Implement an effective and easy home general skin cleansing regimen

by Rhonda Lemmo, RN, CNOR, MBA

Human skin is an amazing, complicated organ. Most of us don’t realize it weighs eight pounds, measures 22 square feet or manufactures vitamin D that turns calcium into healthy bones. Skin enables us to move and “feel” through endless nerves, but most importantly it acts as a protective shield from extreme temperatures, sunlight and dangerous infections.¹ That’s why when skin is broken through a cut, wound or burn, not only do health professionals become concerned about topical infection, but even more worrisome are the potential damaging and even deadly infections that can enter the body and cause havoc on internal organs. Some of these infections include Staphylococcus aureus, methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE) and other complicated or antibiotic-resistant bloodstream infections (BSIs).

The point is that while clean skin is a major, first-line of defense against hospital-acquired infections (HAIs) and surgical-site infections (SSIs), it is often overlooked and underappreciated. Keeping clean, dry, intact skin is one of the most important ways to keep infections out of the body. And while seemingly simple, it is extremely difficult to manage in today’s busy healthcare environment.

Hand hygiene and surgical preparation—of both the surgeon and patient—are accepted, proven strategies in keeping skin clean and infections away from healthcare workers and patients. But in today’s increasingly competitive, cost-controlled healthcare environment, keeping infections, especially antibiotic-resistant ones, out of the entire facility is paramount. That’s why a simple, yet effective approach to surgical patient preparation is just one way to effectively help control costs, while improving patient outcomes and patient satisfaction.

While knowledge, education, standards and protocols around hand hygiene and infection prevention have come a long way,² prevention of surgical site infections goes beyond the hands of the surgeon. Over time, many protocols have been put into practice, including hand hygiene, preoperative bathing, surgical site preparation and antibiotic prophylaxis. However, it is surprising that many institutions haven’t insisted upon an entirely clean patient before making the first incision.

Surgical-Site Infections

In 1992, the Centers for Disease Control and Prevention (CDC) changed the term for infections associated with surgical procedures from surgical wound infection to surgical site infection (SSI).³ These postoperative infections have been proven to be a major cause of patient injury, mortality and healthcare costs:

• An estimated 2.6 percent of nearly 30 million operations are complicated by SSIs each year.⁴ 
• Infection rates, up to 11 percent, are reported for certain types of operations.⁵
• Each infection is estimated to increase a hospital stay by an average of 7 days and add over $3,000 in charges (1992 data).⁶
• Appropriate preoperative administration of antibiotics has been shown to be effective in preventing infection.⁷

In 1999, the Hospital Infection Control Practices Advisory Committee, which advises the National Center for Infectious Diseases, CDC, published its “Guideline for Prevention of Surgical Site Infection” in the journal Infection Control and Hospital Epidemiology. It outlined four areas that must be focused on to decrease risk and prevent SSIs:

1. Patient characteristics;
2. Preoperative issues;
3. Intraoperative issues;
4. Postoperative issues.

All of these factors contribute to the likelihood of SSIs and are important. However, for the purposes of this article, I would like to further explore preoperative issues. It is in this area that I believe we have an opportunity to prevent infections at an exponential rate.

According to the guideline, the preoperative procedure includes:⁸

1. Preoperative antiseptic showering;
2. Preoperative hair removal;
3. Patient skin preparation in the operation room;
4. Preoperative hand/forearm antisepsis for surgical team members;
5. Management of infected or colonized surgical personnel;
6. Antimicrobial prophylaxis.

Preoperative Antiseptic Showering

In the past few years we have focused heavily on procedures two through six listed above. More recently, preoperative antiseptic showering is once again receiving more and more attention, and for good reason.

