Guidelines For Preoperative Patient Skin Antisepsis

Guidelines for Preoperative
Patient Skin Antisepsis

Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.
Developed and originally presented by
Amber Wood, MSN, RN, CNOR, CIC, CPN

Amber Wood is a Perioperative Nursing Specialist at AORN where she has
served as lead author for the AORN Guideline for Environmental Cleaning and
the AORN Guideline for Preoperative Patient Skin Antisepsis. Amber offers
clinical information to members via the AORN Consult Line and contributes
regularly to the Clinical Issues column in the AORN Journal. She serves as the
staff liaison to the CDC Healthcare Infection Control Practices Advisory
Committee (HICPAC) and is a member of the Association for Professionals in
Infection Control and Epidemiology (APIC). Amber’s clinical experience
includes infection prevention, pediatric perioperative nursing, and clinical
research. Amber is a doctoral student in public health nursing at University of
Colorado, Denver, and she is certified as a CNOR, infection prevention and
control professional (CIC), and pediatric nurse (CPN).
Objectives
• Discuss recent revisions in AORN’s guideline for preoperative

patient skin antisepsis.
• Describe the evidence supporting the guideline for
preoperative patient skin antisepsis.
Sections
• Introduction
• Preoperative Bathing & Hair Removal
• Selection
• Application & Handling
INTRODUCTION
Purpose
• Reduce the risk of the patient developing a surgical site

infection (SSI)
• Effective skin antiseptics rapidly and persistently remove

transient microorganisms and reduce resident microorganisms
to subpathogenic levels with minimal skin and tissue irritation.
Scope
• Guidance for preoperative patient skin preparation

• Recommendations
– I: Bathing
– II: Hair removal
– III: Selection of antiseptics
– IV: Application of antiseptics
– V: Safe handling, storage, and disposal of antiseptics
PREOPERATIVE BATHING &
HAIR REMOVAL
I. Preoperative Bathing
I.a. The patient should be instructed to bathe or shower before

surgery with either soap or a skin antiseptic on at least the night
before or the day of surgery. [1: Strong Evidence]
I.b. …develop a mechanism for evaluating and selecting products

for preoperative patient bathing. [2: Moderate Evidence]
Evidence Review
• Collective Evidence
– Patient bathing may reduce the microbial flora
• Limitations/Gaps
– Optimal bathing procedures
– Antiseptics vs. soaps (ie, plain, antimicrobial)
– Whole body or only the surgical site
– Optimal timing before surgery
– Optimal number of baths or showers
• Benefits outweigh harms
CHG-impregnated Cloths
• Growing body of evidence

• Unresolved issue
• Need more generalizable, high-quality research
– Healthy volunteers
– Orthopedic patients
II. Hair Removal
II.a. Hair at the surgical site should be left in place. [1: Strong
Evidence]
II.b. When necessary, hair at the surgical site should be removed

by clipping or depilatory methods in a manner that minimizes
injury to the skin. [1: Strong Evidence]
Evidence Review
– Hair at the surgical site should be left in place.
– When necessary, clipping may be associated with a lower SSI risk than
shaving with a razor.
– Old studies
– Inadequate sample sizes, no standard SSI definition
– No studies comparing clipping and depilatory
• Benefits outweigh harms of leaving hair in place, if hair is
managed (interfere with procedure, fire hazard)
Clipping Hair Outside the OR
• When feasible
• If not (eg, emergency, patient
anxiety), clip in a manner that
prevents dispersal of hair in the
OR
– Wet clipping
– Suction
[4: Benefits Balanced with Harms]
Patient Self-Removal
II.a.1. The patient should be instructed to leave hair in place at

the surgical site before surgery. [2: Moderate Evidence]
• “Do not remove the hair down there.”

