common areas of concern that relate to perioperative best practices. 2. Discuss best practices that could enhance safety in the perioperative area. 3. Describe implementation of evidence-based practice in relation to perioperative nursing care.
Sponsorship or Commercial Support No sponsorship or commercial support was received for this article.
Disclaimer Accreditation AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
AORN recognizes these activities as CE for RNs. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity.
http://dx.doi.org/10.1016/j.aorn.2015.11.002 ª AORN, Inc, 2016
www.aornjournal.org
AORN Journal j 95
Back to Basics: Surgical Skin Antisepsis 1.0 www.aornjournal.org/content/cme
LISA SPRUCE, DNP, RN, CNS-CP, CNOR, ACNS, ACNP, FAAN
ABSTRACT The fundamental basis for preventing surgical site infections is the antiseptic preparation of the skin at the surgical site. All perioperative nurses must learn this skill. The goal of surgical skin antisepsis, frequently referred to as prepping the skin, is to remove soil and transient (ie, temporary) microorganisms living on the skin that could pose a risk for surgical site infections. This Back to Basics article examines the origin of surgical skin antisepsis and the steps perioperative nurses should take to provide the patient with an aseptic surgical site before any surgical or other invasive procedure. AORN J 103 (January 2016) 96-100. ª AORN, Inc, 2016. http://dx.doi.org/10.1016/j.aorn.2015.11.002 Key words: skin preps, antisepsis, surgical site infections, aseptic technique.
S
urgical skin antisepsis (ie, preparing a patient for a surgical procedure by cleaning the skin) is a skill that perioperative nurses must learn as a foundation for providing surgical care. Joseph Lister, FRCS, is credited with being the first surgeon to use surgical skin antisepsis.1 In the 1800s, Lister experimented with using carbolic acid on various types of surgical wounds, most often on patients with compound fractures. By the late 1800s, he had extended the use of carbolic acid from the patient’s skin to his hands and the hands of his assistants, and he was the first physician to publish a work on antisepsis titled On the Antiseptic Principle in the Practice of Surgery.2 Lister’s practice of using carbolic acid to clean surgical sites reduced surgical site infections (SSIs) and death, which were common at that time after surgery. This advance in surgical care was slow to be accepted by his peers, but his work eventually led to the surgical site antisepsis that is now practiced as a part of routine surgical care.1 The goal of surgical skin antisepsis, frequently referred to as prepping the skin, is to remove soil and transient (ie, temporary) microorganisms living on the skin that could pose a risk for SSIs. Skin antiseptics work quickly to remove transient organisms and reduce normal resident organisms or flora to
subpathogenic levels.3 These antiseptics also have persistent antimicrobial effects that reduce bacterial regrowth.3 This Back to Basics article presents steps for the perioperative nurse to provide surgical site skin antisepsis and includes a discussion of skin preparation techniques and other important considerations. It does not provide a detailed look at skin antiseptics, specific surgeries, or preoperative patient bathing.
HOW-TO GUIDE One of the first recommendations from AORN’s evidencebased practice guideline on surgical skin antisepsis3 is that the nurse not remove the patient’s hair at the surgical site. Clinical practice guidelines, such as those published by The National Institute for Health and Care Excellence4 and the Society for Healthcare Epidemiology of America,5 support this practice unless the hair interferes with the procedure. Removing hair could be associated with an increase in SSIs because when hair is removed, there is the potential for trauma to the skin, increasing the risk for an SSI. If hair removal is necessary for the procedure, the nurse should remove it by using a clipper or a depilatory. He or she should remove the hair outside the operating or procedure area unless contraindicated (eg, in an emergency), and the http://dx.doi.org/10.1016/j.aorn.2015.11.002 ª AORN, Inc, 2016
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January 2016, Vol. 103, No. 1
hair should be removed in a manner that prevents its dispersal (eg, wet clipping, use of suction). Before beginning the prep, the nurse should assess the patient for allergies and sensitivities to skin antiseptic products. Fish or
www.aornjournal.org
Back to Basics: Surgical Skin Antisepsis
seafood allergies do not indicate an iodine allergy or a barrier to using iodine antiseptic agents according to the American Academy of Allergy, Asthma, and Immunology.6 Anaphylaxis to a topical iodine solution is extremely rare and has not been tied to iodine.6 AORN Journal j 97
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January 2016, Vol. 103, No. 1
Figure 1. What’s wrong with this picture of hand hygiene? Illustration by Kurt Jones. Reprinted with permission from AORN, Inc, 2170 S. Parker Road, Suite 400, Denver, CO, 80231. All rights reserved. RP ¼ recommended practice. This abbreviation was used in the AORN recommended practices, which are now referred to as AORN guidelines. In addition to allergies, the nurse should assess the patient’s skin integrity before selecting an antiseptic and should base the choice of an antiseptic on the type of procedure being performed. Manufacturer’s instructions for product use on a surgical site should be followed. Table 1 provides examples of prepping agents and their considerations for use. The nurse also should confirm the surgical site with the patient and surgical team before prepping and ensure that any site marking remains visible. Before prepping the patient’s surgical site, the nurse must remove the patient’s jewelry and may need to clean the incision site with soap if the patient is a trauma patient or did not bathe preoperatively. The nurse should clean areas of greater contamination within the prep area (ie, umbilicus, foreskin, under nails, urinary or intestinal stomas) before prepping the surgical site and should isolate areas of high contamination (eg, anus) with a sterile barrier drape. To perform a prep, a nonscrubbed team member should complete the following steps. Perform hand hygiene before beginning the prep.
