Copyright 2015 AORN Inc All rights reserved Used or adapted with permission Developed and originally presented by Amber Wood MSN RN CNOR CIC CPN Amber Wood is a Perioperative Nursing Specialist at AORN where she has served as lead author for the AORN ID: 695419
Download Presentation The PPT/PDF document "Guidelines for Preoperative Patient Ski..." is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
Slide1
Guidelines for Preoperative Patient Skin Antisepsis
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.Slide2
Developed and originally presented by
Amber Wood, MSN, RN, CNOR, CIC, CPNAmber Wood is a Perioperative Nursing Specialist at AORN where she has served as lead author for the AORN Guideline for Environmental Cleaning and the AORN Guideline for Preoperative Patient Skin Antisepsis. Amber offers clinical information to members via the AORN Consult Line and contributes regularly to the Clinical Issues column in the
AORN Journal.
She serves as the staff liaison to the CDC Healthcare Infection Control Practices Advisory Committee (HICPAC) and is a member of the Association for Professionals in Infection Control and Epidemiology (APIC). Amber’s clinical experience includes infection prevention, pediatric perioperative nursing, and clinical research. Amber is a doctoral student in public health nursing at University of Colorado, Denver, and she is certified as a CNOR, infection prevention and control professional (CIC), and pediatric nurse (CPN).
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.Slide3
Discuss recent revisions in AORN’s guideline for preoperative patient skin antisepsis.Describe the evidence supporting the guideline for preoperative patient skin antisepsis.
Objectives
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.Slide4
IntroductionPreoperative Bathing & Hair RemovalSelectionApplication & HandlingSections
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.Slide5
Introduction
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.Slide6
PurposeReduce the risk of the patient developing a surgical site infection (SSI) Effective skin antiseptics rapidly and persistently remove transient microorganisms and reduce resident microorganisms to subpathogenic levels with minimal skin and tissue irritation.
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.Slide7
Guidance for preoperative patient skin preparationRecommendations1. Preoperative Bathing2. Hair removal3. Antiseptic Selection 4. Antiseptic Application
5. Handling and Storage of AntisepticsScope
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.Slide8
Preoperative Bathing & Hair Removal
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.Slide9
1.2. Instruct the patient to bathe or shower before surgery with either soap or a skin antiseptic on at least the night before or the day of surgery. [Recommendation]1.3. Have a multidisciplinary team that includes perioperative RNs, physicians, and infection preventionists develop a mechanism for evaluating and selecting products for preoperative patient bathing.
[Recommendation]I. Preoperative Bathing
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.Slide10
Collective EvidencePatient bathing may reduce the microbial floraLimitations/GapsOptimal bathing proceduresAntiseptics vs. soaps (ie, plain, antimicrobial) Whole body or only the surgical site
Optimal timing before surgery Optimal number of baths or showersBenefits outweigh harmsEvidence Review
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.Slide11
CHG-impregnated ClothsGrowing body of evidenceUnresolved issueNeed more generalizable, high-quality researchHealthy volunteers
Orthopedic patients
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.Slide12
2.2. Leave hair at the surgical site in place. [Recommendation]2.3. When necessary, remove hair at the surgical site by clipping or depilatory methods in a manner that minimizes injury to the skin. [Recommendation]
2. Hair Removal
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.Slide13
Collective EvidenceHair at the surgical site should be left in place. When necessary, clipping may be associated with a lower SSI risk than shaving with a razor.Limitations/GapsOld studiesInadequate sample sizes, no standard SSI definition
No studies comparing clipping and depilatoryBenefits outweigh harms of leaving hair in place, if hair is managed (interfere with procedure, fire hazard)Evidence Review
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.Slide14
Clipping Hair Outside the ORWhen feasibleIf not (eg, emergency, patient anxiety), clip in a manner that prevents dispersal of hair in the ORWet clipping
Suction[4: Benefits Balanced with Harms]
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.Slide15
2.2.1. Instruct the patient to leave hair in place at the surgical site before surgery. [Recommendation]“Do not remove the hair down there.”Patient education campaign
Improved patient compliance from 41% to 27% in a 3-year periodMultiple interventions implementedAdditional research is needed Ng W, Alexander D, Kerr B, Ho MF, Amato M, Katz K. A hairy tale successful patient education strategies to reduce prehospital hair removal by patients undergoing elective caesarean section.
J Hosp Infect.
2013;83(1):64-67. [IIIB]
Patient Self-Removal
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.Slide16
Randomized controlled trial conflicts with recommendations to clip rather than shave hair with a razorClippers (n = 107) vs razors (n = 108)Outcomes: quality of hair removal, skin trauma, and SSI eventsRazors: less skin trauma, better hair removal, no increase in infections
Wet or dry methods?Underpowered for SSIAdditional research is neededGrober ED, Domes T, Fanipour M, Copp JE. Preoperative hair removal on the male genitalia: clippers vs. razors. J Sex Med.