– Patient education campaign
– Improved patient compliance from 41% to 27% in a 3-year period
– Multiple interventions implemented
• Additional research is needed
Ng W, Alexander D, Kerr B, Ho MF, Amato M, Katz K. A hairy tale successful

patient education strategies to reduce prehospital hair removal by patients
undergoing elective caesarean section. J Hosp Infect. 2013;83(1):64-67. [IIIB]
Shaving Hair of Male Genitalia
• Randomized controlled trial conflicts with recommendations to

clip rather than shave hair with a razor
– Clippers (n = 107) vs razors (n = 108)
– Outcomes: quality of hair removal, skin trauma, and SSI events
– Razors: less skin trauma, better hair removal, no increase in infections
– Wet or dry methods?
– Underpowered for SSI
• Additional research is needed
Grober ED, Domes T, Fanipour M, Copp JE. Preoperative hair removal on the
male genitalia: clippers vs. razors. J Sex Med. 2013;10(2):589-594. [IB]
Challenges & Advice
• Patients are not bathing preoperatively

– Evaluate instruction and mechanism for assessing compliance
– Surgeon’s office and inpatient units/ICUs
– Wash patient’s surgical site in preoperative holding area, if feasible
• Patients are shaving before surgery
– Develop a patient education campaign
• Surgeons prefer a shave with a razor
– Mutual respect, collaboration, and involvement in decision making
– Peer to peer discussions, organization culture
References
Bathing Hair Removal
• Webster J, Osborne S. Preoperative bathing or • Tanner J, Norrie P, Melen K. Preoperative hair removal
showering with skin antiseptics to prevent surgical site to reduce surgical site infection. Cochrane Database
infection. Cochrane Database Syst Rev. Syst Rev. 2011;11:CD004122. [IA]
2012;9:CD004985. [IA] • Broekman ML, van Beijnum J, Peul WC, Regli L.
• Jakobsson J, Perlkvist A, Wann-Hansson C. Searching Neurosurgery and shaving: what's the evidence? J
for evidence regarding using preoperative disinfection Neurosurg. 2011;115(4): 670-678. [IIIA]
showers to prevent surgical site infections: a systematic • Sebastian S. Does preoperative scalp shaving result in
review. Worldviews Evid Based Nurs. 2011;8(3):143- fewer postoperative wound infections when compared
152. [IIA] with no scalp shaving? A systematic review. J Neurosci
• Kamel C, McGahan L, Polisena J, Mierzwinski-Urban Nurs. 2012;44(3):149-156. [IIIA]
M, Embil JM. Preoperative skin antiseptic preparations
for preventing surgical site infections: a systematic Both
review. Infect Control Hosp Epidemiol. 2012;33(6):608-
617. [IIA] • National Institute for Health and Care Excellence
(NICE). Surgical site infection: prevention and
• Chlebicki MP, Safdar N, O'Horo JC, Maki DG. treatment of surgical site infection.
Preoperative chlorhexidine shower or bath for https://www.nice.org.uk/guidance/cg74. Accessed
prevention of surgical site infection: a meta-analysis. Am February 11, 2015. [IVA]
J Infect Control. 2013;41(2):167-173. [IIA]
SELECTION
III. Selection
A multidisciplinary team,
including perioperative RNs,
physicians, and infection
preventionists, should select
safe and effective antiseptic
products for preoperative
patient skin antisepsis.
Evidence Review
– No one antiseptic is more effective than another for preventing SSI
– Selection of a safe and effective preoperative skin antiseptic should be
based on individual patient need
– Most effective antiseptic
– Inadequate sample sizes
– Quality
Health Care Organization
III.a. The multidisciplinary team should develop a mechanism for

product evaluation and selection of preoperative skin antiseptics.
[2: Moderate Evidence]
• Review current research literature

• FDA requirements
– Category I in the Tentative Final Monograph (TFM) for Over-the-Counter
(OTC) Healthcare Antiseptic Drug Products
– "New Drug Approval" (NDA)
• Single-use containers
• Colored or tinted
FDA Approval Categories
Table 1. US Food and Drug Administration Categories of Patient Preoperative Skin
Preparations1
Active ingredient Category
Benzalkonium chloride IIIE
Chlorhexidine gluconate "New drug"
Chloroxylenol IIIE
Hexachlorophene II
Iodine tincture USP I
Iodine topical solution USP I
Povidone-iodine 5% to 10% I
Triclosan IIIE
Iodine Povacrylex/Isopropyl Alcohol2 New Drug2
E= Effectiveness
Reference
1. US Food and Drug Administration. Tentative Final Monograph for Healthcare Antiseptic Drug Products proposed rule. Fed Regist.
1994;59(116):31402-31452.
2. US Food and Drug Administration. New Drug Application (NDA) #21-586.
Alcohol
• Isopropyl alcohol 70% is • “Painting” with alcohol is a