98 j AORN Journal
Don sterile gloves; nonsterile gloves may be worn if the antiseptic applicator is long enough to prevent the team member’s hand from touching the solution or the patient’s skin. Ensure that surgical attire (eg, long-sleeved scrub top or jacket) covers the arms while prepping. Use sterile supplies during the prep and ensure that any item that touches the patient’s skin after prepping is sterile. Use aseptic technique o Apply the prep in an area that is large enough to allow for an extension of the incision, additional incisions, drain placement, or shifting of the drapes. o Start the prep at the incision site and move away toward the periphery of the surgical site. o After contact with peripheral or contaminated areas of the prep site, discard the applicator and use another sterile applicator for any additional product applications. o Prep the area of lower bacterial contamination first and then the areas of higher contamination, as opposed to working from the incision to the periphery, when prepping an incision site that is more highly contaminated than the surrounding skin (eg, anus, axilla, open wound).
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January 2016, Vol. 103, No. 1
AORN Resources for Skin Antisepsis Guideline for surgical attire. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2015:97-119. Guideline for patient skin antisepsis. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2015:43-66. Guideline for hand hygiene. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2015:31-42. Periop 101: The Essential Perioperative Nursing Program. AORN. https://www.aorn.org/periop101/. Accessed September 25, 2015. Patient Skin Antisepsis: Clinical FAQs. AORN. https:// www.aorn.org/Secondary.aspx?id¼20981&terms¼surgical% 20skin%20antisepsis. Accessed September 25, 2015. Patient Skin Antisepsis Video. Cine-Med. http://cine-med .com/index.php?nav¼aorn&id¼1974. Accessed September 25, 2015. o o o
o o o
o o
o
Follow the manufacturer’s instructions for use when using a prefilled applicator. Apply the antiseptic with uniform distribution. Use gentle friction on fragile tissue, burns, malignant areas (which have the potential to spread cancer cells), or open wounds. Apply the antiseptic to all surfaces, including between the fingers or toes when prepping a hand or foot. Allow the antiseptic solution to dry for the full time recommended by the manufacturer. Prevent dripping and pooling of the antiseptic on sheets, padding, equipment, tape, electrosurgical unit electrodes, and tourniquets by protecting them from contact with prepping solution. Place a fluid-resistant pad under buttocks when the patient is in the lithotomy position. Remove the antiseptic from the patient’s skin following the procedure unless otherwise indicated by the manufacturer’s instructions. This helps prevent skin irritation. Assess the patient’s skin for injury following the surgery and before transfer to the postanesthesia care unit.
After performing the prep, the team member should document the removal of jewelry and its disposition; skin condition (eg, note rashes, abrasions, redness, irritation, skin eruptions, burns);
www.aornjournal.org
Back to Basics: Surgical Skin Antisepsis
antiseptic used; person who performed the prep; area prepped; and postoperative skin condition, noting irritation, allergic response, or hypersensitivity.
To help the reader understand hand hygiene, Figure 1 provides an opportunity to identify what is wrong with the process shown in the illustration.
BENEFIT Surgical site infections are far too common and preventing SSIs remains a high priority because they can result in an increase in patient readmissions, disfigurement, mortality, and pain and suffering and result in a significant cost increase to facilities.7 According to the Institute of Healthcare Improvement, 40% to 60% of clean-case SSIs are preventable.8 Many components contribute to SSI prevention, and surgical skin antisepsis is the foundation for preventing an SSI.