2013;10(2):589-594. [IB]
Shaving Hair of Male Genitalia
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.Slide17
Challenges & AdvicePatients are not bathing preoperativelyEvaluate instruction and mechanism for assessing complianceSurgeon’s office and inpatient units/ICUs
Wash patient’s surgical site in preoperative holding area, if feasiblePatients are shaving before surgeryDevelop a patient education campaignSurgeons prefer a shave with a razorMutual respect, collaboration, and involvement in decision making
Peer to peer discussions, organization culture
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.Slide18
ReferencesBathingWebster J, Osborne S. Preoperative bathing or showering with skin antiseptics to prevent surgical site infection. Cochrane Database Syst Rev.
2012;9:CD004985. [IA]Jakobsson J, Perlkvist A, Wann-Hansson C. Searching for evidence regarding using preoperative disinfection showers to prevent surgical site infections: a systematic review. Worldviews Evid Based Nurs. 2011;8(3):143-152. [IIA]Kamel C, McGahan L, Polisena J, Mierzwinski-Urban M, Embil JM. Preoperative skin antiseptic preparations for preventing surgical site infections: a systematic review.
Infect Control Hosp Epidemiol.
2012;33(6):608-617. [IIA]
Chlebicki MP, Safdar N, O'Horo JC, Maki DG. Preoperative chlorhexidine shower or bath for prevention of surgical site infection: a meta-analysis. Am J Infect Control. 2013;41(2):167-173. [IIA]
Hair Removal
Tanner J, Norrie P, Melen K. Preoperative hair removal to reduce surgical site infection.
Cochrane Database Syst Rev.
2011;11:CD004122. [IA]
Broekman ML, van Beijnum J, Peul WC, Regli L. Neurosurgery and shaving: what's the evidence?
J Neurosurg.
2011;115(4): 670-678. [IIIA]
Sebastian S. Does preoperative scalp shaving result in fewer postoperative wound infections when compared with no scalp shaving? A systematic review.
J Neurosci Nurs.
2012;44(3):149-156. [IIIA]
Both
National Institute for Health and Care Excellence (NICE). Surgical site infection: prevention and treatment of surgical site infection.
https://www.nice.org.uk/guidance/cg74
. Accessed February 11, 2015. [IVA]
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.Slide19
ANTISEPTIC Selection
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.Slide20
3. Antiseptic Selection3.1. Have a multidisciplinary team, including perioperative RNs, physicians, and infection preventionists, select safe and effective antiseptic products for preoperative patient skin antisepsis. [Recommendation]
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.Slide21
Collective EvidenceNo one antiseptic is more effective than another for preventing SSISelection of a safe and effective preoperative skin antiseptic should be based on individual patient needLimitations/GapsMost effective antisepticInadequate sample sizes
QualityEvidence Review
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.Slide22
Health Care Organization3.2. Develop a mechanism for product evaluation and selection of preoperative skin antiseptics.
[Recommendation]Review current research literatureFDA requirementsCategory I in the Tentative Final Monograph (TFM) for Over-the-Counter (OTC) Healthcare Antiseptic Drug Products "New Drug Approval" (NDA)Single-use containers
Colored or tinted
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.Slide23
FDA Approval Categories
Table 1. US Food and Drug Administration Categories of Patient Preoperative Skin Preparations
1
Active ingredient
Category
Benzalkonium chloride
IIIE
Chlorhexidine gluconate
"New drug"
Chloroxylenol
IIIE
Hexachlorophene
II
Iodine tincture USP
I
Iodine topical solution USP
I
Povidone-iodine 5% to 10%
I
Triclosan
IIIE
Iodine Povacrylex/Isopropyl Alcohol
2
New Drug
2
E= Effectiveness
Reference
1. US Food and Drug Administration. Tentative Final Monograph for Healthcare Antiseptic Drug Products proposed rule.
Fed Regist.
1994;59(116):31402-31452.
2. US Food and Drug Administration. New Drug Application (NDA) #21-586.
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.Slide24
AlcoholIsopropyl alcohol 70% is NOT approved for preoperative patient skin antisepsisApproved only for skin antisepsis before injections (eg, IV start)
“Painting” with alcohol is a fire risk (flammable and clear)Alcohol is not sterile; there have been outbreaks involving Bacillus cereus
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.Slide25
Patient Care Team3.3. Select a safe, effective, health care organization-approved preoperative antiseptic for the individual patient.