According to the guideline, preoperative antiseptic showering or bathing decreases skin microbial colony counts. In a study of more than 700 patients who received two preoperative showers using chlorhexidine, bacterial colony counts reduced nine-fold, while povidone-iodine or triclocarbanmedicated soap reduced colony counts by 1.3- and 1.9-fold, respectively.⁹ That’s why recommendations that encourage showering or bathing prior to surgery with an antiseptic cleanser have expanded throughout professional organizations. In 2008, the Association of periOperative Nurses (AORN) issued guidelines that recommend the use of washes that contain 4 percent chlorhexidine gluconate (CHG) for at-home use prior to surgery, specifically the night before and the morning of surgery.¹⁰

The first step is encouraging a patient to wash at home in advance of surgery is important. Secondly, what the patient washes with can make a difference.

Chlorhexidine has been in use since the 1950s, but its practical value has “not been appreciated” until now, Trish Perl, MD, director of hospital epidemiology and infection control at Johns Hopkins has been quoted as saying.¹¹ Perl was the co-investigator of a study published in Critical Care Medicine in 2009 that showed that 2,650 intensive-care unit patients at six different U.S. hospitals who received a neck-to-toe sponge bath with a mild, 4 percent solution of CHG daily were 73 percent less likely to develop potentially deadly bloodstream infections.¹² CHG is the same antibacterial agent often used by surgeons for “scrubbing in” for an operation and by dentists as a potent mouthwash to guard against gum disease.¹³

Interestingly, even as far back as 1980, a 10-year prospective study of more than 85,000 patients by Cruse and Foord concluded that preoperative showering with CHG prior to surgery was a successful strategy for reducing microbial counts on the skin.^14,15

Much of the reason for using 4 percent CHG is that it bonds with the skin, immediately killing existing microbes and continuing to kill them for up to 6 hours. Because several applications of CHG help attain maximum antimicrobial benefit, repeated antiseptic showers are usually indicated.

The challenge with this strategy is translating this knowledge of antiseptic bathing to the patient concisely, quickly, and in language they can understand. The challenge continues, as compliance with preoperative instructions is always a concern. In the past, patients were often requested to stop at their local pharmacy on the way home from the preoperative appointment to buy a CHG wash. Realistically, a patient heading to surgery the following day is probably 1) frightened and anxious, thus not comprehending every instruction you give them, and only able to remember small bits of information and 2) balancing many other priorities and obligations that require attention before surgery as they will be away from home, the family and the workplace for some time.

Further, in the current economy, with healthcare budget crunches, it has not been financially feasible for hospitals and surgeons to provide washes to send home with patients. Now, that is changing. With the Centers for Medicare and Medicaid (CMS) now limiting what and how much they will cover of infections that are acquired during a hospital stay, healthcare facilities cannot afford to NOT provide patients’ with a pre-surgical home antimicrobial regimen that works.

In fact, for about $5 per patient, hospitals can send patients home with a kit containing a bottle of CHG antimicrobial cleanser, disposable washcloths and simple instructions on how and when to perform general skin cleansing. The instructions, while basic, are adapted from the American Red Cross and aim to help patients understand the importance of thorough bathing. Based on the response from nurses, this easy, plain language is exactly what patients need. This convenient product, which is purchased by providers, is just one of the latest ways healthcare companies are trying to support prevention of SSIs and help healthcare facilities stay safe and “clean.”

Other Uses

CHG is also used for patient skin preparation in the operating room and preoperative hand/forearm antisepsis due to its broad spectrum of antimicrobial activity and the fact that it is not inactivated by blood or serum proteins. In comparison to povidone-iodine, CHG has shown greater reduction in skin microflora and greater residual activity after a single application. For the surgical team, scrubbing immediately before donning sterile gowns and gloves is extremely important. While alcohol-based options have been gaining popularity as surgical hand scrub preparations, povidone-iodine and CHG remain the current agents of choice for most U.S. surgical teams. Of course, there are many factors that contribute to maximizing the benefit of these processes, but utilizing the antiseptic agent with the maximum protection and power is ideal.

Surgical Preparation Starts at Home

With this increased information, continuing studies and ongoing antimicrobial resistance, preventing infections as early as possible, even at home, is not only a trend, but a further step toward keeping infections out of the surgical suite. At the same time, it’s a smart financial decision for healthcare facilities and workers. A study by Nalini Rao, MD, in 2008 showed that a preoperative decolonization protocol (including chlorhexidine baths) for staph infection in total joint arthroplasty patients translated to an adjusted economic gain of approximately $230,000 to the facility.¹⁶

We all know preventing SSIs is about much more than economic gain. It’s about saving lives and healing people. But, when there is something so simple and effective that can be done for low cost, we must work together to institute regimens and protocols that make sense and make us all healthy.

