Four questions: Experts weigh in on key issues related to skin antisepsis

Patients undergoing major inpatient operations are being discharged from the hospital rapidly, and infections are becoming the main reason for emergency room visits and re-admissions. A major, yet often preventable, threat to patients is hospital acquired infections (HAIs), which can be associated with major morbidity.

Earlier this year, thought leaders in the area of Infection Prevention gathered for a virtual round table to discuss the issues around HAIs and skin antisepsis. The group also addressed what types of operating room (OR) protocols can be implemented to have a positive impact on quality outcomes and economics. The roundtable was sponsored by BD, which specifically added the ChloraPrepTM patient preoperative skin preparation to its portfolio with the acquisition of CareFusion.

Following this in depth discussion, it became apparent that there were four key areas that future research and management strategies might address to directly impact skin antisepsis protocols and improve outcomes for the surgical patient.

The Elephant in the Room: Variability
While the U.S. Centers for Disease Control and Prevention (CDC) and other professional bodies detail standards for applying antiseptics, many hospitals and clinicians do not realize that their techniques may be outdated or incorrect, which speaks to the need for constant refreshing of skin antisepsis education. An example of how even basic protocols integral to skin sterilization may not always be followed properly is illustrated in a recent study published in the American Journal of Infection Control. The study reported that healthcare professionals at outpatient care facilities fail to follow recommendations for hand hygiene 37 percent of the time and for safe injection practices 33 percent of the time, even after having policies in place about these infection control issues. Given there are nearly 28 million outpatient procedures per year and 50 million more total inpatient procedures, even something as basic as hand hygiene needs to be taken more seriously.

As an example of how variability persists in skin antisepsis, data presented at the Association of periOperative Registered Nurses (AORN) Surgical Conference and Expo 2014 showed the importance of adequate skin preparation and drying time based on recent data that illustrates only 60 percent of the skin preparation time was followed by the directions for use and 53 percent on drying time. Additionally, only 63 percent of the time, were skin preparations applied according to the FDA-approved product label directions.

Due to the amount of skin preparations on the market, when variability exists in the OR, there is a risk that the proper guidelines may not be met, leading to an increased possibility for infection. Allowing for standardization is the key to meaningfully reduce HAIs. The panel discussed challenges that inhibit the movement of standardization such as the operating room (OR) culture and access to products based on factors such as cost and contracts.

Cultural Hurdles
We concluded that standardization of skin antisepsis and improved outcomes must be a cross-functional effort endorsed and enforced by practitioners across all operating room disciplines, with support from the C-suite administrators. While this is a noble goal, each panelist was able to relate incidents and/or barriers that would prevent meaningful improvements.

Over the past few years, some health care facilities have put into place dedicated skin preparation teams which take the responsibility out of the hands of residents and/or nurses and allows for specialized individuals to have control. For instance, a study in Michigan showed that the implementation of the Comprehensive Unit-based Safety Program (CUSP) in ICUs reduced the rate of blood stream infections from intravenous lines by two-thirds within three months, and helped the average ICU decrease its infection rate from 4 percent to 0. However, during the round table some panelists worried that surgeons wouldn't be able to track patient outcomes as closely if they did not perform or supervise the skin antisepsis procedure themselves. Further, specific incidents were recounted where surgeons only like to use one kind of product in one kind of application style, simply because this was the way it was "always done."

Not only do these examples speak to the need for solid evidence about protocol implementation and outcomes, but it points to problems within the culture of the OR. Even if unspoken, there remains professional segregation by career discipline. Is the nurse or infection control professional empowered to educate or correct residents and/or surgeons about skin antisepsis protocols? Only when open and transparent communication is accepted without retribution, can nursing and other OR personnel provide instruction to inform residents about proper technique and avoid variability in the use of skin antiseptics. Fortunately, there are programs in place that help alleviate the pressure from the nursing staff by bringing in dedicated curriculums that partner with facilities to help communicate the need for continual education and proper protocols.

Better Data, Better Decisions
During the panel, my colleagues and I also discussed how skin antisepsis is directly impacted by the C-suite. Inevitably, product and protocol decisions are affected by factors beyond efficacy, particularly in light of needing to sign contracts with payers, suppliers and other stakeholders. Ideally, administrators need to be armed with more and better data in order to make informed selections and have more negotiating power. The Centers for Medicare & Medicaid Services (CMS) and other payers also should invest in increased information technology and data collection.

In general, the panel also agreed that there is an opportunity to better control health outcomes, and thereby costs, when the entire team, from the environmental service worker, to the nurse, to the surgeon, is trained together on standardized antisepsis protocols and techniques. C-suite support from the institution is vital to promote standardization in skin antisepsis, as teams can be rewarded and recognized for their performance. Recognition for performance raises morale and the level of professionalism in the OR environment.

Working for Change
The individual health care professional has a vital role to play in promoting effective and standardized skin antisepsis. In addition to understanding skin antisepsis protocols, providers should be open to continuing education and being held accountable when corrections are needed. Managers can be better leaders when they communicate about team success and high quality performance, while being transparent in communicating about outcomes. With evidence from objectively collected data, cultural shifts and improved communication can be made among all members of the health care team. Strong evidence also informs institutions so that better decisions can be made about patient care, protocols and products. The net effect will be better outcomes for our patients and an improved bottom line in the era of value-based purchasing.

Disclaimer: The development of this piece was supported by Becton Dickinson.

[1] Xi, H., Parsons, G. "Focus on Quality Care: An Audit of Surgical Prep Practices in U.S. Hospitals" Presented at the Association of peroOperative Registered Nurses (AORN) Surgical Conference & Expo 2014.

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