STRATEGIES FOR SUCCESS Perioperative staff members should form a multidisciplinary team consisting of perioperative nurses, physicians, and infection preventionists to select patient skin antiseptics and to discuss appropriate technique, types of antiseptics, and their indications for use to help reduce the risk for an SSI. Educators and mentors should educate nurses new to perioperative practice on the principles of asepsis and aseptic technique. This should be ongoing training that continues until nurses are comfortable with various techniques and have addressed the challenges posed with prepping the patient for different types of surgeries and positions. This ongoing training helps ensure that all patients are being prepped safely and effectively. Health care team safety is important when lifting and holding various body parts for prepping. The perioperative team member performing the prep should minimize muscle fatigue by
using two hands for lifting, obtaining assistance when needed, using an assistive device when needed, and using a combination of these methods when needed.9
Understanding these techniques help prevent work-related musculoskeletal injuries. AORN Journal j 99
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January 2016, Vol. 103, No. 1
WRAP-UP Lister’s work on germ theory and the principles of antisepsis laid the foundation for surgical preparation in the OR today. Patients deserve and expect that they will receive the highest quality and safest care possible when undergoing surgery or other invasive procedures. A basic step to providing safe care and preventing SSIs is the surgical prep, which all perioperative nurses should be able to skillfully perform. This article provides the fundamental rationale and steps to performing a surgical prep; however, this process also includes patient preoperative bathing and the selection of antiseptics. In its “Guideline for preoperative patient skin antisepsis,”3 AORN has provided an evidence-based guideline on skin antisepsis that provides a full discussion of these topics and more. Following the correct techniques when preparing a patient’s skin for surgery helps ensure that patients begin their surgical procedure with an aseptic surgical site.
References 1. Brand RA. Biographical sketch: Baron Joseph Lister, FRCS, 18271912. Clin Orthop Relat Res. 2010;468(8):2009-2011. 2. Lister BJ. The classic: on the antiseptic principle in the practice of surgery. Clin Orthop Relat Res. 2010;468(8):2012-2016. 3. Guideline for preoperative patient skin antisepsis. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2015:43-66. 4. National Institute for Health and Care Excellence. Surgical site infection: prevention and treatment of surgical site infection.
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5.
6.
7.
8.
9.
October 2008. https://www.nice.org.uk/guidance/cg74. Accessed September 9, 2015. Anderson DJ, Podgorny K, Berríos-Torres SI, et al. Strategies to prevent surgical site infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014;35(Suppl 2):S66-S88. American Academy of Allergy, Asthma, and Immunology. AAAAI Position Statement: The Risk of Severe Allergic Reactions From the Use of Potassium Iodide for Radiation Emergencies. February 2004. https://www.aaaai.org/Aaaai/media/MediaLibrary/PDF%20Documents/ Practice%20and%20Parameters/Potassium-iodide-in-radiation -emergencies-2004.pdf. Accessed September 9, 2015. Douglas RS Jr. The direct medical costs of healthcare-associated infections in U.S. hospitals and the benefits of prevention. Centers for Disease Control and Prevention. http://www.cdc.gov/ HAI/pdfs/hai/Scott_CostPaper.pdf. Accessed August 31, 2015. How-to Guide: Prevent Surgical Site Infections. 2012. Institute for Healthcare Improvement. http://www.ihi.org/resources/Pages/Tools/ HowtoGuidePreventSurgicalSiteInfection.aspx. Accessed August 31, 2015. AORN guidance statement: safe patient handling and movement in the perioperative setting. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2015:733-751.
Lisa Spruce, DNP, RN, CNS-CP, CNOR, ACNS, ACNP, FAAN, is the director, Evidence-based Perioperative Practice, AORN, Inc, Denver, CO. Dr Spruce has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
www.aornjournal.org
EXAMINATION
Continuing Education: Back to Basics: Surgical Skin Antisepsis 1.0 www.aornjournal.org/content/cme
PURPOSE/GOAL To provide the learner with knowledge of best practices related to surgical skin antisepsis and prepping.
OBJECTIVES 1. 2. 3.
Discuss common areas of concern that relate to perioperative best practices. Discuss best practices that could enhance safety in the perioperative area. Describe implementation of evidence-based practice in relation to perioperative nursing care.
The Examination and Learner Evaluation are printed here for your convenience. To receive continuing education credit, you must complete the online Examination and Learner Evaluation at http://www.aornjournal.org/content/cme.
QUESTIONS 1.
The goal of surgical skin antisepsis, frequently referred to as prepping the skin, is to 1. remove soil and transient (ie, temporary) microorganisms living on the skin. 2. reduce normal resident organisms or flora to subpathogenic levels. 3. replace pathogenic bacteria with normal skin flora. 4. reduce bacterial regrowth. a. 1 and 3 b. 2 and 4 c. 1, 2, and 4 d. 1, 2, 3, and 4
2.
