“Surgical site infection (SSI) complicates an estimated 5% of all clean contaminated operations performed annually in US hospitals and accounts for the most common nosocomial infection in surgical patient’s” (Hemani & Lepor, 2009, p. 190). Prior to draping and the incision being made in a surgical procedure the skin around the surgical site is prepped to help decrease the chance of a SSI after the surgery is completed. One of the most common sources for pathogens which contribute to SSI’s is often thought to be the surface of the skin.
This makes skin preparation at the time of the procedure critical. Throughout different hospitals there are several different types of prep solutions that are used. In the surgical department in which I work there are three types of prep solutions used, (Chlorhexidine gluconate (CHG), Chlorhexidine–Alcohol, and Povidone–Iodine). In my research of recent evaluations in this area I have found that there are two key points of the surgical prep where a change in the practice or the product can result in higher productivity, decreased costs and improved safety for the patient.
Basis for Practice The basis for practice in the hospital that I work in is totally physician preference. Each surgeon decides what type of prep is to be used and it is placed on their preference card. There is no standard hospital policy as to which prep to use for different procedures. The only policy which is in place is that Chlorhexidine-Alcohol cannot be used for pelvic or vaginal preps on females. The 1999 CDC Guideline for Prevention of Surgical Site Infection states: “Use an appropriate antiseptic agent for skin preparation” (Manz, Gardner, & Millard, 2006, p.87).
It does not state anywhere in its recommendations that one surgical prep is preferred over another. Therefore it is left up to each individual surgeon to decide what is to be used if there is no hospital policy as in the case where I work. Rationale The goal of any preoperative skin preparation is to reduce the occurrence of SSI in a safe, user-friendly, and cost-effective manner. (Hemani & Lepor, 2009).
The Association of periOperative Registered Nurses (AORN) Recommended Practices for Skin Preparation of Patients state: “Reduce resident microbial counts to sub-pathogenic amounts by the use of antimicrobial preoperative skin prep to inhibit rapid rebound growth of microorganisms a persistent antimicrobial preoperative skin prep agent should be used” (Manz et al. , 2006, p. 88). The primary goal of the surgical skin prep is to decrease the occurrence of SSI’s and to do this must be able to remove dirt, oil and reduce microbial count with as little irritation as possible.
The selection of the prep solution should also be based on “compatibility with the items it comes in contact with, including gloves and draping materials, flammability, whether or not it is inactivated by organic material, how easily it can be removed from the skin surface, the area being prepped, procedure being performed, and the patient’s condition” (Parson, 2003, para. 5). To accomplish this there needs to be evidenced based guidelines in place at the hospital to assist the nurse and physician determine which pre-operative skin prep should be used.
Explanation As stated above the practice of surgical prep at the hospital where I work is physician preference. According to Dr. Joel Feldman, Chief of Surgery at St. Vincent Hospital in Indianapolis, IN where I work, the decision is left up to the specific surgeon because of the many different types of surgery done at the hospital which may require specific types of surgical preps.
Reference List Darouiche, R. O. , Wall, M. J. , Itani, K. M. , Otterson, M. F. , Webb, A. L. , Carrick, M. M. ,… Berger, D. H. (2010, January 7).
Chlorhexidine-Alcohol versus Povidone-Iodine for Surgical-Site Antisepsis. The New England Journal Of Medicine, 362(1). doi:10. 1056/NEJMoa0810988 Hemani, M. L. , & Lepor, H. (2009). Skin Preparation for the Prevention of Surgical Site Infection: Which Agent Is Best? Reviews in Urology, 11(4), 190-195. Retrieved from http://www. ncbi. nlm. nih. gov/pmc/articles/PMC2809986/ Manz, E. A. , Gardner, D. , & Millard, M. (2006, August).
Clipping, Prepping and Drapingfor Surgical Procedures. MANAGING INFECTION CONTROL, 84-97. Retrieved from http://www.csao. net/files/pdfs/70-2009-7475-9-Clip,Prep,Drape806. pdf Parson, R. (2003, September 1). Surgical Prep: The Right Product for the Right FunctionMinor changes bring major improvements in efficiency, safety and costs. Infection Control Today .
Retrieved from http://www. infectioncontroltoday. com/articles/2003/09/infection-control-today-09-2003-surgical-prep. aspx The Association of periOperative Registered Nurses. (2002, January 1).
Recommended practices for skin preparation of patients. AORN Journal. Retrieved from http://findarticles.com/p/articles/mi_m0FSL/is_1_75/ai_83664586/? tag=content;col1 Clinical Implications The review of literature for surgical preps does demonstrate that some surgical prep solutions are superior to others for decreasing SSI’s.
The clinical implications pointed out in these articles should be taken into account when looking at changing the procedure and or solution used for surgical site prep. The patient’s condition should be taken into account when deciding what prep solution to use. Antiseptic agents used on patients with known allergic reactions may cause adverse outcomes.
