Skin Preparation:
The Why, The Where, and
The How
Deb Danna RN BSN
Clinical Consultant, CareFusion
Overview
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Current Regulations and Guidelines
Skin is the Source
Skin Antiseptic Review
Skin preparation Directions for Use
Conclusion
Return Demonstration and Competency
Current Regulations and
Guidelines
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FDA
CDC
AORN
NQF
Joint Commission
CMS
Joint Commission
Best Practices Recommendations
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Hospitals Should Focus on Infection Management
• Policies and Procedures must address regulatory requirements and
evidence based standards
• Involves education of health care workers
• At hire and annually thereafter
• At the time of change in job responsibility within the surgical
environment
Additional Hospital Responsibilities
• Periodic Risk Assessments
• Development of Metrics using Best Practices or Evidence-Based
Guidelines
• Compliance Monitoring and Evaluation
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HAIs: A Costly Toll to U.S. Healthcare
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1
1
1
1. Patient Protection and Affordable Care Act (PPACA) of 2010, S 301, 3008 and 3011;CMS IPPS FY11 Proposed Rule, April 19, 2010
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HAIs: A Costly Toll to U.S. Healthcare
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2. Scott RD. The Direct Medical Costs of Healthcare-Associated Infections in U.S. Hospitals and the Benefits of
Prevention. March 2009, Centers for Disease Control and Prevention. Accessed August 30, 2010 at:
http://www.cdc.gov/ncidod/dhqp/pdf/Scott_CostPaper.pdf
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Clinical and Economic
Impact of HAIs
• Attributable costs due to HAIs are substantial &
carry significant morbidity and mortality
 Approximately 12% (159 patients) developed
an HAI
 Avg. Length of Stay (LOS) was 5.9 to 9.6 days
 Excess LOS totaled 844 to 1,373 hospital days
 Attributable Costs $9,310 - $21,013 per patient
 $1.48 to $3.34 million in medical costs
 $5.27 million for premature death
Costs attributable to healthcare-acquired infection in hospitalized adults and a comparison of
economic methods. Med Care. 2010 Nov;48(11):1026-35.
Roberts RR, et al.
The National Spotlight-CMS
Reimbursement
CMS Reimbursement Final Rule
•ALL hospitals participating in the US Medicare program must report data on specific
HAIs through the Centers for Disease Control and Prevention’s (CDC) National
Healthcare Safety Network (NHSN).
•Hospitals that do not submit data per the final rule are eligible to continue to
participate in the Medicare program, but will be subject to a reduction in their
Medicare Annual Payment Update.
•As with other quality measures, any HAIs that may be added in the future will be
publicly reported on the CMS Hospital Compare website
Antiseptic Categories
• Patient Preoperative Skin Preparation
• Pre-injection vs. Pre-operative
• Surgical Hand Scrub
• Healthcare Personnel Hand
wash
How are you prepping the
skin?
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One Major risk factor for infections:
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Heavy skin colonization of bacteria at
incision site
80% of resident and transient skin flora
resides in the first 5 layers of the stratum
corneum.
Does your application methodology assure
that the solution reaches into the cracks and
fissures of the stratum corneum layer?
Disinfecting the Skin
• The recommended antimicrobial agent should
have the following properties:
• Broad spectrum
• Rapid bactericidal activity
• Persistence or residual properties on the skin
• Effective in the presence of blood
• Non-irritating or have low allergic and/or toxic
responses
• No or minimal systemic absorption
Antiseptic agent
Mechanism of
action
Gram +
bacteria
Gram –
bacteria
Viruses
Rapidity
of action
Persistent/
residual
activity
Use on eye
or ear
Use on
mucous
membranes
Contraindications
Cautions
Alcohol
Denatures
proteins.
Excellent
Excellent
Good
Excellent
None
No. Can cause
corneal damage or
nerve damage.
No
Chlorhexidine
gluconate
Disrupts cell
membrane.
Excellent
Good
Good
Moderate
Excellent
No. Can cause
corneal damage.