NOT approved for fire risk (flammable and
preoperative patient skin clear)
antisepsis • Alcohol is not sterile; there
– Approved only for skin have been outbreaks
antisepsis before injections (eg, involving Bacillus cereus
IV start)
Patient Care Team
III.b. …select a safe, effective, health care organization-approved

preoperative antiseptic for the individual patient. [2: Moderate
Evidence]
Based on:
• Patient assessment
• Procedure type
• Review of the manufacturer’s instructions for use and
contraindications
Procedure Type
III.b.3 The preoperative antiseptic product should be selected

based on the procedure type. [4: Benefits Balanced with Harms]
• Eye
• Gynecologic
• Orthopedic
Allergies
III.b.1 …assess the patient for allergies and sensitivities to

preoperative skin antiseptics. [2: Moderate Evidence]
• Iodine, chlorhexidine, and alcohol

– Shellfish allergy is not related to iodine allergy
• Consider type of exposure (route) and frequency (single vs
repeat application)
Contraindications
III.b.8. …collaboratively evaluate the risks and benefits of using

Class II or Class III FDA-approved antiseptics or other
alternative solutions (eg, soaps, saline). [4: Benefits Balanced
with Harms]
• Allergy
• Anatomical location
• Wounds
Class II or IIIE
Table 1. US Food and Drug Administration Categories of Patient Preoperative Skin
Preparations1
Active ingredient Category
Benzalkonium chloride IIIE
Chlorhexidine gluconate "New drug"
Chloroxylenol IIIE
Hexachlorophene II
Iodine tincture USP I
Iodine topical solution USP I
Povidone-iodine 5% to 10% I
Triclosan IIIE
Iodine Povacrylex/Isopropyl Alcohol2 New Drug2
E= Effectiveness
Reference
1. US Food and Drug Administration. Tentative Final Monograph for Healthcare Antiseptic Drug Products proposed rule. Fed Regist.
1994;59(116):31402-31452.
2. US Food and Drug Administration. New Drug Application (NDA) #21-586.
Iodism
III.b.5. …consult the physician when selecting iodine antiseptics

for patients susceptible to iodism. [2: Moderate Evidence]
• Patients with burns, patients with thyroid disorders, neonates,

pregnant women, lactating mothers
• Consider type of exposure (route) and frequency (single vs
repeat application)
• May rinse with sterile solution (eg, saline) after achieving
contact times required by the manufacturer
Hairy Patients
III.b.4. …When using an alcohol-based skin antiseptic for

procedures involving an ignition source, hair at the surgical site
should be clipped before application of the antiseptic. [4: Benefits
Balanced with Harms]
• Leave the hair and choose an aqueous, water-based antiseptic

OR
• Clip the hair and choose an alcohol-based antiseptic
Challenges & Advice
• Organization will need to approve MANY products

– Indicate preferred antiseptic, may be procedure/anatomical location
specific
• No FDA-approved alternatives when contraindicated (allergy,
wounds)
– Make an organizational decision as evidence and products become
available
• Surgeon preference
– Mutual respect, collaboration, and involvement in decision making
– Peer to peer discussions, organization culture
References
• US National Library of Medicine. DailyMed. Vaginal Prep
http://dailymed.nlm.nih.gov/. • American College of Obstetricians and Gynecologists
• US Food and Drug Administration. Tentative Final Women's Health Care Physicians, Committee on
Monograph for Healthcare Antiseptic Drug Products Gynecologic Practice. Committee Opinion No. 571:
proposed rule. Fed Regist. 1994;59(116):31402- Solutions for surgical preparation of the vagina.
31452. Obstet Gynecol. 2013;122(3):718-720. [IVB]
• Dumville JC, McFarlane E, Edwards P, Lipp A, • Amstey MS, Jones AP. Preparation of the vagina for
Holmes A. Preoperative skin antiseptics for preventing surgery. A comparison of povidone-iodine and saline
surgical wound infections after clean surgery. solution. JAMA. 1981;245(8): 839-841. [IIIB]
Cochrane Database Syst Rev. 2013;3:CD003949. [IA] • Lewis LA, Lathi RB, Crochet P, Nezhat C.
• Maiwald M, Chan ES-Y. The forgotten role of alcohol: Preoperative vaginal preparation with baby shampoo
a systematic review and meta-analysis of the clinical compared with povidone-iodine before gynecologic
efficacy and perceived role of chlorhexidine in skin procedures. J Minim Invasive Gynecol.
antisepsis. PLoS ONE. 2012;7(9). [IIA] 2007;14(6):736-739. [IIA]
• Haas DM, Morgan S, Contreras K. Vaginal
Shellfish preparation with antiseptic solution before cesarean
• American Academy of Allergy Asthma and section for preventing postoperative infections.
Immunology. AAAAI Position Statement: The Risk of Cochrane Database Syst Rev. 2013;1:CD007892. [IB]
Severe Allergic Reactions from the Use of Potassium • Hadiati DR, Hakimi M, Nurdiati DS. Skin preparation
Iodide for Radiation Emergencies. [IVB] for preventing infection following caesarean section.
Cochrane Database Syst Rev. 2012;9:CD007462. [IA]
APPLICATION & HANDLING
IV. Application
Perioperative team members should apply the preoperative

