Perioperative routine practices vary from state to state and even facility to facility. It is important for the surgical nurse to be well versed in perioperative procedures and constantly question the effectiveness and positive/negative outcomes related to each one. Several preoperative procedures take place on the surgical unit of my hospital, and after research and discussions with surgeons, I discovered a preoperative procedure that could be tweaked in order to improve post-op results. A primary concern is post-operative infection.
This is one of the most common complications of surgery and can have serious implications. Since post-operative infections account for one third of all nosocomial infections nationwide, this is an important issue to address. I believe that focusing on better ways to prevent possible post-operative infection would greatly improve surgical patients’ outcomes and experiences. As the procedure states now, the patient is required to take a shower/bath with normal bath soap excluding any lotions or powders prior to surgery and then once in the surgical site, is cleansed with Hibiclens and an intravenous antibiotic is initiated.
This has been standard practice because past research suggested that as long as the patient bathed with normal soap and the site was scrubbed in surgery, post-operative infection has a decreased incidence. While this has proven to drastically reduce infection rate, there are more recent studies that have proven that bathing with normal soap alone is not sufficient enough to prevent a notable amount of nosocomial infections. Hibiclens is a prescription antimicrobial antiseptic skin cleanser used to cleanse a surgical site. It is an effective product; however, I have found that there are still post-operative infections occurring.
For this reason, I decided to analyze the pre-operative procedure of surgical site cleansing. The perioperative procedures are mutually decided upon amongst the education department, practice council and the surgeons. The education department is team members from nursing, administrators of the hospital, and physicians whose roles are to continually study research and distinguish significant advancements that could better our hospital. The education department researches evidence based practices in order to bring the ideas to practice council and the surgeons.
Practice council consists of highly educated charge nurses from each unit in the hospital. Practice council initiates implementation on the unit through a trial period. During this time, the new procedures are measured for effectiveness, positive outcomes, and practicality through empirical and survey-obtained data. If in fact they find that the practice is successful, the practice becomes a hospital wide initiative. The procedure for pre-operative baths was decided in this way. Research has shown that by cleaning the skin 24 hours prior to surgery, there is a dramatic decrease in post-operative infection.
A study by Nalini Rao, MD, in 2008 showed that a preoperative decolonization protocol (including chlorhexidine baths) for MRSA infection in total joint arthroplasty patients translated to an adjusted financial gain of approximately $230,000 to the facility. This demonstrates that a Hibiclens bath played a huge role in decreasing post-operative infection. Staphylococcus aureus is a bacterium that lives on our skin. This does not typically cause problems unless an immune-compromised patient has a breakage in the skin, thus allowing these bacteria to cause a systemic infection (MRSA fact sheet, 2013). My father is a general and vascular surgeon.
I spoke with him concerning post-operative infections and possible hibiclens treatments prior to surgery. With repeated use of Hibiclens, it binds to the skin, reducing microbial amounts further with each use. This would suggest that with a Hibiclens wash performed 24 hours and again at 4 hours prior to surgery the risk for post-operative infection would be greatly reduced. As compared to other antiseptics and soaps, Hibiclens is the only solution that binds to the skin, remains active in the presence of bodily fluids, and has residual anti-microbial activity for up to 6 hours after use (Quaternary
Ammonium Cation, 2013). This alone emphasizes the benefits of utilizing this product 4 hours prior to surgery. My father and his colleagues have discussed implementing hibiclens washes as a standard protocol 24 hours and 4 hours prior to surgery due to the evidence-based research discussed above. In order for this to become effective, the literature must be presented to the education department and practice council. They would decide if the literature substantially supports the trial of this procedure on the surgical unit.
Following the results of the trial period and measurement of effectiveness, either a hospital initiative would be implemented or the washes would not be utilized as standard procedure. I do not foresee many difficulties in translating the research into actual practice on the unit. Hibiclens is abundantly available in the hospital. The only problem that could be encountered includes a rare instance in which outpatients are incapable of retrieving and performing the washes. A solution to this would be to distribute hibiclens washes with the final pre-op appointment and ask a caregiver to perform the wash.
Another difficulty that may be encountered is in the research- discerning the appropriate amount of times to perform hibiclens washes prior to surgery to achieve maximum results. Study results suggest that patients may benefit from bathing or showering with hibiclens for at least 3 days before surgery in order to achieve the most benefit(LaPrade, Robert, 2013); while another study suggests that washes 24 hours and 4-6 hours before surgery is sufficient. Gathering substantial evidence on the effectiveness of preventing post-op infections would be of the utmost importance in order to begin the practice in the hospital.
It is essential that a proper campaign is presented to the education department, practice council and the surgeons. Barriers to employing the hibiclens washes as a routine practice that could be present would be supplying enough of the hibiclens in order to meet the demands of all of the surgeries performed every day and infiltrating the practice into daily routine. I believe these barriers could easily be overcome through two strategies: increasing supply of the product and educating the staff on the new policy and the purpose of the change.
If in fact the results from the trial period prove effective, the clinical coordinator from each unit would discuss adjusting budget needs in order to supply Hibiclens. Education of the frontline staff could occur at mandatory staff meetings. It is important for the education department to understand the research and be well-versed in what they are planning to implement into hospital practice. A presentation of the material would be given to the frontline staff so that they are aware of the reason for the policy change. They would also be made aware of the process of performing the hibiclens wash and instructions on how to teach patients its significance in preventing post-op infection.
References 1. Antibiotic resistant Staph infection MRSA fact sheet for patients, County of Orange. Accessed at: http://www. ochealhinfo. com/docs/public/epi/mrsa/MRSA-FactSheet. pdf 2. LaPrade, Robert, MD. PhD. The Steadman Clinic. Pre-Operative Bathing Instructions. Retrieved: March 2, 2013. Accessed at: http://drrobertlaprademd. com/pre-operative-bathing-instructions 3. Norton, Jeffrey. Surgery: Basic Science and Clinical Evidence.
Pre-Operative Preparation. Accessed March 10, 2013 at: http://books. google. com/books?id=cs6O3QIwrKcC&pg=PA246&lpg=PA246&dq=is+a+shower+before+surgery+sufficient/&source=bl&ots=mbNqkSeYLO&sig=jdH_XwHjtVAywrCDuMow_h8Vfhc&hl=en&sa=X&ei=yFY9UfGmAerw0QHa9YHABg&ved=0CC0Q6AEwAA#v=onepage&q=is%20a%20shower%20before%20surgery%20sufficient%2F&f=false 4. Quaternary Ammonium Cation. Wikipedia, the free encyclopedia. Last accessed on March 2, 2013. Accessed at: http://en. wikipedia. org/wiki/Quaternary_ammonium_cation 5. Rao N, Cannella B, Crossett L, et al. A preoperative decolonization protocol for staphylococcus aureus prevents orthopaedic infections. Clin Orthop Relat Res (2008) 466: 1343-1348.