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Proposed Recommended Practices for Surgical Skin Preparation
JANUARY 1996, VOL 63, NO 1
Proposed Recommended Practices for Surgical Skin Preparation
T
he following draft is being published for review and comment by AORN members and others in the health care arena. The AORN Recommended Practices Committee (RPC) is interested in receiving comments on this proposal from members. These recommended practices are intended as achievable recommendations representing what is believed to be an optimal level of practice. Policies and procedures will reflect variations in practice settings and/or clinical situations that determine the degree to which the recommended practices can be implemented. AORN recognizes the numerous types of settings in which perioperative nurses practice. These recommended practices are intended as guidelines adaptable to various practice settings. These practice settings include traditional ORs, ambulatory surgery units, physicians' offices, cardiac catheterization laboratories, endoscopy suites, radiology departments, and all other areas where surgery may be performed. Although nonmembers may submit comments, the intent of the Committee is to reach a consensus among AORN members. All comments will be acknowledged and considered by the RPC before final approval of these recommendations by the Committee and the AORN Board of Directors. Comments should be sent to AORN, Inc 2170 S Parker Rd, Suite 300 Denver, CO 8023 1-571 1 Attn: Julie Thompson, RN, MSN, CNOR The deadline for comments is Feb 6, 1996. Purpose. These recommended practices provide a guideline for surgical skin preparation of the surgical site. The goal of the surgical skin preparation is to reduce the risk of postoperative wound infection by removing soil and transient microorganisms from the skin, reducing the resident microbial count to subpath-
a
ogenic levels in a short period of time and with the least amount of tissue irritation, and inhibiting rapid rebound growth of microorganisms.
RECOMMENDED PRACTICE I
The surgical site and surrounding areas should be clean. Interpretive statement I : The skin around the surgical site should be free of soil and debris. Cleansing can be accomplished before the application of the surgical prep 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 antimicrobial agent in the practice setting.
Rationale: Removal of superficial soil, debris, and transient microbes before applying an antimicrobial agent(s) reduces the risk of wound contamination by decreasing the organic debris on the skin.' RECOMMENDED PRACTICE II
The surgical site should be assessed before skin preparation. Interpretive statement I : Presence of moles, warts, rashes, or other skin conditions at the surgical site should be assessed and documented before skin preparation.
Rationale: Inadvertent removal of lesions traumatizes the skin at the surgical site and provides an opportunity for wound colonization by microorganisms.* Interpretive statement 2: If hair is to be removed at the surgical site, hair removal should be performed by personnel skilled in hair removal techniques. Rationale: 221
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JANUARY 1996, VOL 63, NO 1
Inappropriate hair removal techniques can traumatize skin and provide an opportunity for colonization of microorganisms at the surgical site.’ Interpretive statement 3: Hair removal at the surgical site should be performed according to physicians’ orders or policies and procedures of the practice setting.
remove and results in fewer microabrasions to the skin surface.1° Wet shaving also controls the dispersal of loose hair. All items used in hair removal need to be properly disposed of or disinfected between surgical procedures.
Rationale:
The surgical site and surrounding area should be prepared with an antimicrobial agent. Interpretive statement I : An antimicrobial agent(s) should be selected according to the AORN “Recommended practices for product and medical device evaluation and selection for the perioperative practice setting” and used in accordance with manufacturers’ written instructions. Rationale: The antimicrobial agent should have a broad range of germicidal action, provide persistent residual antimicrobial action, and be nontoxic.” Discussion: Testing antimicrobial agents i s a complex process and not practical for the practice setting; therefore, the use of data from current research, manufacturers’ literature, and the US Food and Drug Administration is recommended for agent selection. Interpretive statement 2: Selection of antimicrobial agents should be based on patient history of hypersensitivity reactions, location of the surgical site, and patient skin condition. Rationale: Antimicrobial agents used on skin with known hypersensitivity reactions may cause adverse patient outcomes. Agents may be absorbed by the skin or mucous membranes and may be neurotoxic or ototoxic.I* Discussion: Skin preparation techniques vary according to condition of the skin at the surgical site. Burned, denuded, or traumatized skin may be prepared with normal saline irrigation.I3 Areas of high microbial counts within the prepared area may need to be the final areas prepared. Colostomy sites may be isolated from the prepared area or covered with an antimicrobial soaked sponge and prepared last.14 Mucous membrane areas may be prepared by applying an antimicrobial or antiseptic agent only.15 Interpretive statement 3: The surgical site should be prepared by personnel who are knowledgeable about the patient and skilled in skin preparation techniques. Rationale:
Hair is best left at the surgical site; however, the necessity for hair removal depends on the amount of hair, the location of the incision, and the type of surgical procedure to be perf~rmed.~ Interpretive statement 4: Hair removal should be performed as close to the time of surgery as possible.
