What is a step in the process of skin preparation prior to surgical procedure?
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A Practitioner working in the Operating Theatres, who has completed their dual role competencies for Skin Preparation and Draping, Show
Dual Role When a Perioperative Scrub Practitioner acting as the scrubbed person, intermittently during the operative procedure, acts as an assistant to the Operating Clinician, working within defined criteria. Operating Clinician Surgeon/ Practitioner performing the surgery. Medical Assistant A doctor acting as an assistant for a surgical procedure. Surgical Care Practitioner (SCP) A registered healthcare professional (nurse, ODP or other allied health professional) who has extended the scope of their practice to work as a member of a surgical team performing surgical intervention, preoperative & postoperative care under the supervision of the Consultant Surgeon. Surgical First Assistant/ Advanced Scrub Practitioner (SFA/ASP) A registered Nurse or Operating Department Practitioner who provides continuous competent and dedicated assistance under the direct supervision of the operating surgeon throughout the procedure, whilst not performing any form of surgical intervention (PCC 2018).check for latest version
Summary of GuidelineThis guideline aims to support the appropriate selection and use of skin preparation solutions for patients undergoing surgical procedures. AimsTo improve the selection and use of skin preparation solutions within the perioperative environment. BackgroundSurgical Site Skin Preparation refers to the preoperative treatment of skin. This does not only refer to the surgical site but a larger region surrounding the incision site to allow access. The aim of the skin preparation process is to reduce the microbial load on the skin before a surgical incision or invasive procedure is undertaken. AllergiesThe allergy status of the patient must be checked prior to skin preparation including any known allergies to Chlorhexidine, Iodine or other products. All available reference sources must be checked i.e. eMeds, ppm+ and paper records Selection and Use of Surgical Skin Preparation SolutionsPrior to Skin Prepping Only operating clinicians, medical assistants, surgical care practitioners, surgical first assistants or scrub practitioners deemed as competent may undertake surgical skin preparation. Scrub practitioners must complete the relevant Dual Role Competency in order to be deemed competent. Assessable via Leeds Health Pathways: The whole team must protect the patient’s dignity both prior to and during skin preparation, only uncovering the necessary area immediately prior to preparation. Hair should only be removed if absolutely required. It should be done as close to the time of surgery as possible. The only recommended method is by electric/ battery operated clippers (NICE 2019) General Considerations There are two main antiseptic agents used for skin preparation:
They are available in either an aqueous or alcohol-based form. There is limited evidence to suggest that one agent is better than another. NICE (2019) update of clinical guideline 74, shows evidence indicating a beneficial effect of Chlorhexidine over povidone-iodine but it was thought the evidence was insufficient to change the guidance choice of antiseptic solution Staff members preparing patients skin must be aware of the flammability characteristics of the antiseptic alcohol solutions used in their specialty. Alcohol can cause burns by direct application of diathermy to the liquid alcohol solution or through an accumulation of alcohol fumes collecting under the surgical drapes which can then catch fire. Therefore it is essential to ensure all skin prep solutions are allowed to dry by evaporation. Skin antiseptic may be confused with medication if both are placed in unlabelled gallipots on the sterile field. Therefore skin antiseptics should be removed from the sterile field immediately after use and medications must always be drawn directly from source ampoule or bottle using a closed system method. How to select appropriate antiseptics? Expert guidance supports the use of alcohol-based skin preparation solution where possible (). Selection of CHG or PI depends on the patient, the site of incision and nature of procedure and should therefore be guided by local policy (). Children and neonates Special consideration should be taken with choice of skin prep solution in children and neonates. Evidence is lacking re the use of antiseptic solutions in both neonates and pre term infants as shown in a review by S Sathiyamurthy, J Banerjee et al, (2016). NICE guidelines for the prevention and Treatment of Surgical Site infections (2019, last updated 2020) covers preventing and treating surgical site infections in adults, young people and children who are having a surgical procedure involving a cut through the skin. These recommendations include preparation of the skin at the surgical site immediately before incision