Best Practices: Clip, Prep, Drapemultimedia.3m.com/mws/media/787765O/best-practices-clip-prep-dra… · Best Practices: Clip, Prep, Drape Welcome ... Identify the properties of effective

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Best Practices:Clip, Prep, Drape

Welcome!Topic: Best Practices: Clip, Prep, Drape

Facilitators: DeAnn Hammer

Speaker: Maret Millard

Jodi Lippert


Housekeeping• Questions

• Mute feature (*7 = unmute; *6 = mute)

• “Chat” feature

• Technical difficulties

• Post session follow-up

Disclosure Statement

Maret Millard and Jodi Lippert

3M Technical Service Specialists

3M Infection Prevention Division


3M Infection Prevention Division

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How do I get a CE Certificate?

Next week, all of today’s meeting participants will be sent an email containing instructions for obtaining a CE Certificate for today’s meeting.


The email will be sent to the email address you provided when you logged-in to today’s meeting. If there are others listening with you today who did not log-on, you may forward the CE certificate email to them.

Objectives

• Participants will be able to:Discuss the clinical benefits of hair removal by means of clipping

versus shaving

Identify the properties of effective surgical skin preparation t


agents

Describe the principles of draping as they relate to prevention of infection


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Brief History

• Early 19th Century surgeon “operated in a Prince Albert coat and

d th


used the same sponges for every patient treated.”

• Mid 19th century protection of surgical wound

Surgical Conscience

• No Compromise

• Mental discipline

I ti d l ti


• Inspection and regulation

Developing the Surgical Conscience

• Is this the best practice?

• Do I have everything necessary for the


procedure?

• Have I done all I can do to provide a safe,therapeutic environment for the patient?

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Precision Counts!

• Aseptic Technique• Prevention of microbial contamination in the environment

• Sterile Technique:• Creation of and working in a sterile field


g

H i R lHair Removal

What is the first line of defense against infection?

• According to the CDC Guidelines for Prevention of Surgical Site Infections (SSI), for most SSIs, the source of pathogens is the endogenous flora of


pat oge s s t e e doge ous o a othe patient’s skin, mucous membranes or hollow viscera

• When mucous membranes or skin is incised,the exposed tissues are at risk for contamination with endogenous flora

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Hair Removal Methods

Shaving (Razor)


Chemical Depilatory

Clipping


1. Alexander, Wesley et al, “The Influence of Hair Removal Methods on Wound Infections,” Archives of Surgery, 1983; 118:347–352.

2012 AORN Recommendation #III

• The patient’s skin condition should be assessed for the presence of lesions or other tissue conditions at the surgical site before skin preparation begins. Unintentional removal of lesions (eg, nevi) traumatizes the skin on the


surgical site and provides and opportunity for wound colonization by microorganisms.

• The presence of excessive hair that may interfere with the surgical procedure should be identified.

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PreOp Hair Removal


Hair should be removed in a locationoutside of the operating orprocedure room

Hair removal should be performedthe day of surgery.

2012 AORN Recommendation #IV

• Hair at the surgical site should be left in place (i.e., not removed) whenever possible• Patients should be instructed not to shave at home• Hair should not be removed by a razor• Head and Neck surgery alternatives include braiding or the use

of nonflammable gels to keep hair away from incision• If the presence of hair will interfere with the surgical


• If the presence of hair will interfere with the surgical procedure• Remove the day of surgery, outside the OR• Only remove hair that interferes with the procedure should be

clipped • Only the use of a single-use electric or battery operated clipper,

or one with reusable head that can be disinfected between patients, is recommended

• Depilatories can be used if skin testing has been done

AORN and Clipping

• 1-2mm of stubble remaining recommended


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Stubble Length

• Razors cause microscopic cuts and nicks, some of which are not visible to the naked eye. “ In fact the stubble should be reassuring,” commented William C. Beck,MD,FACS, 1986 Surgery, Gynecology & Obstetrics. “ it gives


assurance that the superficial skin squames have not been disturbed.

Supporting Organizations

• American College of Surgeons (ACS) follows the CDC Guidelines

• The Association of Practitioners in Infection Control (APIC) also recommends clipping


pp g

• National Quality Forum (NQF)

• The Surgical Care Improvement Project (SCIP)

Recommended Practices and Guidelines

• CDC: “if hair is removed, remove immediately before the operation, preferably with


p , p yelectric clippers.”