The goal of surgical skin antisepsis is to prevent the risk for surgical site infections (SSIs). a. true b. false
3.
Some basic steps the nurse should take before beginning a skin prep include 1. not removing hair at the surgical site, unless necessary.
2. assessing the patient for allergies, sensitivities, and skin integrity before selecting an antiseptic. 3. following the manufacturer’s instructions for product use. 4. basing the choice of an antiseptic on the type of procedure being performed. 5. removing the patient’s jewelry. 6. confirming the surgical site. a. 1, 3, and 5 b. 2, 4, and 6 c. 2, 3, 5, and 6 d. 1, 2, 3, 4, 5, and 6 4.
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Steps for performing a prep include 1. performing hand hygiene before beginning the prep. 2. donning sterile gloves. 3. ensuring that surgical attire (eg, long-sleeved scrub top or jacket) covers the arms during prepping. 4. using sterile supplies and ensuring that any item that touches the patient’s skin after antisepsis is sterile.
AORN Journal j 101
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5. using aseptic technique. a. 4 and 5 b. 1, 2, and 3 c. 1, 2, 3, and 4 d. 1, 2, 3, 4, and 5
January 2016, Vol. 103, No. 1
2.
3. 5.
Implementations of evidence-based practices include 1. forming a multidisciplinary team consisting of perioperative nurses, physicians, and infection preventionists.
102 j AORN Journal
educating perioperative nurses on the principles of asepsis and aseptic technique after they are practicing independently. discussing appropriate technique, types of antiseptics, and their indications for use. a. 1 and 2 b. 1 and 3 c. 2 and 3 d. 1, 2, and 3
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LEARNER EVALUATION
Continuing Education: Back to Basics: Surgical Skin Antisepsis 1.0 www.aornjournal.org/content/cme
T
his evaluation is used to determine the extent to which this continuing education program met your learning needs. The evaluation is printed here for your convenience. To receive continuing education credit, you must complete the online Examination and Learner Evaluation at http://www.aornjournal.org/content/cme. Rate the items as described below.
6.
Will you be able to use the information from this article in your work setting? 1. Yes 2. No
7.
Will you change your practice as a result of reading this article? (If yes, answer question #7A. If no, answer question #7B.)
7A.
How will you change your practice? (Select all that apply) 1. I will provide education to my team regarding why change is needed. 2. I will work with management to change/implement a policy and procedure. 3. I will plan an informational meeting with physicians to seek their input and acceptance of the need for change. 4. I will implement change and evaluate the effect of the change at regular intervals until the change is incorporated as best practice. 5. Other: __________________________________
7B.
If you will not change your practice as a result of reading this article, why? (Select all that apply) 1. The content of the article is not relevant to my practice. 2. I do not have enough time to teach others about the purpose of the needed change. 3. I do not have management support to make a change.
PURPOSE/GOAL To provide the learner with knowledge of best practices related to surgical skin antisepsis and prepping.
OBJECTIVES To what extent were the following objectives of this continuing education program achieved? 1. Discuss common areas of concern that relate to perioperative best practices. Low 1. 2. 3. 4. 5. High 2.
3.
Discuss best practices that could enhance safety in the perioperative area. Low 1. 2. 3. 4. 5. High Describe implementation of evidence-based practice in relation to perioperative nursing care. Low 1. 2. 3. 4. 5. High
CONTENT 4.
5.
To what extent did this article increase your knowledge of the subject matter? Low 1. 2. 3. 4. 5. High To what extent were your individual objectives met? Low 1. 2. 3. 4. 5. High
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4. Other: __________________________________ 8.
Our accrediting body requires that we verify the time you needed to complete the 1.0 continuing education contact hour (60-minute) program: ______________
AORN Journal j 103
Back to Basics: Surgical Skin Antisepsis 1.0 www.aornjournal.org/content/cme
LISA SPRUCE, DNP, RN, CNS-CP, CNOR, ACNS, ACNP, FAAN Continuing Education Contact Hours
Approvals
indicates that continuing education (CE) contact hours are available for this activity. Earn the CE contact hours by reading this article, reviewing the purpose/goal and objectives, and completing the online Examination and Learner Evaluation at http://www.aornjournal.org/content/cme. A score of 70% correct on the examination is required for credit. Participants receive feedback on incorrect answers. Each applicant who successfully completes this program can immediately print a certificate of completion.