using an antiseptic (aqueous or alcohol-based) preparation: povidone-iodine or chlorhexidine being most suitable. First choice unless contraindicated or the surgical site is next to a mucous membrane Alcohol-based solution of chlorhexidine At the time of publication (April 2019), 0.5% chlorhexidine in 70% alcohol solution (Hydrex; Prevase) was licensed for 'preoperative skin disinfection prior to minor surgical procedures' and 2.0% chlorhexidine in 70% alcohol applicators (ChloraPrep) was licensed for 'disinfection of the skin prior to invasive medical procedures'. Some formulations of chlorhexidine in alcohol were off label for this use. Alternative if the surgical site is next to a mucous membrane Aqueous solution of chlorhexidine At the time of publication (April 2019), 4.0% aqueous chlorhexidine (Hibiscrub) was licensed for 'preoperative and postoperative skin antisepsis for patients undergoing elective surgery'; however, relevant instructions were limited to use as a body wash to be used before the person enters the operating theatre. Other formulations of aqueous chlorhexidine were off label for this use. Alternative if chlorhexidine is contraindicated Alcohol-based solution of povidone-iodine At the time of publication (April 2019), 10% povidone-iodine alcoholic solution (Videne alcoholic tincture) was licensed for 'topical application'. 10% povidone-iodine (Betadine Alcoholic solution) was licensed for 'antiseptic skin cleanser for major and minor surgical procedures'. Other formulations of povidone-iodine alcoholic solution were off label for this use. If both an alcohol-based solution and chlorhexidine are unsuitable Aqueous solution of povidone-iodine At the time of publication (April 2019), 7.5% povidone-iodine surgical scrub solution (Videne) was licensed for disinfecting the site of incision prior to elective surgery' and 7.5% povidone-iodine (Betadine surgical scrub) was licensed for 'preoperative preparation of patients' skin'. 10% iodine antiseptic solution (Videne) was licensed for 'disinfection of intact external skin or as a mucosal antiseptic' and 10% povidone-iodine solution (Standardised Betadine antiseptic solution) was licensed for 'preoperative and postoperative antiseptic skin cleanser for major and minor surgical procedures'. Other formulations of povidone-iodine aqueous solution were off label for this use. If the operating clinician favours the use of ChloraPrep applicators: Standard operating procedure for the insertion and maintenance of peripherally inserted central (PIC) lines in neonates Storage Preparation name Storage conditions Expiry / disposal Chloraprep Flammable. This medicinal product does not require any special temperature storage conditions. Store in the original packaging; applicator is sterile unless seal is broken. Avoid exposure of the container and contents to naked flames during use, storage and disposal. This product is for single use only. Any unused product or waste material should be discarded in accordance with local requirements. No additional environmental precautions for disposal are necessary. Hydrex Pink Do not store above 25°C. Store in the original package. Nil information listed, use expiry date listed on product. Hydrex Clear Do not store above 25°C. Store in the original package. Nil information listed, use expiry date listed on product. Videne alcoholic Do not store above 25°C. Store in the original package. Nil information listed, use expiry date listed on product. Videne antiseptic Do not store above 25°C. Store in the original package. (see below additional information if warming the solution is required e.g. for neonates/children) Nil information listed, use expiry date listed on product. Warmed Videne antiseptic/ Betadine As supported by Leeds Medicines Advisory Service, St James' University Hospital, Leeds Teaching Hospitals NHS Trust Stability data for Videne antiseptic shows no alteration to the product when stored at up to 40°C for 12 months. However, when the product is warmed this it is being used outside the product license. Another product (Betadine) has stability data for up to 6 months at 37.5°C. Some standardisation of approach is helpful. Whilst using to the original expiry date isn't supported by the manufacturer's information, storage for up to 6 months at elevated temperatures would be supportable.
Unisept 0.05% STERETS Chlorhexidine Gluconate Do not store the product above 25°C. Store the sachets in the outer container (plastic pouch).
Use expiry date listed on product.
0.1% Chlorhexidine Gluconate 1 in 1000 sterile solution As supplied by Huddersfield Pharmacy Specials (HPS)
The product is prepared by HPS as an unlicensed medicine by the dilution of Chlorhexidine gluconate 20% concentrated solution with Water for Injection and sterilised by moist heat at 121°C for 15 minutes. The product has been used for skin preparation (although more concentrated solutions are generally used) and bladder irrigation. This particular concentration is used by various hospitals.