Rationale: Microscopic exudative rashes and skin abrasions can occur during hair removal, thus providing a culture medium f o r wound colonization of microorganisms at the surgical site.5 Interpretive statement 5: Hair should be removed in an area outside the room where the surgical procedure will be performed.
Rationale: Hair should not be removed in the vicinity of the sterile field because the dispersal of loose hair has the potential to contaminate the surgical site and sterile field.h Interpretive statement 6: If hair is to be removed, it should be removed in a manner that preserves skin integrity.
Rationale: Hair removal with a razor can disrupt skin integrity. Hair removal with an electric clipper or a depilatory cream has less potential of disrupting skin integrity. Use of a depilatory cream or an electric clipper is preferable to shaving with a razor when hair at the surgical site needs to be removed.’
Discussion: An electric or battery-powered clipper with a disposable or reusable head that can be disinfected between surgical procedures is preferred because it is the most efficient and least irritating method of hair removal.* A depilatory cream needs to be applied before the patient’s arrival in the practice setting. Manufacturers’ written instructions regarding preapplication skin testing and depilatory cream usage should be f o l l ~ w e d If . ~ shaving with a razor is ordered by the physician, wet shaving is preferable to dry shaving. Wetting the hair with soapy water before shaving makes the hair softer and easier to
RECOMMENDED PRACTICE 111
222 AORN JOURNAL
JANUARY 1996, VOL 63, NO 1
Potential complications associated with skin preparation are reduced by personnel who are knowledgeable about the plan of care and skilled in skin preparation.Ih Interpretive statement 4: Preparation of surgical areas should include consideration of the length of the incision and all potential requirements for the surgical procedure. Rationale: The prepared area should be large enough to accommodate extension of the incision, the need for additional incisions, and all potential drain sites.I7 Interpretive statement 5: Preparation of the surgical site should include consideration of the drape fenestration size. Rationale: The prepared area needs to be large enough to avoid wound contamination by inadvertent movement of drapes during the procedure.I8 Interpretive statement 6: Antimicrobial agents used in surgical skin preparation should be applied using sterile supplies and gloves or by using the no-touch technique and proceeding from the incision site to the periphery. Rationale: Wound infections can occur due to a high microbial count at the incision site; therefore, skin preparation is performed by progressing from the incision site to the periphery, using a sponge and discarding the used sponge when the periphery has been reached. A fresh sponge is used as the preparation continues.19 Discussion: A sterile skin preparation set is contaminated when any part of it touches the skin because the skin is not sterile. Removing soil and transient microbes, reducing resident microbial counts, and inhibiting rebound growth of microorganisms is accomplished through friction and antimicrobial agents, not through the use of sterile supplies.*O Data from one small study suggest that a clean prep kit may be as effective as a sterile kit for disinfecting skin.21Additional research and data are required to establish definitive patient outcomes. Interpretive statement 7: Skin preparation should be performed in a manner that preserves skin integrity and prevents injury to the skin. Rationale: Important factors to consider regarding surgical skin preparation outcomes include the following.