[Recommendation]Based on:Patient assessmentProcedure typeReview of the manufacturer’s instructions for use and contraindications
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.Slide26
Procedure Type3.3.3 Select the preoperative antiseptic product based on the procedure type. [Recommendation]
EyeGynecologicOrthopedic
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.Slide27
Allergies3.3.1. Assess the patient for allergies and sensitivities to preoperative skin antiseptics. [Recommendation]
Iodine, chlorhexidine, and alcoholShellfish allergy is not related to iodine allergyConsider type of exposure (route) and frequency (single vs repeat application)
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.Slide28
3.3.7. When FDA-approved antiseptic products are contraindicated, collaboratively evaluate the risks and benefits of using Class II or Class III FDA-approved antiseptics or other alternative solutions (eg, soaps, saline). [Recommendation]AllergyAnatomical location
WoundsContraindications
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.Slide29
Class II or IIIE
Table 1. US Food and Drug Administration Categories of Patient Preoperative Skin Preparations
1
Active ingredient
Category
Benzalkonium chloride
IIIE
Chlorhexidine gluconate
"New drug"
Chloroxylenol
IIIE
Hexachlorophene
II
Iodine tincture USP
I
Iodine topical solution USP
I
Povidone-iodine 5% to 10%
I
Triclosan
IIIE
Iodine Povacrylex/Isopropyl Alcohol
2
New Drug
2
E= Effectiveness
Reference
1. US Food and Drug Administration. Tentative Final Monograph for Healthcare Antiseptic Drug Products proposed rule.
Fed Regist.
1994;59(116):31402-31452.
2. US Food and Drug Administration. New Drug Application (NDA) #21-586.
PCMX
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.Slide30
3.3.5. Consult the physician when selecting iodine antiseptics for patients susceptible to iodism. [Recommendation]Patients with burns, patients with thyroid disorders, neonates, pregnant women, lactating mothersConsider type of exposure (route) and frequency (single vs repeat application)
May rinse with sterile solution (eg, saline) after achieving contact times required by the manufacturerIodism
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.Slide31
3.3.4. Assess the surgical site for the presence of hair. When an alcohol-based skin antiseptic is used for a procedure involving an ignition source, clip the hair at the surgical site before applying the antiseptic. [Recommendation]Leave the hair and choose an aqueous, water-based antiseptic
ORClip the hair and choose an alcohol-based antisepticHairy Patients
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.Slide32
Challenges & AdviceOrganization will need to approve MANY productsIndicate preferred antiseptic, may be procedure/anatomical location specific
No FDA-approved alternatives when contraindicated (allergy, wounds)Make an organizational decision as evidence and products become availableSurgeon preferenceMutual respect, collaboration, and involvement in decision making
Peer to peer discussions, organization culture
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.Slide33
ReferencesUS National Library of Medicine. DailyMed. http://dailymed.nlm.nih.gov/. US Food and Drug Administration. Tentative Final Monograph for Healthcare Antiseptic Drug Products proposed rule. Fed Regist. 1994;59(116):31402-31452.
Dumville JC, McFarlane E, Edwards P, Lipp A, Holmes A. Preoperative skin antiseptics for preventing surgical wound infections after clean surgery. Cochrane Database Syst Rev. 2013;3:CD003949. [IA]Maiwald M, Chan ES-Y. The forgotten role of alcohol: a systematic review and meta-analysis of the clinical efficacy and perceived role of chlorhexidine in skin antisepsis. PLoS ONE.
2012;7(9). [IIA]
Shellfish
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. [IVB]
Vaginal Prep
American College of Obstetricians and Gynecologists Women's Health Care Physicians, Committee on Gynecologic Practice. Committee Opinion No. 571: Solutions for surgical preparation of the vagina.
Obstet Gynecol.
2013;122(3):718-720. [IVB]
Amstey MS, Jones AP. Preparation of the vagina for surgery. A comparison of povidone-iodine and saline solution.
JAMA.
1981;245(8): 839-841. [IIIB]
Lewis LA, Lathi RB, Crochet P, Nezhat C. Preoperative vaginal preparation with baby shampoo compared with povidone-iodine before gynecologic procedures.
J Minim Invasive Gynecol.
2007;14(6):736-739. [IIA]
Haas DM, Morgan S, Contreras K. Vaginal preparation with antiseptic solution before cesarean section for preventing postoperative infections.
Cochrane Database Syst Rev.
2013;1:CD007892. [IB]
Hadiati DR, Hakimi M, Nurdiati DS. Skin preparation for preventing infection following caesarean section.
Cochrane Database Syst Rev.
2012;9:CD007462. [IA]
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.Slide34
Application & Handling
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.Slide35
4.1. Apply the preoperative patient skin antiseptic in a safe and effective manner. [Recommendation] 4.5. Apply skin antiseptics using aseptic technique and according to the manufacturer’s instructions for use. [Recommendation]
4. Antiseptic Application
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.Slide36
4.4. A nonscrubbed perioperative team member should apply the skin antiseptic using sterile technique. [Recommendation]Wear sterile gloves Nonsterile gloves may be worn If the applicator is of sufficient length to prevent contact of the gloved hand with the antiseptic solution and the patient’s skin.
