Introduction
It is estimated that surgical site infections affect more than 5% of all surgery operations conducted on patients in the United States (Hemani, 2009, p. 2). Between 750, 000 and 1 million surgical site infections happen in the United States on a yearly basis (Edminston, 509). Current estimates show that surgical site infections are among the leading causes of patient mortality and morbidity during surgery. In fact, surgical site infections rank third in the number of reported incidences of health care associated infections according to the Centre for Disease Control and Prevention (Edminston, 509). Before dwelling on some of the strategies that may be used to decrease the risk of surgical site infections, it would perhaps be wise to understand what surgical site infections are. According to the Centre for Disease Control and Prevention (2012), a surgical site infection refers to an infection that manifests itself after surgery in the part or section of the body where the surgery has been done. The CDC (2012) states while some surgical site infections can be superficial in nature, that is, involve the skin only, others are more serious and severe and affect the tissues immediately beneath the skin as well as organs. Various strategies and methods of reducing the risk of surgical site infections have been proposed throughout the years. This essay aims to propose and comprehensively explore one method that can be effectively used to prevent surgical site infections. To prevent the risk and occurrence of surgical site infections, there should be the implementation of a standardized best practice surgical skin prep guidelines and a standardized surgical prep solution (chlorhexidine gluconate) in the operating room. This paper will show the correct way of utilizing this prep so as to reduce surgical site postoperative infections.
Evidence Based Solution
Many skin prep guidelines and solutions have been proposed and utilized throughout the years, but the problem of surgical site infections has persisted. This is perhaps an indication of the fact that to acquire better outcomes; there is a need to standardize surgical skin antiseptic protocol. Perioperative skin prepping is a ritual that is traceable to the 19th Century. Back in those days, one of the prepping solutions utilized was carbolic acid aerosol that was used to disinfect the patient skin before any surgical incision took place (Edmisnton, 2010, p.510). Over the years, other prepping solutions sprung up, and their usage in surgery spread.
The main goal of skin antisepsis before surgery is to reduce the burden of microbial organisms on the skin’s surface before surgery, therefore, decreasing wound contamination risk.
This paper proposes chlorhexidine gluconate as the standard solution to be used in skin antisepsis before surgery. One of the reasons why this compound should be used as the standard solution for skin antisepsis is because for the time that it has been used throughout the years, it has managed to create for itself an excellent record for both clinical efficacy and patient’s safety. This has been in a variety of clinical applications including the one of current interest; perioperative skin antisepsis (Edmisnton, 2010, p. 510).
The argument for the use of chlorhexidine gluconate as the standard solution for skin prepping sis supported by the fact that it exhibits an expansive spectrum of antibacterial activity (Edmisnton, 510). This activity is against both gram negative and positive non-spore forming bacteria (Edmisnton, 2010, p. 510).
Chlorhexidine gluconate should also be used as the standard skin prep solution because other antisepsis compounds or solution, it is not deactivated by the serum protein or the blood and in fact exhibits enduring antimicrobial action on the skin’s surface. Therefore, it the growth of microbes on the skin surface form any hours after its application.
The appropriateness of Chlorhexidine gluconate as the standard prepping solution has been documented in various literature publications. A perfect example is a study by Kaiser et al that showed that the use of Chlorhexidine gluconate was more effective than other antisepsis solutions such as povidone iodine in terms of reducing staphylococcal skin colonization (Edmisnton, 2010, p. 513). The CDC, as well as other related organizations such as the AORN, have endorsed Chlorhexidine gluconate as the choice antiseptic when it comes to skin prepping for surgery. In particular, research by both the CDC as well as other independent researcher shows that Chlorhexidine gluconate with a concentration of 4% is very effective in terms of surgical site infection prevention.