Chemical burns may occur if an antimicrobial agent(s) is allowed to pool beneath patients, pneumatic tourniquet cuffs, electrodes, or electrosurgical unit dispersive pads.22 An antimicrobial agent(s) that is allowed to dry before sterile drapes are applied may have a longer duration of action.?’ Sufficient time for complete evaporation of a flammable antimicrobial agent(s) needs to occur before electrosurgery devices or lasers are used. Evaporation of flammable antimicrobial agents decreases the possibility of fire.24 Certain patient medical conditions may require gentle skin preparation technique.25 RECOMMENDED PRACTICE IV
Patient skin preparation should be documented in the patient record according to the AORN “Recommended practices for documentation of perioperative nursing care.” Interpretive statement I : This documentation should include, but is not limited to, the condition of the skin at the surgical site (eg. presence of rashes, skin eruptions, abrasions); hair removal (if performed) including method, time of removal, area; the skin preparation used (ie, cleansing agent, solvent, antiseptic agent); name of person(s) performing skin preparation; and development of any hypersensitivity reactions. Rationale: Documentation of the variables in surgical skin preparation may assist in continuous quality improvement and infection control follow-up. Accountability and source of information are established by recording names of people who perform procedures. Documentation provides communication for all care providers in developing an ongoing plan of patient care.26 RECOMMENDED PRACTICE V
Policies and procedures on surgical skin preparation should be written, reviewed annually, and readily available within the practice setting. Discussion: These recommended practices should be used as guidelines for developing perioperative policies and procedures within the practice setting. Policies and procedures establish authority, responsibility, and accountability and serve as operational 223
AORN JOURNAL
JANUARY 1996, VOL 63, NO 1
guidelines. The AORN recommended practices that deal with surgical skin preparation should be consulted when developing those policies and procedures. An introduction and review of policies and procedures should be included in the orientation and ongoing education of personnel to assist in the development of knowledge, skills, and attitudes that ensure optimal patient outcomes. Policies and proNOTES 1. R Garibaldiet al, “The impact of preoperative skin disinfectionon preventing intraoperative wound contamination,” Infection Control and Hospital Epidemiology 9 no 3 (1988) 109-113; J M Leclair et al, “Effect of preoperative shampoos with chlorhexidine or iodophor on emergence of resident scalp flora in neurosurgery,” Infection Control and Hospital Epidemiology 9 no 1 (1988) 812; “Guideline for prevention of surgical wound infections, 1985”in Guidelinefor the Prevention and Control of Nosocomial Infections (Atlanta: Centers for Disease Control, 1985)5; C Wamer, “Skin preparation in the surgical patient,” Journal of the National Medical Association 80 no 8 (1988) 899-904, T Zdeblick et al, “Preoperativeuse of povidone-iodine: A prospective randomized study,” Clinical Orthopaedics and Related Research 213 (December 1986)211-215. 2. P J E Cruse, R Foord, “The epidemiology of wound infection: A 10-year prospective study of 62,939 wounds,”Surgical Clinics of North America 60 (February 1980) 127140; J Fairclough et al, “Skin shaving: A cause for concern,’’Journal of the Royal College of Surgeons of Edinburgh 32 (April 1987)76-78; M M Olson, J MacCallum, D G McQuanie, “Preoperativehair removal with clippers does not increase infection rate in clean surgical wounds,”Surgery, Gynecology and Obstetrics 162 (February 1986) 181-182. 3. W Altemeier et al, eds, “Preop erative preparation of the patient,” in Manual on Control of Infection in Surgical Patients, second ed
cedures also assist in the development of continuous quality improvement activities. GLOSSARY
No-touch technique: The use of an extension such as a sponge forceps, rather than hands, to handle or touch contaminated items or to handle sterile items. A
(Philadelphia:J B Lippincott Co, 1984) 82; C Grundler, “Tourniquet use; preoperative scrub responsibility questioned,”(Clinical Issues)AORN Journal 44 (August 1986) 298-299. 4. W C Beck, “Hair and asepsis and antisepsis,”Surgery, Gynecology and Obstetrics 163 (November 1986) 479; G W Geelhoed,“An irrational ritual,’’ Infections in Surgery 6 (July 1987) 384,407; “Research reinforces doubts about need for prep shaves,” Hospital Infection Control 16 (June 1989) 82-83. 5. Altemeier et al, eds, “Preoperative preparation of the patient,” 80; Fairclough et al, “Skin shaving; A cause for concern,” 76-78; R Seropian, B M Reynolds, “Wound infections after preoperativedepilatory versus razor preparation,” American Journalof Surgery 121 (March 1971) 251-254. 6. Geelhoed,“An irrational ritual,” 384. 7. “Guidelinefor prevention of surgical wound infections, 1985,”5; Beck, “Hair and asepsis and antisep sis,” 479; W C Beck, “A new depilatory tool for asepsis,”Infections in Surgery 6 (February 1987). 8. Beck, “Hair and asepsis and antisepsis,” 479; Beck, “A new depilatory asepsis,” 78, 135; J Davis, “Clipping vs shaving,”Journal of Healthcare Materiel Management 4 (May/June 1986) 54-55; Olson et al, “Preoperative hair removal with clippers does not increase infection rate in clean surgical wounds,” 181-182. 9. C P Craig, “Preparationof the skin for surgery,” Infection Control and Hospital Epidemiology 7 no 5 (1986) 257-258; B Jaffray et al, “Bacterial colonizationof the skin