Can cause deafness
if in contact with
inner ear. Use with
caution.
Use with
caution.
Known
hypersensitivity to
drug or any
ingredient. Lumbar
puncture and use
on meninges.
Povidone-Iodine
Oxidation/
substitution
with free
iodine.
Excellent
Good
Good
Moderate
Minimal
Yes. Moderate
ocular irritant.
Yes.
Sensitivity to
povidone-iodine
(shellfish allergies
are not a
contraindication).
Chlorhexidine
gluconate with
alcohol
Disrupts cell
membrane
and denatures
proteins.
Excellent
Excellent
Good
Excellent
Excellent
No. Can cause
corneal damage.
Can cause deafness
if in contact with
inner ear.
No
Known
hypersensitivity to
drug or any
ingredient. Lumbar
puncture and use
on meninges.
Flammable.
Iodine-based with
alcohol
Oxidation/
substitution
by free iodine
denatures
proteins.
Excellent
Excellent
Good
Excellent
Moderate
No. Can cause
corneal damage or
nerve damage.
No.
Sensitivity to
povidone-iodine
(shellfish allergies
are not a
contraindication).
Flammable.
Parachoroxylenol
(PCMX)
Disrupts cell
membrane.
Good
Fair
Fair
Moderate
Moderate
Yes
Yes
Known
hypersensitivity to
PCMX or any
ingredient.
Minimally effective in the
presence of organic matter.
The FDA has classified
PCMX as a Category III (data
are insufficient to classify it
as safe and effective). The
FDA continues to evaluate
PCMX.
Flammable. Does not
penetrate organic material.
Optimum concentration is
60% to 90%
Prolonged skin contact may
cause irritation in sensitive
individuals. Rare severe
hypersensitivity reactions
have been reported. Use
with caution on mucous
membranes.
Prolonged skin contact may
cause irritation. May cause
iodism in susceptible
individuals; avoid use in
neonates. Inactivated by
blood.
Common Skin Preparations
and Application Techniques
Scrub and Paint
7.5% PVP Scrub and 10% PVP Paint
Solution
Preoperative Skin Prep:
Application Techniques
7.5% Povidone Iodine Scrub and 10% Povidone Iodine Paint Solution
• Scrub of the operative site should begin at the incision site, working
out to the outer parameter in a concentric circular motion for 5
minutes.
• Paint solution should be applied starting at the site of incision and
working in a circular motion out to the perimeter of the area prepped.
It should be allowed to dry for 2 to 3 minutes or until completely dry.
Dry time of the paint application is a must for full efficacy of the
product, due to the release of free available iodine necessary to kill
bacteria on the skin.
DuraPrep/Prevail-FX/Prevail
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DuraPrep: 0.7%Povidone Iodine /74% Isopropyl alcohol,
povacrylex (6 ml & 26 ml)
PREVAIL-FX: 0.83%Povidone Iodine /72.5% Isopropyl alcohol,
polymer (40 ml)
PREVAIL: 0.5% Povidone Iodine/ 62% ethanol alcohol (59 ml &
40 ml)
Preoperative Skin Prep:
Application Techniques
• To activate the applicator: twist the applicator head and push down. Lightly squeeze
the bottle to initiate the flow of the prep solution.
 Application: Apply for thin even coat starting at the incision site and working
outward in a circular motion. The flow of the solution is controlled by squeezing
the applicator body. The solution should not be blotted, but simply allowed to
dry.
 Dry time for larger volume alcohol based skin antiseptics is a minimum 3 minutes
in non-hairy areas and up to 1 hour in hairy areas
Chlorhexidine Gluconate
2%-4% formulations
Hibiclens/BetaSept/ Exidine
Preoperative Skin Prep:
Application Techniques
2% - 4% Chlorhexidine Gluconate
• Chlorhexidine Gluconate skin prep agents should be
applied liberally to the surgical site and swabbed for at
least 2 minutes, starting from the incision site out to the
periphery. The prepped area should be blotted dry with
a sterile towel; this procedure is then repeated for an
additional 2 minutes and dried with a sterile towel.