Nonscrubbed Person
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.Slide37
4.5.4. When using a pre-filled antiseptic applicator, follow the manufacturer's instructions for use (eg, maximum and minimum surface area per applicator) to apply the skin antiseptic with uniform distribution. [Recommendation]Sample:
Pre-filled Applicators
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.Slide38
4.5.6. For preoperative patient skin antisepsis with aqueous povidone-iodine, either scrub (ie, 7.5% povidone-iodine) and paint (ie, 10% povidone-iodine) or paint only may be used. [Conditional Recommendation]Conflicting evidenceNeed more researchRegardless, the surgical site should be clean from soil and debris before antisepsis (4.3.)
Scrub & Paint vs. Paint only
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.Slide39
4.5.7. When performing preoperative skin antisepsis of the hand or foot, take care to apply the antiseptic to all surfaces between fingers or toes. [Recommendation]Bag techniqueNeed more research
Fingers & Toes
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.Slide40
4.5.8. When performing preoperative patient skin antisepsis of the mouth, take care to prevent patient aspiration of the antiseptic solution. [Recommendation]Case report of pneumonitis after aspirationThroat pack used
Advise NOT to irrigate the oral cavityChepla KJ, Gosain AK. Interstitial pneumonitis after betadine aspiration. J Craniofac Surg.
2012;23(6):1787-1789. [VA]
Prepping the Mouth
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.Slide41
4.6. Allow the antiseptic to dry for the full time recommended in the manufacturer’s instructions for use before sterile drapes are applied. [Recommendation]Safety & Efficacy
4.8.3. Communicate use of flammable skin antiseptics as part of the fire risk assessment involving the entire perioperative team before beginning a surgical procedure. [Recommendation]
Dry Times
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.Slide42
4.7.3. Place a fluid-resistant pad under the patient's buttocks during preoperative patient skin antisepsis for patients in the lithotomy position. Remove the pad after the antiseptic is dry and before sterile drapes are applied. [Recommendation]Added “fluid-resistant pad”Absorbent pad with fluid-resistant side
Remove pad after antiseptic is dry and before sterile drapes are appliedIf removed when wet, solution will continue to dripPrepping in Lithotomy
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.Slide43
4.9. When lifting and holding the patient's extremity or head … minimize muscle fatigue. [Recommendation]Use two hands for holdingObtain assistanceUse an assistive device
(Combination of these methods)AORN guidance statement: Safe patient handling and movement in the perioperative setting. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2015:733-752.
Ergonomics
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.Slide44
5. Handling and Storage of AntisepticsLand of regulatory requirementsSingle-use containersDilution
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.Slide45
5.2. Skin antiseptics must be stored in the original, single-use container. [Regulatory Requirement]FDA drug safety communication, Nov 2013Single-use packagingOne time, one patient
Single-use Containers
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.Slide46
5.3. Skin antiseptics must not be diluted after opening. [Regulatory Requirement]FDA drug safety communication, Nov 2013Do not dilute antiseptic products after openingReduce product contamination
Diluting Antiseptics
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.Slide47
Challenges & AdviceWearing jackets while preppingShedding skin & hair
Cover armsProtect the prep from contaminationButton jacket
Wear appropriate size
Tape up the sleeve
Long sleeve scrub tops Single-use jacket or gown (it doesn't have to be sterile)*
*Scrubbed team members should not prep
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.Slide48
ReferencesOver-the-Counter Topical Antiseptic Products: Drug Safety Communication - FDA Requests Label Changes and Single-Use Packaging to Decrease Risk of Infection. US Food and Drug Administration. http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm374892.htm. Accessed February 11, 2015.
Guideline for a safe environment of care, part 1. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2015: 239-263. [IVA]Gottardi W. The influence of the chemical behaviour of iodine on the germicidal action of disinfectant solutions containing iodine. J Hosp Infect. 1985;6(Suppl A):1-11. [VA]
Bag Technique
Naderi N, Maw K, Thomas M, Boyce DE, Shokrollahi K. A quick and effective method of limb preparation with health, safety and efficiency benefits.
Ann R Coll Surg Engl.
2012;94(2):83-86. [IIB]
Incoll IW, Saravanja D, Thorvaldson KT, Small T. Comparison of the effectiveness of painting onto the hand and immersing the hand in a bag, in pre-operative skin preparation of the hand.
J Hand Surg Eur Vol.
2009;34(3):371-373. [IIB]
Chou J, Choudhary A, Dhillon RS. Comparing sterile bag rubbing and paint on technique in skin preparation of the hands.
ANZ J Surg.
2011;81(9):629-632. [IIC]
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.