224 AORN JOURNAL
after chemical depilation,”Journal of the Royal College of Surgeons of Edinburgh 35 (August 1990) 243244; “Guideline for prevention of surgical wound infection, 1985,” 5. 10. L K Groah, “Preparationof the patient and surgical team members,” in Operating Room Nursing: The Perioperative Role, second ed (Norwalk, Conn: Appleton & Lange, 1990)211. 11. “Guideline for prevention of surgical wound infections, 1985,”8; I Mackenzie, “Preoperative skin preparation and surgical outcome,” Journal of Hospital Infection 11 supp B (1988) 27-32; Wamer, “Skin preparation in the surgical patient,” 899-904. 12 Altemeier et al, eds, “Preoperative preparation of the patient,” 84; Craig, “Preparation of the skin for surgery,” 257; Wamer, “Skin preparation in the surgical patient,” 903; J E Sebben, “Sterile technique and the prevention of wound infection in office surgery-Part II,” Journal of Dermatology, Surgery and Oncology 15 (January 1989) 39. 13. Altemeier et al, eds, “Preoperative preparation of the patient,” 85. 14. B D Gamer, “Infection Control,” in Alexander’s Care of the Patient in Surgery, loth ed, M H Meeker, J C Rothrock, eds (St Louis: Mosby-Year Book, Inc, 1995)72-76. 15. D L Gilliam, C L Nelson, “Comparison of a one-step iodophor skin preparation versus traditional preparation in total joint surgery,” Clinical Orthopaedics and Related Research 250 (January 1990)258260; B J Masterson, “Skin preparation,” Clinical Obstetrics and Gynecology 31 (September 1988) 736-743; Zdeblick et al, “Preoperative use of povidone-iodine:A
JANUARY 1996, VOL 63, NO 1
prospective randomized study,” 21 3. 16. Altemeier et al, eds, “Preoperative preparation of the patient,” 82; Grundler, “Tourniquet use; preoperative scrub responsibility questioned,” 298. 17. “Guideline for prevention of surgical wound infections, 1985,”8.
22. Warner, “Skin preparation in the surgical patient,” 899-902. 23. J Leclair, “A Review of antiseptics,” Today’s OR Nurse 12 (October 1990) 25-28; Masterson, “Skin preparation,” 739. 24. E Larson, “APIC guideline for use of topical antimicrobial agents,”
18. Ibid. 19. Ibid. 20. J M Mathias, “Do surgical prep sets need to be sterile?’ OR Manager 7 (June 1991) 1, 13. 2 1. D K Gauthier, P T O’Fallon, D
American Journal of Infection Control 16 (December 1988) 262; B R Klein, ed, Health Care Facilities Handbook (Quincy, Mass: National Fire Protection Association, 1990) 393. 25. Altemeier et al, eds, “Preoperative preparation of the patient,” 85; L Morgenstem, “Is this scrub neces-
Coppage, “Clean vs sterile surgical skin preparation kits,” AORN Journal 58 (September 1993) 486-495.
sary?” The American Journal of Surgery 156 (November 1988) 335;
Warner, “Skin preparation in the surgical patient,” 902. 26. “Recommended practices for documentation of perioperative nursing care,” in AORN Standards and Recommended Practices for Perioperative Nursing (Denver: Association of Operating Room Nurses, Inc, 1995) 151-153;“Standards of perioperative administrative practice,” in AORN Standards and Recommended Practices for Perioperative Nursing (Denver: Association of Operating Room Nurses, Inc, 1995) 99-105.
Nurses/Exhibitors Day at Congress Tuesday of Congress week marks the opening of the Congress exhibits. The exhibitors at the 1996 AORN Congress are proud to offer the products, services, and programs perioperative nurses need to make smart choices in health care. The exhibitors appreciate the relationship they have developed with perioperative nurses, and they are committed to supporting opportunities for perioperative nurses’ professional development.
Tuesday of Congress week is NursesExhibitors Day. This all-day event, which is sponsored by the exhibiting companies, will recognize industry’s support of AORN. Plan to attend these events. Continental breakfast Jerry G. Peers Lectureship: Vivien De Back, RN, PhD, FAAN Ribbon cutting and exhibits General Session: J. Charles Plumb
Direct Sales of Products Allowed on AORN Exhibit Floor AORN will allow direct sales of products on the exhibit floor again this year. Sales and order taking are permitted provided all transactions are conducted
in a manner consistent with the professional nature of the exhibits. Companies must have obtained all applicable sales tax permits.
Congress Badge Identification All Congress badges will be white and will be printed with this year’s Congress logo. For easy identification, exhibitor badges will have clay-colored
bands across the bottom. Nurse and general registrants’ badges will have the words member, delegate, or alternate centered across the bottom.
Headquarters Customer Service Congress Hours The customer service department at AORN Headquarters in Denver will be fully staffed during Congress to assist members. Customer service staff
members will be available by telephone from 7 AM to 4:30 PM mountain time Monday through Friday and may be reached by dialing (800)755-2676 x 1.
