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Katherine J. Ganzon, BSN, RN.

Background: Why is skin antisepsis important?
The preoperative preparation of the skin with the use of antiseptic solutions, prior to surgical incision has long been standard practice. Research evidence shows that this practice significantly reduces the microbial count on the skins surface, thereby decreasing the incidence of postoperative surgical site infections (SSIs). However, the evidence behind the actual method of application of such antiseptic solutions remains unclear.

Evidence-based research say?





There are no conclusive clinical studies that compare circular and back-and-forth skin antisepsis techniques, in regard to its microbial count reduction, or reduction of SSIs. Thus, the methods of application that are listed in this review are primarily based on theoretical rationales and not statistically significant scientific data.

Implications for practice: Fundamental principles to consider when performing skin antisepsis Ensure the skin is clean (not visibly soiled) and dry prior to applying the skin antiseptic solution Begin cleaning at the centre of the intended surgical site and continue to the periphery of the area Never bring a soiled applicator back over a previously prepared surface The prepared area should be large enough to extend the incision or create new incisions The application of the skin preparation may need to be modified, depending on the condition of the skin (e.g. burns) or location of the incision site (e.g. face) Do not blot or dry the antiseptic solution Allow the antiseptic solution to dry on the skin before applying any drapes over the area Pooling of excess liquid below the patient should not be allowed to occur Skin disinfectants should be labelled with the date when first opened, and the expiry date must be adhered to

Method of application: Circular motion or back and forth scrubbing?

Many preoperative guidelines suggest that a gentle circular motion should be used when applying antiseptic solutions - starting at the centre (intended surgical site) and working outwards to the periphery. The rationale behind this practice is that the outward circular movement will ensure that no microbial matter from the periphery will be introduced to the surgical site.

Evidence-based practice: Why is it important?

Nurses and clinicians should continually strive to use the best available evidence to guide their practice. With the evidence-based practice model, health care can better keep in line with the latest technological advances and developments. Furthermore, such evidence-based practices can also provide opportunities for health care to become more individualized, and therefore more effective.

Figure 1.1 Circular motion

Figure 1.2 Back and forth scrubbing

On the other hand, there are also guidelines in existence, that encourage the application of friction to the patients skin, when applying the antiseptic solution. This is done by using a vigorous back and forth movement above the intended surgical site, moving downwards. The rationale behind this particular practice is that, the back and forth motion enables the solution, to better penetrate the top layers of the epidermis, and reduce microbial count more effectively.

Summary: Does the lack of research data infer that it does not matter how nurses and clinicians should perform skin antisepsis?
Unfortunately, due to ongoing time-constraints and financial issues, evidence-based research data will not always be readily available. Thus, the most current policies and guidelines in existence should be followed, to ensure that the nurse and or clinician will provide safest form of patient care.

References: 1. Hopper, W. & Moss , R. (2010). Common Breaks in Sterile Technique: Clinical Perspectives and Perioperative implications 2. Day, L. (2009) American Journal of Critical Care. vol. 18 no. 5 479-482 3. Surgical site infection (SSI) event. Centers for Disease Control and Prevention. Accessed May 10, 2012. 4. Ray-Barruel, G. & Rickard, C. (2009) Systematic Review of Infection Control Literature Relating to Intravascular Devices Accessed May 10, 2012. 5. Surgical site infection (SSI) event. Centers for Disease Control and Prevention. Accessed January 20, 2012. 6. Surgical Skin Antisepsis in Operating Theatres, Queensland Health Guideline (2013). Accessed May 10, 2012.