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S i l Ski A ti iSurgical Skin Antisepsis

2012 AORN Recommended Practices for Skin Preparation of Patients

The goal of pre-op skin prep is to reduce the risk of postoperative surgical site infection by:

Remove soil and transient organisms


Remove soil and transient organisms Reduce resident microbial count to sub pathogenic levels

with the least amount of tissue irritation Inhibit rapid rebound growth of microorganisms


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P Sh /WiPreop Showers/Wipes

Recommended Practices and Guidelines

• The 1999 CDC Guideline for Prevention of Surgical Site Infection• Require patients to shower or bathe with an antiseptic agent


q p p gon at least the night before the operation

• Remove gross contamination before performing antiseptic skin prep

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2012 AORN Recommended Practice # I

• Patients undergoing open Class 1 surgical procedures below the chin should have two preoperative showers with CHG before surgery when appropriate


• Sufficient evidence –reduction of microbial counts

• Insufficient research – link reduction in SSI

2012 AORN Recommended Practice # I

• Patients undergoing head and neck procedures• Two shampoos with 4% CHG prior to surgery

• Avoid CHG contactE ld l d


• Eye – could cause corneal damage

• Inner ears – could result in permanent deafness

S i l P ti t PSurgical Patient Prep

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CDC SSI Guideline

• Use an appropriate antiseptic agent for skin preparation.

• No one antiseptic is preferred over other antiseptics.

• Skin prep should be applied in concentric circles moving


• Skin prep should be applied in concentric circles moving toward the periphery, prep area should be large enough to extend the incision or create new incisions or drain sites

National Quality Forum

• 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 per product guidelines.


2012 AORN Recommended Practice# II

• Preoperative skin antiseptic agents that have been FDA-approved or –cleared and approved by the health care organization’s infection control personnel should be used for all preoperative skin


preparation. Agents Should:

• Significantly reduce microorganisms• Non irritating • Broad spectrum• Fast acting and persistent

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2012 AORN Recommended Practice# III

• The antiseptic agent should be selected based on the patient assessment• Allergies

C t i di ti


• Contraindications

• Surgical site

• manufacture’s written information

• Surgeon preference

• Skin condition

• ID surgical site before prep

2012 AORN Recommended Practice # V

• The skin around the surgical site should be free of soil, debris, exudates, and transient microorganisms to minimize contamination of the surgical wound before application of the antiseptic


su g ca ou d be o e app cat o o t e a t sept cskin preparation. • Efficacy dependent on clean skin

• umbilicus cleaned before prep

• Specific information on several areas –

2012 AORN Recommended Practice # VI

• Protective measures should be implemented to prevent skin and tissue injury due to prolonged contact with skin prep agents.

• Detailed protective measures


Detailed protective measures• Soaked linen / tape• Lithotomy / vaginal procedures• ESU, tourniquets

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2012 AORN Recommended Practice # VII

• The antiseptic agent should be applied to the skin over the surgical site and surrounding area in a manner to minimize contamination, preserve skin integrity, and prevent tissue damage.


2012 AORN Recommended Practice # VIII

• If a flammable prep agent is used, additional precautions should be taken to minimize the risk of a surgical fire and patient burn injury. • Storage, use & disposal

• Single use


Single use• Contact with fabrics – remove solution soaked

materials• Pooling –wicked away• Allowed to dry & vapors to dissipated • Disposal-• Alcohol product use discussed during “time

out’

CMS Guidance on Alcohol-based Skin Preparations in Anesthetizing Locations

• Risk Reduction Measures - 2007• Use unit dose applicators• manufacture directions• Prevent soaking into patient’s hair or linens


• Prevent soaking into patient s hair or linens• Completely dry before draping• Verification and documentation

• Establish & document use of policies & procedures • When risk reduction measures not taken – could be cited

as non-compliance with CMS

http://www.ashe.org/ashe/codes/advisories/pdfs/cmssurgicalprep.pdf

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2012 AORN Recommended Practice # IX

• Manufactures’ written recommendations and MSDSs for handling, storing, and heating of all skin

ti t h ld b dil il bl


preparation agents should be readily available, reviewed, and followed.