227 AORN JOURNAL
Proposed Recommended Practices for Surgical Skin Preparation
T
he following draft is being published for review and comment by AORN members and others in the health care arena. The AORN Recommended Practices Committee (RPC) is interested in receiving comments on this proposal from members. These recommended practices are intended as achievable recommendations representing what is believed to be an optimal level of practice. Policies and procedures will reflect variations in practice settings and/or clinical situations that determine the degree to which the recommended practices can be implemented. AORN recognizes the numerous types of settings in which perioperative nurses practice. These recommended practices are intended as guidelines adaptable to various practice settings. These practice settings include traditional ORs, ambulatory surgery units, physicians' offices, cardiac catheterization laboratories, endoscopy suites, radiology departments, and all other areas where surgery may be performed. Although nonmembers may submit comments, the intent of the Committee is to reach a consensus among AORN members. All comments will be acknowledged and considered by the RPC before final approval of these recommendations by the Committee and the AORN Board of Directors. Comments should be sent to AORN, Inc 2170 S Parker Rd, Suite 300 Denver, CO 8023 1-571 1 Attn: Julie Thompson, RN, MSN, CNOR The deadline for comments is Feb 6, 1996. Purpose. These recommended practices provide a guideline for surgical skin preparation of the surgical site. The goal of the surgical skin preparation is to reduce the risk of postoperative wound infection by removing soil and transient microorganisms from the skin, reducing the resident microbial count to subpath-
a
ogenic levels in a short period of time and with the least amount of tissue irritation, and inhibiting rapid rebound growth of microorganisms.
RECOMMENDED PRACTICE I
The surgical site and surrounding areas should be clean. Interpretive statement I : The skin around the surgical site should be free of soil and debris. Cleansing can be accomplished before the application of the surgical prep 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 antimicrobial agent in the practice setting.
Rationale: Removal of superficial soil, debris, and transient microbes before applying an antimicrobial agent(s) reduces the risk of wound contamination by decreasing the organic debris on the skin.' RECOMMENDED PRACTICE II
The surgical site should be assessed before skin preparation. Interpretive statement I : Presence of moles, warts, rashes, or other skin conditions at the surgical site should be assessed and documented before skin preparation.
Rationale: Inadvertent removal of lesions traumatizes the skin at the surgical site and provides an opportunity for wound colonization by microorganisms.* Interpretive statement 2: If hair is to be removed at the surgical site, hair removal should be performed by personnel skilled in hair removal techniques. Rationale: 221
AORN JOURNAL
JANUARY 1996, VOL 63, NO 1
Inappropriate hair removal techniques can traumatize skin and provide an opportunity for colonization of microorganisms at the surgical site.’ Interpretive statement 3: Hair removal at the surgical site should be performed according to physicians’ orders or policies and procedures of the practice setting.
remove and results in fewer microabrasions to the skin surface.1° Wet shaving also controls the dispersal of loose hair. All items used in hair removal need to be properly disposed of or disinfected between surgical procedures.
Rationale:
The surgical site and surrounding area should be prepared with an antimicrobial agent. Interpretive statement I : An antimicrobial agent(s) should be selected according to the AORN “Recommended practices for product and medical device evaluation and selection for the perioperative practice setting” and used in accordance with manufacturers’ written instructions. Rationale: The antimicrobial agent should have a broad range of germicidal action, provide persistent residual antimicrobial action, and be nontoxic.” Discussion: Testing antimicrobial agents i s a complex process and not practical for the practice setting; therefore, the use of data from current research, manufacturers’ literature, and the US Food and Drug Administration is recommended for agent selection. Interpretive statement 2: Selection of antimicrobial agents should be based on patient history of hypersensitivity reactions, location of the surgical site, and patient skin condition. Rationale: Antimicrobial agents used on skin with known hypersensitivity reactions may cause adverse patient outcomes. Agents may be absorbed by the skin or mucous membranes and may be neurotoxic or ototoxic.I* Discussion: Skin preparation techniques vary according to condition of the skin at the surgical site. Burned, denuded, or traumatized skin may be prepared with normal saline irrigation.I3 Areas of high microbial counts within the prepared area may need to be the final areas prepared. Colostomy sites may be isolated from the prepared area or covered with an antimicrobial soaked sponge and prepared last.14 Mucous membrane areas may be prepared by applying an antimicrobial or antiseptic agent only.15 Interpretive statement 3: The surgical site should be prepared by personnel who are knowledgeable about the patient and skilled in skin preparation techniques. Rationale:
Hair is best left at the surgical site; however, the necessity for hair removal depends on the amount of hair, the location of the incision, and the type of surgical procedure to be perf~rmed.~ Interpretive statement 4: Hair removal should be performed as close to the time of surgery as possible.
