Want to get a jump start on preventing infections? Have patients do the prep work

By Joy Daughtery Dickinson, Executive Editor

The times, they are a changin'. Surgical patients used to arrive at hospitals the day before surgery, where staff did all the prep work to ensure patients were as clean as possible to avoid post-surgical infections.

"Now you stay home and take several showers with special soap so you are squeaky clean when you go in," says Barb Ludlow, a patient who blogged about her experience having outpatient surgery at http://www.greenbaypressgazette.com. Additionally, some providers are telling their patients, including Ludlow, to wash their hair twice, wear freshly laundered clothes or pajamas, plus sleep in freshly laundered sheets before surgery.

You might learn something from some of these practices. Surgical teams at Cedars-Sinai in Los Angeles reduced surgical site infections by more than 60% for patients who undergo colorectal procedures by introducing evidence-based protocols that included patients using chlorhexidine antiseptic solution to shower the evening and morning before surgery. (For more information on this project, see story, below.)

Outpatient surgery programs are joining the trend toward at-home prep for surgery. Sometimes these changes are in response to infection monitoring. This past year, DISC Surgery Center in Marina del Rey, CA, had its first infection in six years, says Karen Reiter, RN, CNOR, RNFA, chief operating officer. "It made us look at what we were doing," Reiter says. "We brought the [patient skin preps with chlorhexidine gluconate] back in, inserviced all staff, and started education for the patients."

In terms of staff, "everyone thinks they're doing it the right away," she says. Much of the center's educational efforts focused on the surgeons, with the help of a lead surgeon, Reiter says.

Here are some practices that outpatient surgery providers are taking to reduce the opportunity for infection:

• Screen for methicillin-resistant Staphylococcus aureus (MRSA) and any infection that didn't heal.

At Reiter facilities, patients are asked if they have a history of MRSA or any infection that didn't heal when they are being screened for surgery at the doctor's office and during the preop nurse call. If patient has had a positive history of MRSA, staff members try to obtain a preoperative screen and have the patient treated prior to surgery. If the patients haven't had the swab conducted before they arrive for surgery, the swab is conducted when they arrive at the center, and they are isolated. The center is considering switching to a new nasal treatment with povidone-iodine topical antiseptics.

• Preoperative showering.

Gina Parsons, senior product manager for surgical products at StartClean Procedural Solutions, part of Leawood, KS-based CareFusion, says, "The literature is growing in regard to including preoperative bathing regimens as part of the pre-surgical bundle." StartClean combines a chlorhexidine gluconate (CHG) cleansing kit with an individualized service that reminds patients to cleanse before they come in for surgery. (For more on the StartClean product, see resource at end of this article.)

Guidelines from the Centers for Disease Control and Prevention (CDC) include one for patients to shower or bathe with an antiseptic agent on at least the night before the operative day. That guideline was ranked as Category IB, which means strongly recommended for implementation and supported by some experimental, clinical, or epidemiological studies and strong theoretical rationale. (For information on how to access the guidelines, see resource at end of this story.)

The Association of perioperative Registered Nurses (AORN) recommends preoperative showers. "We generally say two showers before surgery" usually using CHG, says Sharon A. Van Wicklin, MSN, RN, CNOR/CRNFA, CPSN, PLNC, perioperative nursing specialist at AORN. The information is included in the recommended practice "Preoperative Patient Skin Antisepsis."

Reiter's facility follows the two-shower guidance by asking patients to buy a bottle of antiseptic antimicrobial skin cleanser. They are told to shower with it the night before and the morning of surgery. "We don't let them shave the morning of, and no 'lotions or potions,'" Reiter says.

• Preop skin preparation.

The CDC recommends thorough washing and cleaning at and around the incision site before performing antiseptic skin preparation, as well as using an appropriate antiseptic agent for skin preparation (both Category IB). AORN specifies that the agent should be approved by the Food and Drug Administration, such as CHG or povidone-iodine.

Van Wicklin says, "You don't want to use Dial soap. It's not approved for that."

The CDC also recommends applying preoperative antiseptic skin preparation in concentric circles moving toward the periphery. This is a Category II recommendation, which means it is suggested for implementation and supported by suggestive clinical or epidemiological studies or theoretical rationale.