• Total prep time is 4 minutes.
ChloraPrep
2% Chlorhexidine gluconate
70% Isopropyl Alcohol
Preoperative Skin Prep:
Application Techniques
2% CHG / 70% Isopropyl Alcohol
• For dry surgical sites (e.g., the abdomen or arm): Repeated back-and-forth
strokes of the sponge should be used for approximately 30 seconds on the
incision site and outward to the periphery.
• For moist surgical sites (e.g., inguinal fold or axilla): Repeated back-and-forth
strokes of the sponge should be used for approximately 2 minutes on the
incision site and outward to the periphery.
 As noted above, using a back and forth scrub applies the antiseptics with
sufficient friction to encourage exfoliation and/or deeper penetration of
the superficial layers, as well as the cracks and fissures of the skin.
 Total prep time is 30 seconds / 2 minutes followed by a 3 minute dry
time in non-hairy areas and up to 1 hour for hairy areas
Preoperative Skin Prep:
Application Techniques
2% CHG/70% Isopropyl Alcohol
• Latex free
• External use only
• No contact to patient’s eyes, ears, or mouth,
lumbar puncture, intravaginal, etc.
• Do not use on children under 2 months
• Avoid freezing and excessive heat
• Allow to dry
 No pooling of solution
 26 ml Not recommended for head and neck surgery
 Remove wet materials before starting procedure
Preoperative Skin Prep:
Application Techniques
2% CHG / 70% Isopropyl
Alcohol
• Allow to dry completely
• Do not let solution pool
• Do not use 26ml applicator
for head and neck
• Do not use on small areas
• Remove any wet materials
prior to using ignition source
Fire Safety
• Flammable prep agent = ALCOHOL
• Do not allow prep agent to pool on or
under body parts
• Allow prep agent to dry
• Allow vapors to dissipate before
applying drape
Fire Safety
• Alert all personnel about the use of a
flammable preparation agent through
active communication and during the
“time out” period
• Do not heat flammable
skin preparation agents
Issues Related to Shaving
• Shaving attributed to microscopic cuts in the
skin
• Cuts are foci for bacterial multiplication1
• If shaving performed >24 hours prior to
operation, infection rate exceeds 20%2
1. Martorell C, Engelman R, Corl A, Brown RB. Surgical site infections in cardiac surgery: an 11-year perspective. AM J Infect Control. 2004;32(2):63-68.
2. Institute of Healthcare Improvement. Surgical Site Infections. Available at: http://www.ihi.org/IHI/Topics/PatientSafety/SurgicalSiteInfections. Accessed
December, 2007.
1.
Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999. Hospital Infection
Control Practices Advisory Committee. Infect Control Hosp Epidemiol 1999; 20: 250-278; quiz 279-280.
2.
Seropian R, Reynolds BM. Wound infections after preoperative depilatory versus razor preparation. Am J Surg 1971;121:251-4.
Micro Abrasions
Before Clipping
Before Shaving
After Clipping
After Shaving
Recommended Practices for
Clipping
Leading healthcare industry organizations
recommend that, when preoperative hair
removal is necessary, it should be done with
clippers instead of razors.
• Centers for Disease Control and Prevention (CDC)
• Association of Perioperative Registered Nurses
(AORN)
• The Institute for Healthcare Improvement (IHI)
• The Surgical Care Improvement Project (SCIP)
• The 2008 ISDA Compendium
• Greater Healthcare now-Canadian SSI guidelines
Recommendations: AORN
• If hair interferes with the surgical procedure,
ideally remove it:
• the day of surgery
• outside the operating or procedure room
• From only those areas where it interferes with the
surgical procedure
• using a single-use electric or battery-operated
clipper, or a clipper with reusable head that can be
disinfected between patients
• Always follow Manufacturers’ Directions for Use
(DFUs)
In Conclusion
• KEY to effective preoperative patient
skin antisepsis
 Antiseptic agents supported by clinical
evidence
 Proper application technique
Questions?