Skin Preparation and Patient Skin Antisepsis
You learned in course one that the skin cannot be made sterile; therefore, skin antisepsis refers to the removal of dirt and transient microbes to reduce the count on the skin surface and prevent microbial rebound growth.
Skin preparation may begin before a patient even sets foot into the surgical suite and includes more than just the surgical typical ‘prep’ solution. Additional steps can include:
- Pre-operative cleaning wipes or pre-operative baths.
- Removing hair in the surgical site.
- Pre-scrub washes in the operating room.
(King & Spry, 2019)
Pre-Operative Bathing
Evidence has shown that bathing the night before or the day of surgery with soap or a provided antiseptic, can help reduce microbial skin count and lower the patient’s risk of developing a surgical site infection (SSI).
Depending on the surgical site and the institution’s protocol, patients may be provided with a chlorhexidine-based soap product and asked to use it before coming to the hospital. Inpatients or sites with access to pre-operative patient skin preparation wipes may have patients perform a focused cleansing in the pre-operative area or the inpatient unit prior to entering the OR.
Patient Bathing
An example of instructions for an Ontario pediatric hospital…
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(WHO, 2018)
Hair Removal Before Surgery
Years ago, it was common to see patients having large areas of their bodies shaved prior to surgery. The best evidence now shows that this is NOT recommended. The World Health Organization and ORNAC recommend that hair should not be removed unless necessary, and if so, it should be clipped and not shaved. Shaving can cause irritation or abrasions to the skin surface and increase the risk of SSIs (Surgical Site Infections).
ORNAC recommends that required hair clipping be done no more than two hours before the surgical start time. Evidence has shown a correlation between the length of time between clipping and the surgery in terms of SSIs.
Any clipping that is done before surgery, must be done with care, ensuring that all clippings are collected, and stray hair is not left on the surgical site. Often the perioperative team members use tape to collect any stray hairs.
(ORNAC, 2021 – 2.19.16; Phillips & Hornacky, 2021; WHO, 2018)
Pre-Surgical Scrub and Areas Requiring Additional Care
When a patient arrives in the OR with an open wound, trauma, infection, or areas requiring additional care, the surgeon may choose to cleanse the area or perform a pre-surgical scrub prior to prepping. A pre-surgical scrub contains an antiseptic detergent and is helpful to remove microbes and debris before performing the surgical prep.
Some areas requiring additional care include:
- Fingernails
- They can harbour microorganisms.
- They should be cleaned separately from the prep to prevent these organisms from spreading to the surgical site.
- They should be short and natural. There is insufficient evidence to determine if fresh or chipped nail polish in the surgical field increases the risk of Surgical Site Infections (SSIs). However, there is a theoretical risk of polish fragments entering the wound.
Each institution will decide if it is acceptable for patients to have polish on.
- Under the foreskin
- This is another area that can harbour microorganisms.
- If the surgical field includes the penis, the foreskin should be retracted, and the glans gently cleansed.
- Then the foreskin should be pulled back, to prevent circulatory compromise.
- Limbs
Choosing Skin Disinfection Methods
There are a variety of ways to disinfect and clean the skin prior to a surgical procedure. To choose the most appropriate method, perioperative personnel must consider the following:
- The condition of the skin in the involved area.
- Which types of contaminants are involved and if there are multiple contaminants?
- Characteristics of the skin to be disinfected.
- The physical condition of the patient.
- The manufacturer’s guidelines and instructions for use.
- Patient allergies.
(ORNAC, 2021 – 2.19.5)
Choosing the Right Antiseptic Product
Using the latest evidence, the perioperative team must determine the best product for the patient based on:
(Phillips & Hornacky, 2021)
Antimicrobial Properties of Skin Antiseptics
Qualities of a good antiseptic:
- It remains active in the presence of organic matter, soap, and detergent.
- Persistent antimicrobial activity helps decrease rebound microbial growth after skin prep. For example, Chlorhexidine Gluconate provides excellent persistent activity, and Povidone-Iodine [Betadine] has minimal persistence.
- It causes a rapid decrease in the microbial count.
- It’s quick to apply and has a persistent effect.
- It is broad spectrum (gram +, gram – and viruses).
- It’s non-irritating.
- It is non-flammable.
- It has clear manufacturer’s instructions for use and safety data sheets.
- It is non-toxic.
(ORNAC, 2021)