Use expiry date listed on product. Storage should be in a locked cupboard away from direct sunlight or artificial light. Chlorhexidine solutions will darken on storage in the light and on ageing. The shelf life of the product is 2 years stored below 25°C, not refrigerated, protected from light. Once opened: Discard remaining solution after procedure. Chlorhexidine solutions are very toxic to aquatic life with long lasting effects. Avoid release to the environment. Collect spillages. Dispose of the contents as pharmaceutical waste. EscalationAction to be taken if a problem is identified ProvenanceRecord:5949Objective:To provide evidence-based recommendations for appropriate selection and use of skin preparation solutions. Clinical condition:Target patient group:All surgical patientsTarget professional group(s):MidwivesSecondary Care Doctors Secondary Care Nurses Allied Health Professionals Adapted from: Evidence baseReferences and Evidence levels:
Approved ByTrust Clinical Guidelines Group Document historyLHP version 2.0 Related informationAppendix 1 Properties of active agents in pre-operative skin preparations
Active Antiseptic Agent Chlorhexidine Iodophors (PI) Alcohol Mechanism of action Disrupts cell membrane Releases iodine which oxidises Denatures cell wall protein Preparation strength 0.5%; 2% 7 – 10% 70% isopropyl or ethyl alcohol Quick kill High (up to 48hrs)
Rapid Persistent activity Moderate Moderate None Use on eyes No (damage to cornea) Dilute 1:1 10% solution with No Use on ears No (damages middle ear) Yes external (caution - ototoxic if it enters the inner ear) No Use on mouth Use 0.12% oral rinse Yes No Use on genital area No Yes No Use on tissues No No No Contraindications
• Sensitivity or allergy • Sensitivity or allergy • Sensitivity or allergy Cautions
• Neonates • Neonates • Neonates • Neonates
 Appendix 2 SURGICAL SITE – skin prep area dependent on surgical/ invasive procedureAlways follow Manufacturer’s Instructions for Skin Prepping Solutions Abdomen Start at umbilicus then discard this applicator/swab/sponge - work out in concentric circles. Cover up to nipple line and down to upper thighs and down abdominal sides dependent on procedure Groin Incision site then out in concentric circles to level of umbilicus down abdominal side, upper thigh and pubic region/ scrotum Chest From neck to below diaphragm, to include upper arm, axilla and across sternum/ spine of opposite side to incision if unilateral, dependent on surgery. If bilateral or midline, include both sides Back If prone neck to sacrum and down sides dependent on surgery Do not use Chlorhexidine gluconate or alcohol skin prep on brain/ meninges/ spinal cord Neck Prep from incision site and out in concentric circles Head/ Face/ Scalp Do not use Chlorhexidine gluconate or alcohol skin prep near or on/in the eyes – it may cause corneal damage Eyes must be protected when prepping the surrounding area (this can be using a simple ophthalmic ointment and a film shield). If it is necessary to prep the eyelids do so from medial to lateral then working out in half circles to bridge of nose, cheek and forehead with gentle strokes. Povidone- iodine antiseptic solution 5% i.e. Povidone- iodine 10% mixed with the same volume of 0.9% saline solution may be used. For intraocular use Povidone-iodine 5% may be used On the scalp ensure the prep solution penetrates the hair and reaches the skin. There is a high risk of combustion with alcohol based preps as prep can take considerably longer to dry on hairy surfaces Do not use Chlorhexidine gluconate or alcohol skin prep on the middle ear or external ear with perforated tympanic membrane as they are ototoxic and can cause sensorineural deafness if it comes into contact with the inner ear Do not use povidone-iodine as skin prep in the ear canal as povidone-iodine can also be ototoxic if it enters the inner ear Place cotton wool ball in the external ear canal prior to skin prep. Start with external ear then extend to edge of hairline, cheek and jaw. Remove cotton wool ball if operating through the canal and document Do not use Chlorhexidine gluconate or alcoholic skin prep on mucous membranes e.g. mouth/ inner lip Shoulder Prep chest, neck, shoulder, upper arm, scapula, axilla - prepping the axilla last Arm For upper arm prep from mid forearm to shoulder including axilla, commencing at incision site - prepping the axilla last Hand Clean under fingernails prior to prep. Prep hand to mid forearm commencing with incision site. Complete one side of the hand prior to turning the hand then prep up the forearm in circular motions Perineum/ anus Prevent pooling of skin prep fluid under sacrum. Prep pubic region, then labia/scrotum to inner thighs. Prep anus last. Do not penetrate the