Rationale: Microscopic exudative rashes and skin abrasions can occur during hair removal, thus providing a culture medium f o r wound colonization of microorganisms at the surgical site.5 Interpretive statement 5: Hair should be removed in an area outside the room where the surgical procedure will be performed.
Rationale: Hair should not be removed in the vicinity of the sterile field because the dispersal of loose hair has the potential to contaminate the surgical site and sterile field.h Interpretive statement 6: If hair is to be removed, it should be removed in a manner that preserves skin integrity.
Rationale: Hair removal with a razor can disrupt skin integrity. Hair removal with an electric clipper or a depilatory cream has less potential of disrupting skin integrity. Use of a depilatory cream or an electric clipper is preferable to shaving with a razor when hair at the surgical site needs to be removed.’
Discussion: An electric or battery-powered clipper with a disposable or reusable head that can be disinfected between surgical procedures is preferred because it is the most efficient and least irritating method of hair removal.* A depilatory cream needs to be applied before the patient’s arrival in the practice setting. Manufacturers’ written instructions regarding preapplication skin testing and depilatory cream usage should be f o l l ~ w e d If . ~ shaving with a razor is ordered by the physician, wet shaving is preferable to dry shaving. Wetting the hair with soapy water before shaving makes the hair softer and easier to
RECOMMENDED PRACTICE 111
222 AORN JOURNAL
JANUARY 1996, VOL 63, NO 1
Potential complications associated with skin preparation are reduced by personnel who are knowledgeable about the plan of care and skilled in skin preparation.Ih Interpretive statement 4: Preparation of surgical areas should include consideration of the length of the incision and all potential requirements for the surgical procedure. Rationale: The prepared area should be large enough to accommodate extension of the incision, the need for additional incisions, and all potential drain sites.I7 Interpretive statement 5: Preparation of the surgical site should include consideration of the drape fenestration size. Rationale: The prepared area needs to be large enough to avoid wound contamination by inadvertent movement of drapes during the procedure.I8 Interpretive statement 6: Antimicrobial agents used in surgical skin preparation should be applied using sterile supplies and gloves or by using the no-touch technique and proceeding from the incision site to the periphery. Rationale: Wound infections can occur due to a high microbial count at the incision site; therefore, skin preparation is performed by progressing from the incision site to the periphery, using a sponge and discarding the used sponge when the periphery has been reached. A fresh sponge is used as the preparation continues.19 Discussion: A sterile skin preparation set is contaminated when any part of it touches the skin because the skin is not sterile. Removing soil and transient microbes, reducing resident microbial counts, and inhibiting rebound growth of microorganisms is accomplished through friction and antimicrobial agents, not through the use of sterile supplies.*O Data from one small study suggest that a clean prep kit may be as effective as a sterile kit for disinfecting skin.21Additional research and data are required to establish definitive patient outcomes. Interpretive statement 7: Skin preparation should be performed in a manner that preserves skin integrity and prevents injury to the skin. Rationale: Important factors to consider regarding surgical skin preparation outcomes include the following.