patient skin antiseptic in a safe and effective manner.
IV.d. Skin antiseptics should be applied using aseptic technique

and according to the manufacturer’s instructions for use. [4:
Benefits Balanced with Harm]
Nonscrubbed Person
IV.c. A nonscrubbed perioperative team member should apply the

skin antiseptic using sterile technique. [4: Benefits Balanced with
Harm]
• Sterile gloves should be worn

• Nonsterile gloves may be worn
– If the applicator is of sufficient length to prevent contact of the gloved
hand with the antiseptic solution and the patient’s skin.
• Wear surgical attire that covers the arms
Pre-filled Applicators
IV.d.4. …follow the manufacturer's instructions for use (eg,

maximum and minimum surface area per applicator) to apply the
skin antiseptic with uniform distribution. [4: Benefits Balanced
with Harms]
Sample:
Scrub & Paint vs. Paint only
IV.d.6. …either scrub (ie, 7.5% povidone-iodine) and paint (ie,

10% povidone-iodine) or paint only may be used. [2: Moderate
Evidence]
• Conflicting evidence
• Need more research
• Regardless, the surgical site should be clean from soil and
debris before antisepsis (IV.b.)
Fingers & Toes
IV.d.7. …care should be taken to apply the antiseptic to all

surfaces between fingers or toes. [2: Moderate Evidence]
• Bag technique
• Need more research
Prepping the Mouth
IV.d.8. …care should be taken to prevent patient aspiration of the

antiseptic solution. [2: Moderate Evidence]
• Case report of pneumonitis after aspiration

– Throat pack used
– Advise NOT to irrigate the oral cavity
Chepla KJ, Gosain AK. Interstitial pneumonitis after betadine aspiration. J Craniofac
Surg. 2012;23(6):1787-1789. [VA]
Dry Times
IV.e. …dry for the full time recommended in the manufacturer's

instructions for use before sterile drapes are applied. [2:
Moderate Evidence]
• Safety & Efficacy
IV.g.3. …communicate use of flammable skin antiseptics as part

of the fire risk assessment involving the entire perioperative team
before beginning a surgical procedure. [1: Strong Evidence]
Prepping in Lithotomy
IV.f.3. A fluid-resistant pad should be placed under the patient's

buttocks... [2: Moderate Evidence]
• Added “fluid-resistant pad”

– Absorbent pad with fluid-resistant side
• Remove pad after antiseptic is dry and before sterile drapes are
applied
– If removed when wet, solution will continue to drip
Ergonomics
IV.h. When lifting and holding the patient's extremity or head …

minimize muscle fatigue. [2: Moderate Evidence]
• Use two hands for holding

• Obtain assistance
• Use an assistive device
(Combination of these methods)
AORN guidance statement: Safe patient handling and movement in the perioperative
setting. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2015:733-
752.
V. Handling, Storage, Disposal
• Land of regulatory
requirements
– Single-use containers
– Dilution
Single-use Containers
V.a. Skin antiseptics must be stored in the original, single-use

container. [1: Regulatory Requirement]
• FDA drug safety communication, Nov 2013

• Single-use packaging
• One time, one patient
Diluting Antiseptics
V.b. Skin antiseptics must not be diluted after opening. [1:

Regulatory Requirement]
• FDA drug safety communication, Nov 2013

• Do not dilute antiseptic products after opening
• Reduce product contamination
Challenges & Advice
• Wearing jackets while prepping

