Proper skin prep defends against SSIs

ealthcare-associated infections (HAIs) account for a large portion of the harms caused by healthcare and are associated with high costs," stated a report by Zimlichman et al.1 Whereas the editor's note accompanying this study stated, "The reason to prevent healthcareassociated infections is to save lives, not costs," the study clearly connected saving costs with saving lives. "Better evaluation of these infections could help providers and payers to justify investing in prevention," the authors noted.

The costs of HAIs, an astounding figure of approximately $10 billion per year in the United States alone,1 may very well provide the motivation for healthcare administration to make it a priority to decrease HAIs. Although quality patient care is the foremost priority, to administration, few things carry as much weight as does money. When the Centers for Medicare and Medicaid stopped paying for HAIs in 2009, and private insurers began following suit, it definitely hit where it hurt.

One of the top, and most costly, HAIs is surgical-site infection (SSI). The Zimlichman study estimated that each SSI case costs an average of $20,785.* If the SSI is caused by methicillin-resistant Staphylococcus aureus, the costs can be higher.* Studies such as this, allowing hospital administration to compare the cost of avoiding infections versus the cost of responding to infections, are an important step in the right direction. If reducing infection to reduce costs also saves lives in the process, who can complain? It is a win-win situation.

Skin-prep selection criteria

Nipping it in the bud may be the ideal approach for handling SSIs. Preparing skin for surgery is the initial and vital first step. Kimberly Prinsen, RN, MSN, Technical Service Specialist, 3M Infection Prevention, Perioperative Division, talked to Healthcare Purchasing News about the importance of effective preoperative skin preparation. "The surgical skin prep is a critical step in reducing the risk of an SSI for patients undergoing surgery. Because all commonly used patient skin preps meet the Food and Drug Administration (FDA) criteria for immediate microbial kill and persistent antimicrobial activity, it's important to look at other factors that may affect performance when choosing a prep for each surgical patient."

Prinsen offered specific advice on skinprep selection criteria. "Selection of a patient prep is based on multiple factors, including patient allergies and sensitivities, age of the patient, location and type of procedure, anticipated amount of fluid or blood exposure to the surgical site, and surgeon preference. Once these are evaluated, the prep choice also should consider the following: ease of application, ability to immobilize bacteria on the skin, effectiveness of prep after blood and saline challenge, coverage area, and cost/value of each surgical prep."

Noting that "Each patient requires a unique approach to skin antisepsis," J. Hudson Garrett, Jr, PhD, MSN, MPH, Vice President, Clinical Affairs, PDI Inc., outlined a few more factors to consider when matching appropriate skin-preparation products to patients. "It is important to ensure that the skin antiseptic chosen is broad-spectrum, FDA-approved, safe for the patient and the clinician, and demonstrates the ability to bind to the skin and reduce microbial growth. To select broadspectrum skin antiseptics, efficacy should be evaluated for common causative microbial categories such as gram-positive and -negative bacteria, pathogenic fungi, and other pathogens."

It is always advisable to be aware of guidelines, recommendations, and best practices. Colleen Glynn, Senior Marketing Director of Surgical Businesses, BD, referred to guidelines on skin prep, outlining the basics. "Skin antisepsis guidelines explain that standardized patient preparation should remove bioburden (e.g., soil and transient microorganisms) from skin, decrease resident microorganism counts quickly while not irritating tissue, prevent regrowth and rebound of microorganisms, and have a persistent effect."2-3

Application method makes a difference

How preoperative skin preparations are applied can make a difference in eliminating pathogens effectively and in ensuring compliance. Prinsen explained why. "The application method for a prep is how a prep achieves its efficacy. It is necessary for staff to know and follow the nuances for each prep. Following manufacturer's instructions for use is critical not only to help reduce the risk of an SSI but also to ensure patient safety. Some surgical skin preparations have different application methods based on the location of the body that is being prepped, e.g., a dry site (abdomen) versus a moist site (groin). 3M DuraPrep is applied in a single painted-on coat, with no variation for dry or moist sites. Taking the variability out of application method assists the clinician in being compliant with the instructions."

Remember that tired old joke, "If all else fails, read the directions?" Instructions are there for a reason. "All antiseptics should be applied to the patient's skin as directed in the manufacturer's instructions for use," said Garrett, PDI. "Some antiseptics are applied with concentric circles, whereas newer formulations, such as those containing Chlorhexidine gluconate, are applied in a back-and-forth motion." Garrett explained that the back-and-forth application technique dislodges the transient flora found in the epidermis of the skin, which can cause SSIs.

Glynn explained in a nutshell why the method of product application merits attention. "An estimated eighty percent of skin flora reside in the first five layers of our outermost skin. When the skin is incised, the exposed tissues are at risk for contamination. Bacteria on patient skin is a leading cause of HAIs."4

How they work

Prinsen described 3M's skin-prep solution, explaining how its formulation stops infection in its tracks. "3M DuraPrep Surgical Solution [iodine povacrylex (0.7 percent available iodine) and isopropyl alcohol, 74 percent w/w] Patient Preoperative Skin Preparation is applied in a single painted coat. Iodine povacrylex contains a unique polymer that dries to a water-insoluble film. The film enables the prep to resist removal by blood and irrigating solutions, thus optimizing the persistent effect of iodine. The film also immobilizes bacteria remaining on the skin after prepping, helping to prevent bacteria migration into the surgical wound and enhancing incise drape adhesion."