anus with skin prep swab Vagina Do not use Chlorhexidine gluconate or alcohol skin prep on mucous membranes. Prevent pooling of prep fluid under sacrum. Prep pubic region to iliac crests then labia to inner thighs, prep vagina with clean skin prep swab, then the anus last Hip Start at incision site, working out in concentric circles to midline abdomen, to lateral costal margin, to buttock on affected side. Prep down the leg to knee, then prep groin and perineal area last (may require the leg raised during skin prep) Knee Elevate the leg. Prep circumferentially from incision site up to tourniquet (if used) and down to ankle. Ankle/ foot Clean under the toe nails prior to skin prep. Elevate the limb. Prep to mid-calf not forgetting between the toes Appendix 3 Skin Preparation solutionsAppendix 4 Joint RCS/MHRA Statement on use of Topical Chlorhexidine for Skin Preparation Prior to Surgery (2015)Statement on the use of topical chlorhexidine for skin preparation prior to surgery Topical chlorhexidine is a common disinfectant used to prepare the skin prior to surgery in order to prevent surgical site infection. However, it has been reported to the College that some operating theatres may be using biocidal chlorhexidine, a form of the chemical registered with the Health and Safety Executive (HSE), rather than products registered as medicines with the Medicines and Healthcare Products Regulatory Agency (MHRA). Chlorhexidine - MHRA position The manufacture and supply of a medicinal product containing chlorhexidine should be in accordance with Human Medicines Regulations. The product should have a marketing authorisation and there are restrictions on how it may be used.
Where an authorised product exists this should be used in preference to another product as only it will be fully supported by risk-benefit analyses as to its use for that specific purpose. Appendix 5 Surgical Skin Preparation Audit - Auditor to observeAudit standard: Auditor: Theatre/Procedure Room: Date:
Lead Anaesthetist: Please return this form to Joan Ingram, Head of Nursing, Theatres and Anaesthesia CSU, 2nd Floor, Bexley Wing link corridor, St James's University Hospital, Leeds, LS9 7TF. Email: [email protected] Surgical Skin Preparation 1 Site of surgical procedure
2 Skin preparation solution selected Solution: Concentration: 3 Is the skin preparation solution selected suitable for use? Yes No
4 If no please state why:
5 Is the person preparing the patients skin deemed ‘competent’? Please check guideline for definition. Yes No
6 Which staff group does the member of staff preparing the patients skin belongs to? Operating Clinician Scrub Practitioner Surgical Care Practitioner (SCP) Surgical First Assistant/ Advanced Scrub Practitioner (SFA/ASP) 7 Did the person preparing the patients skin carry out the preparation using the recommended technique. Please refer to the guideline (Appendix two) Yes No
8 If no please state technique used: 9 Was the skin prep solution removed from the sterile field immediately after use? Yes No
10 Was the skin prep solution allowed to dry prior to draping? Yes No
11 Has the prep solution been documented in the patient record of care? Yes No
Equity and DiversityThe Leeds Teaching Hospitals NHS Trust is committed to ensuring that the way that we provide services and the way we recruit and treat staff reflects individual needs, promotes equality and does not discriminate unfairly against any particular individual or group. How is skin preparation before the surgery done?Preoperative/Preadmission Skin Preparation:
On the day of surgery, gently wipe the skin with either an alcohol or chlorhexidine based solution (i.e. 70% isopropyl alcohol, chlorhexidine gluconate) in the preoperative area or in the operating room to provide a preliminary cleanse of the entire surgical field.
Which step comes first in preparing a patient's skin for surgery?Step 1: Soap Scrub
A disinfectant soap is used in the first step of skin preparation. Commonly used soaps for preparing surgical patients contain chlorhexidine or povidone-iodophors as the main antibacterial agent.
What is skin preparation and how it is performed?Surgical site skin preparation is the preoperative treatment (cleaning and disinfection) of the patient's intact skin done prior to surgery within the operating room (OR). Carefully wash and clean the skin around the incision site.
When performing surgical skin preparation you should use?60%-95% alcohol is the most effective. Additionally, antiseptic solutions that contain alcohol, such as chlorohexidine with 70% alcohol, are less effective at higher alcohol concentrations since the denaturing of proteins does not easily occur in the absence of water.
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