This program meets criteria for CNOR and CRNFA recertification, as well as other CE requirements.
Event: #16503 Session: #0001 Fee: For current pricing, please go to: http://www.aornjournal .org/content/cme.
Conflict-of-Interest Disclosures
The contact hours for this article expire January 31, 2019. Pricing is subject to change.
Purpose/Goal To provide the learner with knowledge of best practices related to surgical skin antisepsis and prepping.
AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this activity for relicensure.
Lisa Spruce, DNP, RN, CNS-CP, CNOR, ACNS, ACNP, FAAN, has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. The behavioral objectives for this program were created by Helen Starbuck Pashley, MA, BSN, CNOR, clinical editor, with consultation from Susan Bakewell, MS, RN-BC, director, Perioperative Education. Ms Starbuck Pashley and Ms Bakewell have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article.
Objectives 1. Discuss common areas of concern that relate to perioperative best practices. 2. Discuss best practices that could enhance safety in the perioperative area. 3. Describe implementation of evidence-based practice in relation to perioperative nursing care.
Sponsorship or Commercial Support No sponsorship or commercial support was received for this article.
Disclaimer Accreditation AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
AORN recognizes these activities as CE for RNs. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity.
http://dx.doi.org/10.1016/j.aorn.2015.11.002 ª AORN, Inc, 2016
www.aornjournal.org
AORN Journal j 95
Back to Basics: Surgical Skin Antisepsis 1.0 www.aornjournal.org/content/cme
LISA SPRUCE, DNP, RN, CNS-CP, CNOR, ACNS, ACNP, FAAN
ABSTRACT The fundamental basis for preventing surgical site infections is the antiseptic preparation of the skin at the surgical site. All perioperative nurses must learn this skill. The goal of surgical skin antisepsis, frequently referred to as prepping the skin, is to remove soil and transient (ie, temporary) microorganisms living on the skin that could pose a risk for surgical site infections. This Back to Basics article examines the origin of surgical skin antisepsis and the steps perioperative nurses should take to provide the patient with an aseptic surgical site before any surgical or other invasive procedure. AORN J 103 (January 2016) 96-100. ª AORN, Inc, 2016. http://dx.doi.org/10.1016/j.aorn.2015.11.002 Key words: skin preps, antisepsis, surgical site infections, aseptic technique.
S
urgical skin antisepsis (ie, preparing a patient for a surgical procedure by cleaning the skin) is a skill that perioperative nurses must learn as a foundation for providing surgical care. Joseph Lister, FRCS, is credited with being the first surgeon to use surgical skin antisepsis.1 In the 1800s, Lister experimented with using carbolic acid on various types of surgical wounds, most often on patients with compound fractures. By the late 1800s, he had extended the use of carbolic acid from the patient’s skin to his hands and the hands of his assistants, and he was the first physician to publish a work on antisepsis titled On the Antiseptic Principle in the Practice of Surgery.2 Lister’s practice of using carbolic acid to clean surgical sites reduced surgical site infections (SSIs) and death, which were common at that time after surgery. This advance in surgical care was slow to be accepted by his peers, but his work eventually led to the surgical site antisepsis that is now practiced as a part of routine surgical care.1 The goal of surgical skin antisepsis, frequently referred to as prepping the skin, is to remove soil and transient (ie, temporary) microorganisms living on the skin that could pose a risk for SSIs. Skin antiseptics work quickly to remove transient organisms and reduce normal resident organisms or flora to
subpathogenic levels.3 These antiseptics also have persistent antimicrobial effects that reduce bacterial regrowth.3 This Back to Basics article presents steps for the perioperative nurse to provide surgical site skin antisepsis and includes a discussion of skin preparation techniques and other important considerations. It does not provide a detailed look at skin antiseptics, specific surgeries, or preoperative patient bathing.