Chemical burns may occur if an antimicrobial agent(s) is allowed to pool beneath patients, pneumatic tourniquet cuffs, electrodes, or electrosurgical unit dispersive pads.22 An antimicrobial agent(s) that is allowed to dry before sterile drapes are applied may have a longer duration of action.?’ Sufficient time for complete evaporation of a flammable antimicrobial agent(s) needs to occur before electrosurgery devices or lasers are used. Evaporation of flammable antimicrobial agents decreases the possibility of fire.24 Certain patient medical conditions may require gentle skin preparation technique.25 RECOMMENDED PRACTICE IV
Patient skin preparation should be documented in the patient record according to the AORN “Recommended practices for documentation of perioperative nursing care.” Interpretive statement I : This documentation should include, but is not limited to, the condition of the skin at the surgical site (eg. presence of rashes, skin eruptions, abrasions); hair removal (if performed) including method, time of removal, area; the skin preparation used (ie, cleansing agent, solvent, antiseptic agent); name of person(s) performing skin preparation; and development of any hypersensitivity reactions. Rationale: Documentation of the variables in surgical skin preparation may assist in continuous quality improvement and infection control follow-up. Accountability and source of information are established by recording names of people who perform procedures. Documentation provides communication for all care providers in developing an ongoing plan of patient care.26 RECOMMENDED PRACTICE V
Policies and procedures on surgical skin preparation should be written, reviewed annually, and readily available within the practice setting. Discussion: These recommended practices should be used as guidelines for developing perioperative policies and procedures within the practice setting. Policies and procedures establish authority, responsibility, and accountability and serve as operational 223
AORN JOURNAL
JANUARY 1996, VOL 63, NO 1
guidelines. The AORN recommended practices that deal with surgical skin preparation should be consulted when developing those policies and procedures. An introduction and review of policies and procedures should be included in the orientation and ongoing education of personnel to assist in the development of knowledge, skills, and attitudes that ensure optimal patient outcomes. Policies and proNOTES 1. R Garibaldiet al, “The impact of preoperative skin disinfectionon preventing intraoperative wound contamination,” Infection Control and Hospital Epidemiology 9 no 3 (1988) 109-113; J M Leclair et al, “Effect of preoperative shampoos with chlorhexidine or iodophor on emergence of resident scalp flora in neurosurgery,” Infection Control and Hospital Epidemiology 9 no 1 (1988) 812; “Guideline for prevention of surgical wound infections, 1985”in Guidelinefor the Prevention and Control of Nosocomial Infections (Atlanta: Centers for Disease Control, 1985)5; C Wamer, “Skin preparation in the surgical patient,” Journal of the National Medical Association 80 no 8 (1988) 899-904, T Zdeblick et al, “Preoperativeuse of povidone-iodine: A prospective randomized study,” Clinical Orthopaedics and Related Research 213 (December 1986)211-215. 2. P J E Cruse, R Foord, “The epidemiology of wound infection: A 10-year prospective study of 62,939 wounds,”Surgical Clinics of North America 60 (February 1980) 127140; J Fairclough et al, “Skin shaving: A cause for concern,’’Journal of the Royal College of Surgeons of Edinburgh 32 (April 1987)76-78; M M Olson, J MacCallum, D G McQuanie, “Preoperativehair removal with clippers does not increase infection rate in clean surgical wounds,”Surgery, Gynecology and Obstetrics 162 (February 1986) 181-182. 3. W Altemeier et al, eds, “Preop erative preparation of the patient,” in Manual on Control of Infection in Surgical Patients, second ed
cedures also assist in the development of continuous quality improvement activities. GLOSSARY
No-touch technique: The use of an extension such as a sponge forceps, rather than hands, to handle or touch contaminated items or to handle sterile items. A
(Philadelphia:J B Lippincott Co, 1984) 82; C Grundler, “Tourniquet use; preoperative scrub responsibility questioned,”(Clinical Issues)AORN Journal 44 (August 1986) 298-299. 4. W C Beck, “Hair and asepsis and antisepsis,”Surgery, Gynecology and Obstetrics 163 (November 1986) 479; G W Geelhoed,“An irrational ritual,’’ Infections in Surgery 6 (July 1987) 384,407; “Research reinforces doubts about need for prep shaves,” Hospital Infection Control 16 (June 1989) 82-83. 5. Altemeier et al, eds, “Preoperative preparation of the patient,” 80; Fairclough et al, “Skin shaving; A cause for concern,” 76-78; R Seropian, B M Reynolds, “Wound infections after preoperativedepilatory versus razor preparation,” American Journalof Surgery 121 (March 1971) 251-254. 6. Geelhoed,“An irrational ritual,” 384. 7. “Guidelinefor prevention of surgical wound infections, 1985,”5; Beck, “Hair and asepsis and antisep sis,” 479; W C Beck, “A new depilatory tool for asepsis,”Infections in Surgery 6 (February 1987). 8. Beck, “Hair and asepsis and antisepsis,” 479; Beck, “A new depilatory asepsis,” 78, 135; J Davis, “Clipping vs shaving,”Journal of Healthcare Materiel Management 4 (May/June 1986) 54-55; Olson et al, “Preoperative hair removal with clippers does not increase infection rate in clean surgical wounds,” 181-182. 9. C P Craig, “Preparationof the skin for surgery,” Infection Control and Hospital Epidemiology 7 no 5 (1986) 257-258; B Jaffray et al, “Bacterial colonizationof the skin