The National Quality Forum (NQF) board of directors has maintained endorsement of Safe Practice 22, which addresses appropriate skin preparation to prevent surgical site infection. The final safe practice directs providers to preoperatively use solutions that contain isopropyl alcohol as skin antiseptic preparation until other alternatives have been proven as safe and effective, and allow appropriate drying time.

Reiter says, "We hit the code clock when you finish the prep, and wait three minutes before draping." This clock helps staff at some facilities address concerns about surgeons who are in a hurry, she says. "You may as well not prep if you don't follow manufacturer specifications," says Reiter.

Providers, as well as patients, are buying in to these practices, says Marcia Patrick, RN, MSN, CIC, consultant in infection prevention and former member of the board for the Association for Professionals in Infection Control and Epidemiology. "I can tell you on personal note, if I was going to have a hip or knee replaced, any kind of significant surgery, I would do exactly that: shower the night before with a CHG-containing product, then again the morning of," she says. "I would put on clean pajamas. I would sleep in clean sheets. And I would put on freshly laundered clothes to go to hospital or wherever [I'm] having outpatient surgery."


  • The "1999 CDC Guideline for Prevention of Surgical Site Infection" from the Centers for Disease Control and Prevention. Web: http://www.cdc.gov/hicpac/pdf/guidelines/SSI_1999.pdf.
  • The StartClean program encourages compliance for preoperative bathing. The surgeon or staff enters the patient's contact information into the reminder program and provides him or her with the kit and a patient education template. This program combines a 4% CHG cleanser and sponges with an individualized service that reminds patients (text, email, or voice message) to cleanse before surgery. For more information, call (800) 523-0502 or visit www.carefusion.com/startclean.

SSIs reduced 60% for colorectal patients

Surgical teams at Cedars-Sinai in Los Angeles have reduced surgical site infections by more than 60% for patients who undergo colorectal procedures by introducing evidence-based protocols that are easy to follow and relatively low in cost.

Surgeons, nurses, operating room staff, and patients collaborated in a quality improvement project that measured surgical site infection rates for one year.

"This work marks a significant step toward achieving Cedars-Sinai's goal of zero hospital-acquired infections," said Rekha Murthy, MD, director of hospital epidemiology. "It represents the first of several projects to eliminate postop infections." The new approach modified or optimized past practices:

  • Patients used chlorhexidine antiseptic solution to shower the evening and morning before surgery.
  • Surgical teams prepared operative sites with a sterile chlorhexidine and alcohol antiseptic solution. After surgery, patients were bathed with chlorhexidine wipes daily.
  • Antibiotics used immediately prior to surgery were standardized, which allowed only those from a short list of appropriate alternatives. For operations lasting more than four hours, a second dose of antibiotics was administered to reduce infection risk.
  • Use of wound protectors was encouraged to reduce contamination of the skin while handling the intestines.
  • After completing the contaminated portion of colorectal procedures, members of surgical teams changed to new gowns and gloves, used new instruments, and re-draped operative sites with sterile covers. This reduced contamination of the abdomen and skin during surgical closing procedures.
  • The technique of daily wound probing was broadly applied in some cases of wounds considered to be at high risk for infection. This involved a simple and inexpensive daily process using cotton-tipped applicators to release contaminated fluid trapped in wounds. As a result of these steps and others, the rate of postoperative surgical site infections (SSIs) after colorectal surgeries dropped from a baseline of 15% to less than 5% within six months.

Cedars-Sinai conducted its test as part of a larger national research project on surgical site infections piloted at seven large hospitals across the country. Under the collaboration coordinated by The Joint Commission's Center for Transforming Healthcare, the hospitals each worked to develop a protocol to dramatically reduce surgical site infections among patients who underwent colorectal procedures. (For more information, go to http://bit.ly/V1uspJ.)

Shirin Towfigh, MD, a faculty member in the Cedars-Sinai Division of General Surgery and the Center for Minimally Invasive Surgery, said, "Our work illustrates that with institutional collaboration and low-cost changes in practice, surgeons can dramatically reduce their patients' surgical site infections."