HOW-TO GUIDE One of the first recommendations from AORN’s evidencebased practice guideline on surgical skin antisepsis3 is that the nurse not remove the patient’s hair at the surgical site. Clinical practice guidelines, such as those published by The National Institute for Health and Care Excellence4 and the Society for Healthcare Epidemiology of America,5 support this practice unless the hair interferes with the procedure. Removing hair could be associated with an increase in SSIs because when hair is removed, there is the potential for trauma to the skin, increasing the risk for an SSI. If hair removal is necessary for the procedure, the nurse should remove it by using a clipper or a depilatory. He or she should remove the hair outside the operating or procedure area unless contraindicated (eg, in an emergency), and the http://dx.doi.org/10.1016/j.aorn.2015.11.002 ª AORN, Inc, 2016
96 j AORN Journal
www.aornjournal.org
January 2016, Vol. 103, No. 1
hair should be removed in a manner that prevents its dispersal (eg, wet clipping, use of suction). Before beginning the prep, the nurse should assess the patient for allergies and sensitivities to skin antiseptic products. Fish or
www.aornjournal.org
Back to Basics: Surgical Skin Antisepsis
seafood allergies do not indicate an iodine allergy or a barrier to using iodine antiseptic agents according to the American Academy of Allergy, Asthma, and Immunology.6 Anaphylaxis to a topical iodine solution is extremely rare and has not been tied to iodine.6 AORN Journal j 97
Spruce
January 2016, Vol. 103, No. 1
Figure 1. What’s wrong with this picture of hand hygiene? Illustration by Kurt Jones. Reprinted with permission from AORN, Inc, 2170 S. Parker Road, Suite 400, Denver, CO, 80231. All rights reserved. RP ¼ recommended practice. This abbreviation was used in the AORN recommended practices, which are now referred to as AORN guidelines. In addition to allergies, the nurse should assess the patient’s skin integrity before selecting an antiseptic and should base the choice of an antiseptic on the type of procedure being performed. Manufacturer’s instructions for product use on a surgical site should be followed. Table 1 provides examples of prepping agents and their considerations for use. The nurse also should confirm the surgical site with the patient and surgical team before prepping and ensure that any site marking remains visible. Before prepping the patient’s surgical site, the nurse must remove the patient’s jewelry and may need to clean the incision site with soap if the patient is a trauma patient or did not bathe preoperatively. The nurse should clean areas of greater contamination within the prep area (ie, umbilicus, foreskin, under nails, urinary or intestinal stomas) before prepping the surgical site and should isolate areas of high contamination (eg, anus) with a sterile barrier drape. To perform a prep, a nonscrubbed team member should complete the following steps. Perform hand hygiene before beginning the prep.
98 j AORN Journal
Don sterile gloves; nonsterile gloves may be worn if the antiseptic applicator is long enough to prevent the team member’s hand from touching the solution or the patient’s skin. Ensure that surgical attire (eg, long-sleeved scrub top or jacket) covers the arms while prepping. Use sterile supplies during the prep and ensure that any item that touches the patient’s skin after prepping is sterile. Use aseptic technique o Apply the prep in an area that is large enough to allow for an extension of the incision, additional incisions, drain placement, or shifting of the drapes. o Start the prep at the incision site and move away toward the periphery of the surgical site. o After contact with peripheral or contaminated areas of the prep site, discard the applicator and use another sterile applicator for any additional product applications. o Prep the area of lower bacterial contamination first and then the areas of higher contamination, as opposed to working from the incision to the periphery, when prepping an incision site that is more highly contaminated than the surrounding skin (eg, anus, axilla, open wound).
www.aornjournal.org
January 2016, Vol. 103, No. 1
AORN Resources for Skin Antisepsis Guideline for surgical attire. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2015:97-119. Guideline for patient skin antisepsis. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2015:43-66. Guideline for hand hygiene. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2015:31-42. Periop 101: The Essential Perioperative Nursing Program. AORN. https://www.aorn.org/periop101/. Accessed September 25, 2015. Patient Skin Antisepsis: Clinical FAQs. AORN. https:// www.aorn.org/Secondary.aspx?id¼20981&terms¼surgical% 20skin%20antisepsis. Accessed September 25, 2015. Patient Skin Antisepsis Video. Cine-Med. http://cine-med .com/index.php?nav¼aorn&id¼1974. Accessed September 25, 2015. o o o
o o o
o o
o
Follow the manufacturer’s instructions for use when using a prefilled applicator. Apply the antiseptic with uniform distribution. Use gentle friction on fragile tissue, burns, malignant areas (which have the potential to spread cancer cells), or open wounds. Apply the antiseptic to all surfaces, including between the fingers or toes when prepping a hand or foot. Allow the antiseptic solution to dry for the full time recommended by the manufacturer. Prevent dripping and pooling of the antiseptic on sheets, padding, equipment, tape, electrosurgical unit electrodes, and tourniquets by protecting them from contact with prepping solution. Place a fluid-resistant pad under buttocks when the patient is in the lithotomy position. Remove the antiseptic from the patient’s skin following the procedure unless otherwise indicated by the manufacturer’s instructions. This helps prevent skin irritation. Assess the patient’s skin for injury following the surgery and before transfer to the postanesthesia care unit.