– Shedding skin & hair  Cover arms
– Protect the prep from contamination
• Button jacket
• Wear appropriate size
• Tape up the sleeve
• Long sleeve scrub tops
• Single-use jacket or gown (it doesn't have to be sterile)*
*Scrubbed team members should not prep
References
• Over-the-Counter Topical Antiseptic Bag Technique
Products: Drug Safety Communication - • Naderi N, Maw K, Thomas M, Boyce
FDA Requests Label Changes and DE, Shokrollahi K. A quick and effective
Single-Use Packaging to Decrease Risk method of limb preparation with health,
of Infection. US Food and Drug safety and efficiency benefits. Ann R Coll
Administration. Surg Engl. 2012;94(2):83-86. [IIB]
http://www.fda.gov/Safety/MedWatch/Sa • Incoll IW, Saravanja D, Thorvaldson KT,
fetyInformation/SafetyAlertsforHumanM Small T. Comparison of the effectiveness
edicalProducts/ucm374892.htm. of painting onto the hand and immersing
Accessed February 11, 2015. the hand in a bag, in pre-operative skin
• Guideline for a safe environment of care, preparation of the hand. J Hand Surg Eur
part 1. In: Guidelines for Perioperative Vol. 2009;34(3):371-373. [IIB]
Practice. Denver, CO: AORN, Inc; 2015: • Chou J, Choudhary A, Dhillon RS.
239-263. [IVA] Comparing sterile bag rubbing and paint
• Gottardi W. The influence of the on technique in skin preparation of the
chemical behaviour of iodine on the hands. ANZ J Surg. 2011;81(9):629-632.
germicidal action of disinfectant [IIC]
solutions containing iodine. J Hosp
Infect. 1985;6(Suppl A):1-11. [VA]
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Guidelines for Preoperative

Patient Skin Antisepsis

Amber Wood, MSN, RN, CNOR, CIC, CPN

• Discuss recent revisions in AORN’s guideline for preoperative

• Reduce the risk of the patient developing a surgical site

• Effective skin antiseptics rapidly and persistently remove

• Guidance for preoperative patient skin preparation

I.a. The patient should be instructed to bathe or shower before

I.b. …develop a mechanism for evaluating and selecting products

• Growing body of evidence

II.b. When necessary, hair at the surgical site should be removed

II.a.1. The patient should be instructed to leave hair in place at

• “Do not remove the hair down there.”

Ng W, Alexander D, Kerr B, Ho MF, Amato M, Katz K. A hairy tale successful

• Randomized controlled trial conflicts with recommendations to

• Patients are not bathing preoperatively

III.a. The multidisciplinary team should develop a mechanism for

• Review current research literature

• Isopropyl alcohol 70% is • “Painting” with alcohol is a

III.b. …select a safe, effective, health care organization-approved

III.b.3 The preoperative antiseptic product should be selected

III.b.1 …assess the patient for allergies and sensitivities to

• Iodine, chlorhexidine, and alcohol

III.b.8. …collaboratively evaluate the risks and benefits of using

III.b.5. …consult the physician when selecting iodine antiseptics

• Patients with burns, patients with thyroid disorders, neonates,

III.b.4. …When using an alcohol-based skin antiseptic for

• Leave the hair and choose an aqueous, water-based antiseptic

• Organization will need to approve MANY products

Perioperative team members should apply the preoperative

IV.d. Skin antiseptics should be applied using aseptic technique

IV.c. A nonscrubbed perioperative team member should apply the

• Sterile gloves should be worn

IV.d.4. …follow the manufacturer's instructions for use (eg,

IV.d.6. …either scrub (ie, 7.5% povidone-iodine) and paint (ie,

IV.d.7. …care should be taken to apply the antiseptic to all

IV.d.8. …care should be taken to prevent patient aspiration of the

• Case report of pneumonitis after aspiration

IV.e. …dry for the full time recommended in the manufacturer's

• Safety & Efficacy

IV.g.3. …communicate use of flammable skin antiseptics as part

IV.f.3. A fluid-resistant pad should be placed under the patient's

• Added “fluid-resistant pad”

IV.h. When lifting and holding the patient's extremity or head …

• Use two hands for holding

V.a. Skin antiseptics must be stored in the original, single-use

• FDA drug safety communication, Nov 2013

V.b. Skin antiseptics must not be diluted after opening. [1:

• FDA drug safety communication, Nov 2013

• Wearing jackets while prepping

*Scrubbed team members should not prep

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