BD's ChloraPrep formulation is two percent Chlorhexidine gluconate and 70 percent isopropyl alcohol, fast-acting, broad-spectrum, and persistent. "The entire ChloraPrep portfolio is designed to reduce significantly bacteria on the skin that can cause infection, and it is appropriate for most minor and major procedures," stated Glynn.

"By cleansing the surgical-site area with gentle back and forth motions, ChloraPrep penetrates into cracks and crevices on the skin, eliminating microbes in less-accessible areas of the skin's surface."

Glynn continued, "ChloraPrep solution continues to be the only FDA-approved formulation of two percent Chlorhexidine gluconate and seventy percent isopropyl alcohol (IPA) with a single-use applicator. It has appeared in more than 20 peerreviewed publications and been shown to outperform iodine-based products."5,6

One of the studies Glynn referred to, by Ostrander et al, compared three skinprep solutions on 125 consecutive foot and ankle surgeries. The study concluded: "The combination of Chlorhexidine and alcohol (ChloraPrep) was the most effective solution for eliminating potential wound contaminants from the forefoot prior to surgery."6

PDI Inc., also offers a Chlorhexidine gluconate and isopropyl alcohol skin prep. Ease of use and a continued antimicrobial effect on the patient's skin up to seven days with a single application are just two of its attractions. Garrett described how Prevantics differs from other similar products. "Prevantics is fully compliant with the current evidence-based recommendations from both the Centers for Disease Control and Prevention and the Association of PeriOperative Registered Nurses. Prevantics is the only 3.15 percent Chlorhexidine gluconate/70 percent isopropyl alcohol, FDA-approved antiseptic available in the United States. The product is fully activated and ready for immediate use by the clinician, saving time and improving efficiency in the skin-antisepsis process. Prevantics tinctured formulation delivers the immediate efficacy provided by the isopropyl alcohol and also the sustained antimicrobial effect from the chlorhexidine gluconate. Prevantics is less expensive than other similar products, due to its intuitive and simple design.

"Prevantics has been used in many facilities to improve quality, reduce costs, and improve the overall patient experience," stated Garrett. "Several recent published clinical studies have demonstrated its impact on reducing HAIs."

Garrett relayed a study conducted and published by a community hospital in the Dallas-Fort Worth area, where Prevantics was implemented to reduce blood-culture contamination, a concern because contaminated blood cultures can lead to patients being unnecessarily exposed to antibiotics. "This can result in significant risk for infections with postoperative surgical patients," noted Garrett. "As a result of the intervention, the facility's contamination rate dropped from nine percent to just under three percent, well below the national average for blood-culture contamination rates."

Clorox Healthcare's Nasal Antiseptic Swabs also may play a role in good antibiotic stewardship. Because the swabs can be used as an alternative in nasal decolonization, and because bacteria have not developed resistance to povidoneiodine antiseptics, fewer antibiotics may be required.

Rosie D. Lyles, MD, MHA, MSc, Head of Clinical Affairs, Clorox Healthcare, explained, "Clorox Healthcare Nasal Antiseptic Swabs are pre-saturated, readyto-use swabs that are used in patient nostrils prior to surgery as part of a bundled intervention for patient decolonization, to help reduce the risk of postoperative SSIs. They are clinically shown to reduce 99.4 percent of Stapln/lococcus aureus at one hour, maintaining persistence through twelve hours. They are non-irritating and well-tolerated in the nares after 10 applications. When used as part of preoperative or inpatient protocol, the swabs are proven to be a safe and effective alternative to antibiotics for nasal decolonization, which can help enable antibiotic-stewardship plans, as there is no clinical evidence of bacteria developing resistance to povidone-iodine antiseptics."

Lyles continued, "Nasal carriage of S aureus is a significant risk factor for developing an SSI with S aureus,7 which is why effective nasal decolonization plays an important role as part of a bundled approach to reduce the risk of infection. However, there is growing evidence that nasal decolonization with antibiotics may contribute to bacterial resistance. Clorox Healthcare Nasal Antiseptic Swabs can safely and efficiently reduce S aureus in the nares without contributing to bacterial resistance, differentiating them from other nasal decolonization treatments with antibiotics such as mupirocin."

Lyles also considered the importance of patient comfort and ease of use in application of the product. Naturally, if a product causes discomfort, or if it is difficult for the healthcare workers to apply, compliance can suffer. "Clorox Healthcare Nasal Antiseptic Swabs are applied to a patient's nostrils by a healthcare provider one hour before surgery. This method of application increases the likelihood of compliance and reduces the risk of patient error. Patients have found the swabs comfortable during application and report an overall positive experience, with 96 percent of study participants reporting no discomfort throughout product application. Compliance and ease of use are important considerations when selecting a nasal decolonization method prior to surgery, because if a product is difficult to use or uncomfortable for patients, it is less likely to be used effectively."

Referring to the high cost of treating SSIs, Lyles compared the cost of Clorox Healthcare Nasal Antiseptic Swabs to the cost of caring for a patient with a resistant strain of S aureus. "SSIs are the third most frequently reported HAI, are a source of significant patient morbidity and mortality, and are extremely costly. The average per-patient cost for an SSI caused by resistant strains of S aureus can be as high as $60,000. Clorox Healthcare Nasal Antiseptic Swabs are a cost-effective decolonization method, decolonizing the nose for less than the cost to screen for S aureus." HPN