After performing the prep, the team member should document the removal of jewelry and its disposition; skin condition (eg, note rashes, abrasions, redness, irritation, skin eruptions, burns);
www.aornjournal.org
Back to Basics: Surgical Skin Antisepsis
antiseptic used; person who performed the prep; area prepped; and postoperative skin condition, noting irritation, allergic response, or hypersensitivity.
To help the reader understand hand hygiene, Figure 1 provides an opportunity to identify what is wrong with the process shown in the illustration.
BENEFIT Surgical site infections are far too common and preventing SSIs remains a high priority because they can result in an increase in patient readmissions, disfigurement, mortality, and pain and suffering and result in a significant cost increase to facilities.7 According to the Institute of Healthcare Improvement, 40% to 60% of clean-case SSIs are preventable.8 Many components contribute to SSI prevention, and surgical skin antisepsis is the foundation for preventing an SSI.
STRATEGIES FOR SUCCESS Perioperative staff members should form a multidisciplinary team consisting of perioperative nurses, physicians, and infection preventionists to select patient skin antiseptics and to discuss appropriate technique, types of antiseptics, and their indications for use to help reduce the risk for an SSI. Educators and mentors should educate nurses new to perioperative practice on the principles of asepsis and aseptic technique. This should be ongoing training that continues until nurses are comfortable with various techniques and have addressed the challenges posed with prepping the patient for different types of surgeries and positions. This ongoing training helps ensure that all patients are being prepped safely and effectively. Health care team safety is important when lifting and holding various body parts for prepping. The perioperative team member performing the prep should minimize muscle fatigue by
using two hands for lifting, obtaining assistance when needed, using an assistive device when needed, and using a combination of these methods when needed.9
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WRAP-UP Lister’s work on germ theory and the principles of antisepsis laid the foundation for surgical preparation in the OR today. Patients deserve and expect that they will receive the highest quality and safest care possible when undergoing surgery or other invasive procedures. A basic step to providing safe care and preventing SSIs is the surgical prep, which all perioperative nurses should be able to skillfully perform. This article provides the fundamental rationale and steps to performing a surgical prep; however, this process also includes patient preoperative bathing and the selection of antiseptics. In its “Guideline for preoperative patient skin antisepsis,”3 AORN has provided an evidence-based guideline on skin antisepsis that provides a full discussion of these topics and more. Following the correct techniques when preparing a patient’s skin for surgery helps ensure that patients begin their surgical procedure with an aseptic surgical site.
References 1. Brand RA. Biographical sketch: Baron Joseph Lister, FRCS, 18271912. Clin Orthop Relat Res. 2010;468(8):2009-2011. 2. Lister BJ. The classic: on the antiseptic principle in the practice of surgery. Clin Orthop Relat Res. 2010;468(8):2012-2016. 3. Guideline for preoperative patient skin antisepsis. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2015:43-66. 4. National Institute for Health and Care Excellence. Surgical site infection: prevention and treatment of surgical site infection.
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5.
6.
7.
8.
9.
October 2008. https://www.nice.org.uk/guidance/cg74. Accessed September 9, 2015. Anderson DJ, Podgorny K, Berríos-Torres SI, et al. Strategies to prevent surgical site infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014;35(Suppl 2):S66-S88. American Academy of Allergy, Asthma, and Immunology. AAAAI Position Statement: The Risk of Severe Allergic Reactions From the Use of Potassium Iodide for Radiation Emergencies. February 2004. https://www.aaaai.org/Aaaai/media/MediaLibrary/PDF%20Documents/ Practice%20and%20Parameters/Potassium-iodide-in-radiation -emergencies-2004.pdf. Accessed September 9, 2015. Douglas RS Jr. The direct medical costs of healthcare-associated infections in U.S. hospitals and the benefits of prevention. Centers for Disease Control and Prevention. http://www.cdc.gov/ HAI/pdfs/hai/Scott_CostPaper.pdf. Accessed August 31, 2015. How-to Guide: Prevent Surgical Site Infections. 2012. Institute for Healthcare Improvement. http://www.ihi.org/resources/Pages/Tools/ HowtoGuidePreventSurgicalSiteInfection.aspx. Accessed August 31, 2015. AORN guidance statement: safe patient handling and movement in the perioperative setting. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2015:733-751.
Lisa Spruce, DNP, RN, CNS-CP, CNOR, ACNS, ACNP, FAAN, is the director, Evidence-based Perioperative Practice, AORN, Inc, Denver, CO. Dr Spruce has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
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EXAMINATION
Continuing Education: Back to Basics: Surgical Skin Antisepsis 1.0 www.aornjournal.org/content/cme
PURPOSE/GOAL To provide the learner with knowledge of best practices related to surgical skin antisepsis and prepping.