However, research seems to indicate the standardization of the guidelines and instructions of skin prepping can go an even longer way in preventing surgical site infections. According to Edminston (2010, p. 513), surgical site prevention would be even more effective if health care providers were able to give surgery patients a standardized set of guidelines or instructions to guide the application of the antiseptic solutions. Edmisnton also references a study involving clinical trials where the outcomes of surgical patients who had been prepped using the Chlorhexidine gluconate antiseptic was compared with those who had used other alternatives such as bar soaps, placebo or no preoperative cleaning. The results of the study showed that using Chlorhexidine gluconate for preoperative cleansing did not result in any significance reduction in surgical site infections mainly because in all the trials, no standard form of practice was used (Edminston 2010, p. 513). This again shows that using Chlorhexidine gluconate is not merely enough to completely solve the problem of surgical site infections; a uniform standard of practice is required.
This paper proposes several basic guidelines and instructions that should be standardized in all skin prepping exercises so as to reduce the risk of surgical site infections.
1. The antiseptic agent utilized in skin prepping procedures be approved by an appropriate body such as the CDC; in this case, the standard agent to be used is Chlorhexidine gluconate (Winnipeg Regional Health Authority, 2011).
2. That before the initiation of any skin preparation, the patient’s skin must be devoid of gross contamination such as soil, dirt, oily particles and so on. For patients that exhibit conspicuously unclean or soiled skin, scrubbing and paint prep actions should be performed (Winnipeg Regional Health Authority, 2011).
3. For those procedures that do not entail perianal prep, Foley catheter insertion should be performed before the actual skin prep and by using a completely different set up
4. The personnel performing the prepping action should receive some form of training to familiarize themselves with the properties of the antiseptic agents, for instance, its flammability.
5. The antiseptic should be applied using specific devices or tools that include sponges and free cloth.
Actual Procedure
1. Wash hands with soap and antiseptic before having any contact with the patient.
2. Expose the particular site to be prepped and mark. Make sure not to expose other un-required or irrelevant region of the patient’s body in order to preserve both his warmth and privacy (Winnipeg Regional Health Authority, 2011).
3. Place an appropriate amount by volume of the Chlorhexidine gluconate solution onto a clean washcloth and start applying on the exposed site. Do not under any circumstances dip the cloth into the container with the antiseptic solution because by dipping back, one will simply be transferring microorganisms into the solution and then transferring them back into the site when the cloth is dipped again (Winnipeg Regional Health Authority, 2011).
4. Do not under any circumstances “back track” on an area or site that has been prepped already using the same sponge and cloth
5. Delicate sites such as eyes, trachea, occluded vessels, and arteries should be prepped very carefully (Winnipeg Regional Health Authority, 2011).
6. Ensure that the prepped area is large or extensive enough to accommodate unexpected extension of incisions, the potential shift of drape fenestration amongst other related actions.
7. Use the principle of “clean to dirty” but never vice versa
8. The prepping solution applied on a particular site should not be wiped off; instead, it should be allowed to dry by itself.
9. After surgery, a postoperative assessment of the skin should be performed to identify defects such as areas where pooling of the solution might have occurred.
Change Model
The recommendation given in the above discussion will follows the Lippit’s Change model. The particular change that is proposed by this recommendation is the standardization of practice surgical skin prep guidelines to reduce the risk of surgical site infections in the hospital. This model is comprised of seven distinctive stages. The first stage is the diagnosis of the problems which in this case is surgical site infections. The second stage assesses the as well the capacity and motivation for change (Lippitt et al, 1958). The motivation for the change is to increase patient health outcomes after surgical operations. The third phase of this change model involves the assessment of the motivation and resources of the agent of change (Lippitt et al, 1958). The fourth stage is of particular relevance to this project surgical site infection prevention as it involves defining the progressive stages of the change. This is where the concept of standardized prep guidelines comes in. The fifth stage involves ensuring the responsibilities and roles of the change agent are clear to everyone. In regards to this project every stakeholder including the surgeon, the patients nurse and hospital management are made aware of their role in establishing and implementation the use of standardized prep solution and standardized prep guidelines. The next change will involve maintain the change through various measurement and assessment tools and making corrective measures. Some of these measures will be mentioned later in the paper. Finally, the final stage will involve the new change aspect becoming part and parcel of the organization. Here the standardized prep solution together with standardized solution will become an inseparable aspect of surgical related care.