Some prep solutions may get absorbed by the skin and or mucous membranes and may act as a neurotoxin or ototoxic. Some of the antiseptic agents used for surgical prep have been shown to be potentially harmful to fetuses or neonates, this should be taken into consideration when used on pregnant women or nursing mothers (The Association of periOperative Registered Nurses [AORN], 2002). Procedural Changes By having an evidence based practice standard procedure for surgical site prep in the operating room (OR) the efficiency of the surgical prep could be improved.
If the safety and productivity benefits of using single use pre-measured applicator scrub solutions were taken into account, these types of applicators are more attractive in spite of their somewhat higher price when compared to multi-use bottles (Parson, 2003). Another area of surgical prep that could be enhanced without affecting safety is to do away with the waste produced by archaic practices, such as throwing away sterile exam gloves in favor of surgical gloves when prepping patients.
“Exam gloves, which cost 10 to 20 times less, provide more than adequate protection and won’t degrade during the few minutes it takes to prep a patient (Parson, 2003, para. 8). Stakeholders By forming a task group to investigate the different available products, their cost, effectiveness, and ease of use, the group could come up with specific products which could be standardized for use as surgical preps. These products could then be evaluate for their effectiveness on preventing SSI’s through research in the OR.
The data then could be presented to the surgeons, administrative personnel involved, and the infection control officer as evidenced based research which would help to convince the parties with a vested interest that by having a standard of practice for surgery prep could not only reduce SSI’s, but increase efficiency as well as save money. Translation of Research and Barriers Translation of research into practice takes place in three stages. These are awareness of a problem, acceptance of the proposed solution, to adoption of the new practice.
The first two stages of this are the longest in the process. Not everyone is going to agree that there is a problem to begin with. Some surgeons do not want or are not willing to change. They are of the opinion that what has worked in the past will continue to work in the future. They may not be willing to give up some of the control of what surgical prep is used on their patients. The change may be difficult for nursing staff to incorporate into everyday practice because of some nurses just wanting to do what they have always done.
Administration may have a hard time changing vendors to accommodate the new products. It can sometimes years to make a change in the medical field even though the research is sound and based on evidence. Strategies The people involved in any change must be convinced of the need for change. People are more likely to buy-in and contribute in a change initiative if they understand how it will contribute to the overall patient outcome and from the hospitals perspective the bottom line. There must be team members who “own” and drive the change who can serve as champions of the propose change.
Manage feelings and help other team member’s deal with their emotional reactions to the proposed change. Support the change yourself with evidence. Use measurement tools to monitor the progress. When changes in procedures are introduced in an organization, getting the people who are accountable for delivering the results involved is the key to the successful implementation of the change. Application of Findings The purpose of preoperative skin preparation is to decrease the occurrence of SSI in a safe, comprehensible, and cost effective way.
By using appropriate products made from the proper materials, it is achievable to improve the safety and speed of the surgical prep process while at the same time cutting costs by eliminating waste, rising efficiency and reducing inventory expenses. The cost may be more than multi-use bottles, but they save money because they are less messy, more rapidly applied, cleanse more effectively and improve drape adhesion, therefore preventing the sterile surface from being compromised (Parson, 2003). By standardizing prep solutions in the hospital a savings can be realized through volume purchases and patient safety be upheld.
References Darouiche, R. O. , Wall, M. J. , Itani, K. M. , Otterson, M. F. , Webb, A. L. , Carrick, M. M. ,… Berger, D. H. (2010, January 7). Chlorhexidine-Alcohol versus Povidone-Iodine for Surgical-Site Antisepsis. The New England Journal Of Medicine, 362(1). doi:10. 1056/NEJMoa0810988 Hemani, M. L. , & Lepor, H. (2009). Skin Preparation for the Prevention of Surgical Site Infection: Which Agent Is Best? Reviews in Urology, 11(4), 190-195. Retrieved from http://www. ncbi. nlm. nih. gov/pmc/articles/PMC2809986/ Manz, E. A. , Gardner, D. , & Millard, M. (2006, August). Clipping, Prepping and Drapingfor Surgical Procedures.
MANAGING INFECTION CONTROL, 84-97. Retrieved from http://www. csao. net/files/pdfs/70-2009-7475-9-Clip,Prep,Drape806. pdf Parson, R. (2003, September 1). Surgical Prep: The Right Product for the Right FunctionMinor changes bring major improvements in efficiency, safety and costs. Infection Control Today . Retrieved from http://www. infectioncontroltoday. com/articles/2003/09/infection-control-today-09-2003-surgical-prep. aspx The Association of periOperative Registered Nurses. (2002, January 1). Recommended practices for skin preparation of patients. AORN Journal.