OBJECTIVES 1. 2. 3.
Discuss common areas of concern that relate to perioperative best practices. Discuss best practices that could enhance safety in the perioperative area. Describe implementation of evidence-based practice in relation to perioperative nursing care.
The Examination and Learner Evaluation are printed here for your convenience. To receive continuing education credit, you must complete the online Examination and Learner Evaluation at http://www.aornjournal.org/content/cme.
QUESTIONS 1.
The goal of surgical skin antisepsis, frequently referred to as prepping the skin, is to 1. remove soil and transient (ie, temporary) microorganisms living on the skin. 2. reduce normal resident organisms or flora to subpathogenic levels. 3. replace pathogenic bacteria with normal skin flora. 4. reduce bacterial regrowth. a. 1 and 3 b. 2 and 4 c. 1, 2, and 4 d. 1, 2, 3, and 4
2.
The goal of surgical skin antisepsis is to prevent the risk for surgical site infections (SSIs). a. true b. false
3.
Some basic steps the nurse should take before beginning a skin prep include 1. not removing hair at the surgical site, unless necessary.
2. assessing the patient for allergies, sensitivities, and skin integrity before selecting an antiseptic. 3. following the manufacturer’s instructions for product use. 4. basing the choice of an antiseptic on the type of procedure being performed. 5. removing the patient’s jewelry. 6. confirming the surgical site. a. 1, 3, and 5 b. 2, 4, and 6 c. 2, 3, 5, and 6 d. 1, 2, 3, 4, 5, and 6 4.
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Steps for performing a prep include 1. performing hand hygiene before beginning the prep. 2. donning sterile gloves. 3. ensuring that surgical attire (eg, long-sleeved scrub top or jacket) covers the arms during prepping. 4. using sterile supplies and ensuring that any item that touches the patient’s skin after antisepsis is sterile.
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5. using aseptic technique. a. 4 and 5 b. 1, 2, and 3 c. 1, 2, 3, and 4 d. 1, 2, 3, 4, and 5
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2.
3. 5.
Implementations of evidence-based practices include 1. forming a multidisciplinary team consisting of perioperative nurses, physicians, and infection preventionists.
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educating perioperative nurses on the principles of asepsis and aseptic technique after they are practicing independently. discussing appropriate technique, types of antiseptics, and their indications for use. a. 1 and 2 b. 1 and 3 c. 2 and 3 d. 1, 2, and 3
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LEARNER EVALUATION
Continuing Education: Back to Basics: Surgical Skin Antisepsis 1.0 www.aornjournal.org/content/cme
T
his evaluation is used to determine the extent to which this continuing education program met your learning needs. The evaluation is printed here for your convenience. To receive continuing education credit, you must complete the online Examination and Learner Evaluation at http://www.aornjournal.org/content/cme. Rate the items as described below.
6.
Will you be able to use the information from this article in your work setting? 1. Yes 2. No
7.
Will you change your practice as a result of reading this article? (If yes, answer question #7A. If no, answer question #7B.)
7A.
How will you change your practice? (Select all that apply) 1. I will provide education to my team regarding why change is needed. 2. I will work with management to change/implement a policy and procedure. 3. I will plan an informational meeting with physicians to seek their input and acceptance of the need for change. 4. I will implement change and evaluate the effect of the change at regular intervals until the change is incorporated as best practice. 5. Other: __________________________________
7B.
If you will not change your practice as a result of reading this article, why? (Select all that apply) 1. The content of the article is not relevant to my practice. 2. I do not have enough time to teach others about the purpose of the needed change. 3. I do not have management support to make a change.
PURPOSE/GOAL To provide the learner with knowledge of best practices related to surgical skin antisepsis and prepping.
OBJECTIVES To what extent were the following objectives of this continuing education program achieved? 1. Discuss common areas of concern that relate to perioperative best practices. Low 1. 2. 3. 4. 5. High 2.
3.
Discuss best practices that could enhance safety in the perioperative area. Low 1. 2. 3. 4. 5. High Describe implementation of evidence-based practice in relation to perioperative nursing care. Low 1. 2. 3. 4. 5. High
CONTENT 4.
5.
To what extent did this article increase your knowledge of the subject matter? Low 1. 2. 3. 4. 5. High To what extent were your individual objectives met? Low 1. 2. 3. 4. 5. High
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4. Other: __________________________________ 8.
Our accrediting body requires that we verify the time you needed to complete the 1.0 continuing education contact hour (60-minute) program: ______________
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