2012 AORN Recommended Practice # X

• At the end of the surgical procedure, the skin preparation agent should be thoroughly removed from the skin unless otherwise indicated by the manufacturer’s written instructions.


2012 AORN Recommended Practice # XI

• Competency

Education

Training


Competency validation

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2012 AORN Recommended Practice # XII

• DocumentationPatient skin preparation should be documented in the medical record. • Pre-op instruction, compliance with shower


• Hair removal method• Area prepped, Jewelry removal• Precautions with flammable agents• Removal of prepping agent• Postoperative skin condition

2012 AORN Recommended Practice # XIII

• Policies and Procedures

Policies and procedures on the skin preparation of patients should be written, reviewed annually, and


p , y,readily available within the practice setting.

2012 AORN Recommended Practice # XIV

• QualityA quality management program should be in place to evaluate skin preparation procedures and identify and respond to opportunities for improvement


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Factors to Consider When Choosing a Patient Skin Prep

• Immediate and persistent activity

• Drape adhesion

• Affect of blood and/or saline


• Application instructions for both clean dry skin and moist areas (groin)

• Product warnings

Choosing the Right Antimicrobial

• Challenges that face surgical preps • very different from those for surgical hand antisepsis and even

intravascular catheter site preps.

• Choosing the right antimicrobial for the right indication is


critical in helping reduce the risk of surgical site infection for your patients

S i l DSurgical Drapes

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CDC SSI Guidelines

• Use surgical gowns and drapes that are effective barriers when wet (i.e., materials that resist liquid penetration).

Category IB


Category IB

Drape Materials

• Reusable or multiple use products

• Disposable or single use products


• Regardless of material - must meet drape characteristics

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AORN Recommended Practices for Selection and Use of Gowns/Drapes

• Surgical Drapes should:

• Provide appropriate barriers


• Be appropriate to methods of sterilization

• Maintain adequate integrity and durability

• Withstand physical conditions

• Resist tears, punctures, fiber strains, and abrasions

AORN Recommended Practices for Selection and Use of Gowns/Drapes

• Surgical Drapes should:

• Be free of toxic ingredients


Be free of toxic ingredients

• Be low linting

• Have positive cost;benefit ratios

• Have an acceptable quality level

• Be used and processed according to manufacturers’ written instructions

Surgical DrapesAAMI TIR11:2005

AAMI protective barriers classification and minimum requirements for protective apparel and drapes used


Resistant 1 2 3 4 Barrier

Low Level

“Splash and Spray” Protocol using water

High Level

“Pressure Protocol” using bloodbourne pathogen

stimulants

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Principles of Draping

• Isolate –


• Barrier –

• Sterile Field -

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• Equipment Covers

• Fluid Control


• Fluid Control

• Sterile Surface

Sterile Surface

• Incise drapes provide a sterile surface to the wound edge

• Lock bacteria under the drape

• Antimicrobial incise drapes kill bacteria


Skin flora is the leading causeof surgical site infection


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Bacteria can be a resourceful traveler.

• Organisms that remain on the skin can potentially migrate into the surgical wound


wound.

• Bacteria can be transferred to the wound through contact with instruments, gloves or sponges.

Drape Adhesion

• The adhesion of the incise drape is critical in maintain the adhesion of the drape to the would edge.

• One study showed that drape lift at the wound edge was associated with a 6-fold increase in SSI


6-fold increase in SSI

• The choice of prep can play a significant role in drape adhesion.• Water insoluble preps will provide better drape adhesion than

water soluble preps.

Summary

• SSIs - second most common healthcare associated infection (HAI) among hospitalized patients

• These infections number approximately 500,000 per year, among an estimated 27 million surgical procedures, and account for approximately one quarter


of the HAIs in the United States each year • Infections result in longer hospitalization and higher

costs • Bacteria from the patient’s own skin are often the cause

of surgical site infections

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Summary

• Best practices for clipping, prepping and draping can help reduce skin bacteria and help reduce the risk of SSI

• Following manufacturers directions for use help ensure that products are applied and removed is a safe and


effective manner• Patient safety should always be at the forefront of all we

do in caring for the surgical patient



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