Preoperative skin preparation of cardiac patients

AORN Journal,  Nov, 2002  by Cynthia G. Segal,  Jacqueline J. Anderson

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Numerous in vitro studies have compared the effectiveness of prepping methods and agents against various pathogens. (18) In vivo studies are fewer and less conclusive, and each study differs in objectives and method of prepping. (19) One researcher specifically evaluated the use of a polyester antimicrobial incise drape in combination with various aqueous skin preparations, specifically 70% alcohol and 2% iodine in 90% aqueous alcohol compared to a specific povidone-iodine solution. The separation or "lifting" of the drape at the edges of the incision was related to a six-fold increase in infection. (20)

Other groups of researchers evaluated the effectiveness of the traditional povidone-iodine scrub paint preparation compared to the one-step iodophor/ alcohol water insoluble film using an iodophor impregnated incise drape on three different populations of patients (ie, patients undergoing CABG, general surgery, or total joint surgery). (21) Each group of researchers reported improvement in adhesion of the incise drape with the one-step iodophor/alcohol water insoluble film. They also reported the one-step film was as effective as the traditional five-minute scrub/paint preparation. No significant difference was found between the types of preps because of the small sample sizes and the generally low incidence of infection.

A group of researchers who studied patients undergoing CABG noticed a trend of lower incidence of infection using the one-step iodophor/alcohol water insoluble film, especially in older adult patients and patients with diabetes. (22) No studies, however, have compared the effects of different preoperative skin preparations on sternal SSI rates of patients undergoing CABG who are at high risk for infection. The purpose of the current initiative was to evaluate the effect of four different skin preparations on the incidence of sternal SSIs in patients undergoing CABG who were identified as high-risk by the model.

INITIATIVE PARAMETERS

After the internal review board of the hospital and the surgeons agreed to the proposal, the initiative was introduced to the nurses in the OR. They were educated on the predictor model and how to identify patients at high risk for sternal SSIs. The cardiovascular outcomes manager oriented the nurses on the use of the data collection sheet and how to randomly select one of the four predetermined prep methods (Table 1). Patients undergoing CABG who had one or more of the high-risk predictive factors were recognized preoperatively and asked to participate in the initiative. If they agreed, perioperative nurses initiated a data collection sheet and chose the prep method by drawing from a closed sack. Considering the surgeons' current practice and the extensive literature review, the four preps used were

* povidone-iodine paint (ie, group 1),

* povidone-iodine five-minute scrub with paint (ie, group 2),

* one-step iodophor/alcohol water insoluble film (ie, group 3), and

* one-step iodophor/alcohol water insoluble film with iodine impregnated incise drape (ie, group 4). Patients with an allergy to topical iodine or with a preexisting infection, indicated by white blood cell counts higher than 10,000 or by a temperature higher than 100.5[degrees]F (38.06[degrees]C), were excluded because their procedures were performed emergently.