The expected outcomes of the listed guidelines include:
1. Significant reduction of the transient and resident microbial activity at the site of surgery before actual incision takes place (Winnipeg Regional Health Authority, 2011)
2. Significant minimization of rebound microbial growth and activity during both the intraoperative as well as the post-operative periods of surgery.
3. Prevent the occurrence of injuries to the patient during the pre-operative skin prep
4. Significantly reduce post-surgical site infection risk
5. Standardization of procedures will result in fewer errors, less water and better quality products for both the patient and the organization.
6. Decreased levels of patient mortality and morbidity due to enhanced and more effective skin prepping that results from the standardization of the process including the use of a standard antiseptic.
7. Decreased lengths of stays at the hospital after the surgery. This is because proper prepping will facilitate faster surgical wound healing and at the same time reduce the chances of wound re-infection
8. Reduce the overall cost of healthcare for the patient (Butler, 2013).
Measurement of Performance
The measurement of performance in the process of standardizing the skin prepping process should involve the tracking of surgeons as well as the support staff. These individuals must be tracked to make sure that they are abiding by the standard guidelines of pre-surgery skin prepping (Butler, 2013).
The second aspect of measurement and evaluation should be conduction infection control compliance audits for several tasks that make sure that frontline practice in actual sense matches what is reflected in health or medical records (Butler, 2013). This is because some unscrupulous individuals may indicate wrongly medical records that are meant to show abidance to the formal skin prep guidelines when in actual sense, the guidelines are not followed, and the outcomes are extremely exaggerated.
Expected outcomes should be listed and described before the prepping process. This should be in the form of descriptive statistics. These outcomes should then be appropriately compared with actual outcomes, for instance, the number of surgical site infections after the surgery are compared with the expected number of such incidences after the use of the standardized best practice surgical skin prep guidelines.
Utilization of new Modalities of Scholarship
Before the change takes, place, initial education of all stakeholders is to be performed so that they can all become acquainted with the supportive evidence or indicators of the change initiative at the hospital. Proper teaching or education of all stakeholders in this proposed change initiative will ensure that the project goes on successfully and that everyone is at par with the guidelines and requirements of the project.
Conclusion
Surgical site infection continue to devastate both surgical patients as well medical practice across health institutions and consequently, an appropriate strategy is needed to ensure the risk for this infection is reduced. This paper has proposed one strategy that if implemented will significantly reduce the risk for this, infection that is responsible for a huge level of patient mortality and morbidity. The proposed strategy is the use of chlorhexidine gluconate as the standardized surgical prep solution accompanied by the formulation and implementation of standardized best practice surgical skin prep guidelines. This strategy is to be implemented in accordance with the Timothy Galpin’s Change model and once it has gained ground, it will have a lot of positive health outcomes not only for the patients but for the health institutions as well.
References
Centers for Disease Control and Prevention. (2012, May 17). Surgical Site Infection (SSI). Retrieved September 28, 2014, from http://www.cdc.gov/hai/ssi/ssi.html
Hemani, M. L., & Lepor, H. (2009). Skin preparation for the prevention of surgical site infection: which agent is best?. Reviews in urology, 11(4), 190.
Edmiston Jr, C. E., Okoli, O., Graham, M. B., Sinski, S., & Seabrook, G. R. (2010). Evidence For Using Chlorhexidine Gluconate Preoperative Cleansing To Reduce The Risk Of Surgical Site Infection.AORN, 92(5), 509-518.
Lippitt R, Watson J, Westley B (1958) Dynamics of Planned Change. Harcourt, Brace, New York
Butler, Sharon L. (2013). Standardizing Surgical Skin Antiseptic Protocols.
Winnipeg Regional Health Authority. (2011). Bets Practice Guidelines