224 AORN JOURNAL
after chemical depilation,”Journal of the Royal College of Surgeons of Edinburgh 35 (August 1990) 243244; “Guideline for prevention of surgical wound infection, 1985,” 5. 10. L K Groah, “Preparationof the patient and surgical team members,” in Operating Room Nursing: The Perioperative Role, second ed (Norwalk, Conn: Appleton & Lange, 1990)211. 11. “Guideline for prevention of surgical wound infections, 1985,”8; I Mackenzie, “Preoperative skin preparation and surgical outcome,” Journal of Hospital Infection 11 supp B (1988) 27-32; Wamer, “Skin preparation in the surgical patient,” 899-904. 12 Altemeier et al, eds, “Preoperative preparation of the patient,” 84; Craig, “Preparation of the skin for surgery,” 257; Wamer, “Skin preparation in the surgical patient,” 903; J E Sebben, “Sterile technique and the prevention of wound infection in office surgery-Part II,” Journal of Dermatology, Surgery and Oncology 15 (January 1989) 39. 13. Altemeier et al, eds, “Preoperative preparation of the patient,” 85. 14. B D Gamer, “Infection Control,” in Alexander’s Care of the Patient in Surgery, loth ed, M H Meeker, J C Rothrock, eds (St Louis: Mosby-Year Book, Inc, 1995)72-76. 15. D L Gilliam, C L Nelson, “Comparison of a one-step iodophor skin preparation versus traditional preparation in total joint surgery,” Clinical Orthopaedics and Related Research 250 (January 1990)258260; B J Masterson, “Skin preparation,” Clinical Obstetrics and Gynecology 31 (September 1988) 736-743; Zdeblick et al, “Preoperative use of povidone-iodine:A
JANUARY 1996, VOL 63, NO 1
prospective randomized study,” 21 3. 16. Altemeier et al, eds, “Preoperative preparation of the patient,” 82; Grundler, “Tourniquet use; preoperative scrub responsibility questioned,” 298. 17. “Guideline for prevention of surgical wound infections, 1985,”8.
22. Warner, “Skin preparation in the surgical patient,” 899-902. 23. J Leclair, “A Review of antiseptics,” Today’s OR Nurse 12 (October 1990) 25-28; Masterson, “Skin preparation,” 739. 24. E Larson, “APIC guideline for use of topical antimicrobial agents,”
18. Ibid. 19. Ibid. 20. J M Mathias, “Do surgical prep sets need to be sterile?’ OR Manager 7 (June 1991) 1, 13. 2 1. D K Gauthier, P T O’Fallon, D
American Journal of Infection Control 16 (December 1988) 262; B R Klein, ed, Health Care Facilities Handbook (Quincy, Mass: National Fire Protection Association, 1990) 393. 25. Altemeier et al, eds, “Preoperative preparation of the patient,” 85; L Morgenstem, “Is this scrub neces-
Coppage, “Clean vs sterile surgical skin preparation kits,” AORN Journal 58 (September 1993) 486-495.
sary?” The American Journal of Surgery 156 (November 1988) 335;
Warner, “Skin preparation in the surgical patient,” 902. 26. “Recommended practices for documentation of perioperative nursing care,” in AORN Standards and Recommended Practices for Perioperative Nursing (Denver: Association of Operating Room Nurses, Inc, 1995) 151-153;“Standards of perioperative administrative practice,” in AORN Standards and Recommended Practices for Perioperative Nursing (Denver: Association of Operating Room Nurses, Inc, 1995) 99-105.
Nurses/Exhibitors Day at Congress Tuesday of Congress week marks the opening of the Congress exhibits. The exhibitors at the 1996 AORN Congress are proud to offer the products, services, and programs perioperative nurses need to make smart choices in health care. The exhibitors appreciate the relationship they have developed with perioperative nurses, and they are committed to supporting opportunities for perioperative nurses’ professional development.
Tuesday of Congress week is NursesExhibitors Day. This all-day event, which is sponsored by the exhibiting companies, will recognize industry’s support of AORN. Plan to attend these events. Continental breakfast Jerry G. Peers Lectureship: Vivien De Back, RN, PhD, FAAN Ribbon cutting and exhibits General Session: J. Charles Plumb
Direct Sales of Products Allowed on AORN Exhibit Floor AORN will allow direct sales of products on the exhibit floor again this year. Sales and order taking are permitted provided all transactions are conducted
in a manner consistent with the professional nature of the exhibits. Companies must have obtained all applicable sales tax permits.
Congress Badge Identification All Congress badges will be white and will be printed with this year’s Congress logo. For easy identification, exhibitor badges will have clay-colored
bands across the bottom. Nurse and general registrants’ badges will have the words member, delegate, or alternate centered across the bottom.
Headquarters Customer Service Congress Hours The customer service department at AORN Headquarters in Denver will be fully staffed during Congress to assist members. Customer service staff
members will be available by telephone from 7 AM to 4:30 PM mountain time Monday through Friday and may be reached by dialing (800)755-2676 x 1.
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