References

1. National Geographic, http://science.nationalgeographic.com/science/health-and-human-body/human-body/skin-article.html.
2. Centers for Disease Control and Prevention. Guideline for Hand Hygiene in Health-Care Settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR 2002;51(No. RR-16).
3. Horan TC, Gaynes RP, Martone WJ, Jarvis WR, Emori TG. CDC definitions of nosocomial surgical site infections 1992: a modification of CDC definitions of surgical wound infections. Infect Control Hosp Epidemiol 1992;13:606-8.
4. Institute for Healthcare Improvement. (n.d.). Surgical Site Infections. Retrieved May 2010, from IHI.org: http://www.ihi.org/IHI/Topics/PatientSafety/SurgicalSiteInfections/.
5. Institute for Healthcare Improvement. (n.d.). Surgical Site Infections. Retrieved May 2010, from IHI.org: http://www.ihi.org/IHI/Topics/PatientSafety/SurgicalSiteInfections/.
6. Institute for Healthcare Improvement. (n.d.). Surgical Site Infections. Retrieved May 2010, from IHI.org: http://www.ihi.org/IHI/Topics/PatientSafety/SurgicalSiteInfections/.
7. Institute for Healthcare Improvement. (n.d.). Surgical Site Infections. Retrieved May 2010, from IHI.org: http://www.ihi.org/IHI/Topics/PatientSafety/SurgicalSiteInfections/.
8. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR, the Hospital Infection Control Practices Advisory Committee. Guideline for the prevention of surgical site infection, 1999. Infect Control Hosp Epidemiol 1999;20:247-280.
9. Mangram AJ, Horan TC, Pearson ML, Silver LC, et al. Guideline for Prevention of Surgical Site Infection, 1999. Infection Control and Hospital Epidemiology, 247-78.
10. 2009 AORN Perioperative Standards and Recommended Practices; AORN Recommended Practices for Preoperative Patient Skin Antisepsis; Recommendation I, 1.a. and 1.a.1.  
11. Surgical Scrub Solution: Chlorhexidine Bathing Is Cheap And Effective Means Of Protecting Patients From Superbugs. (2009, September 8). Retrieved February 22, 2010, from Science Daily: http://www.sciencedaily.com/releases/2009/09/090904103351.htm.
12. Climo MW, Sepkowitz KA, Zuccotti G, et al. The Effect of Daily Bathing with Chlorhexidine on the Acquisition of Methicillin-resistant Staphylococcus aureus, Vancomycin-resistant Enterococcus, and Healthcare-associated Bloodstream Infections: Results of a Quasi-experimental Multicenter Trial. <I>Crit Care Med<$>. 2009; 37(6):1858-1865. 
13. Surgical Scrub Solution: Chlorhexidine Bathing Is Cheap And Effective Means Of Protecting Patients From Superbugs. (2009, September 8). Retrieved February 22, 2010, from Science Daily: http://www.sciencedaily.com/releases/2009/09/090904103351.htm.
14. Cruse, P.J.E. and Foord, R.: A five-year prospective study of 23,649 surgical wounds; Arch. Surg., 107:206,1973.
15. Cruse, P.J.E. and Foord, R.: The Epidemiology of Wound Infection, A ten-year prospective study of 62,939 surgical wounds; Surgical Clinics of North America; Feb. 1980.
16. Rao N, Cannella B, Crossett L, et al. A preoperative decolonization protocol for staphylococcus aureus prevents orthopaedic infections. Clin Orthop Relat Res (2008) 466: 1343-1348.

Rhonda Lemmo is a manager at Mölnlycke Health Care in Norcross, Ga. and a Registered Nurse (RN) and Certified Nurse of the Operating Room (CNOR).