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The Guideline for Preoperative Patient Skin Antisepsis was approved by the AORN Guidelines Advisory Board and became effective as of May 13, 2021. The recommendations in the guideline are intended to be achievable and represent what is believed to be an optimal level of practice. Policies and procedures will reflect variations in practice settings and/or clinical situations that determine the degree to which the guideline can be implemented. AORN recognizes the many diverse settings in which perioperative nurses practice; therefore, this guideline is adaptable to all areas where operative or other invasive procedures may be performed.

Purpose

This guideline provides perioperative registered nurses (RNs) and other perioperative team members with evidence-based practice guidance for preoperative patient skin antisepsis to promote patient safety and reduce the risk of surgical site infection (SSI). Topics include decolonization for Staphylococcus aureus; preoperative bathing; hair removal; selection of surgical site antiseptics; application of surgical site antiseptics; safe handling, storage, and disposal of antiseptics; and skin antisepsis as part of SSI prevention bundles.

The goal of preoperative patient skin antisepsis is to reduce the patient’s risk of developing an SSI by removing soil and transient microorganisms at the surgical site.1  Reducing the amount of bacteria on the skin near the surgical incision lowers the risk of contaminating the surgical incision site.1  As part of preparing the skin for antisepsis, preoperative decolonization, preoperative bathing, and hair management at the surgical site contribute to a reduction of microorganisms on the skin.2-5  Effective skin antiseptics rapidly and persistently remove transient microorganisms and reduce resident microorganisms to subpathogenic levels with minimal skin and tissue irritation.1 

Perioperative RNs play an essential role in developing protocols for preoperative decolonization and preoperative bathing; selecting and applying preoperative patient skin antiseptics; facilitating hair removal when necessary; and implementing SSI prevention bundles.

The following topics are outside the scope of this document: patient skin antisepsis after incision; antiseptic irrigation (See the AORN Guideline for Sterile Technique6 ); preoperative patient skin antisepsis with no incision; patient skin antisepsis for postoperative incision site care, including suture removal; patient bathing not intended for surgical preparation; decolonization for Staphylococcus aureus not intended for surgical preparation; mechanical and oral antimicrobial bowel preparation; adhesive incise drapes (See the AORN Guideline for Sterile Technique6 ); and preoperative prophylactic antibiotic selection.

Evidence Review

A medical librarian with a perioperative background conducted a systematic search of the databases Ovid MEDLINE®, Ovid Embase®, EBSCO CINAHL®, and the Cochrane Database of Systematic Reviews. The search was limited to literature published in English from January 2014 through January 2020. At the time of the initial search, weekly alerts were created on the topics included in that search. Results from these alerts were provided to the lead author until June 2020. The lead author requested additional articles that either did not fit the original search criteria or were discovered during the evidence appraisal process. The lead author and the medical librarian also identified relevant guidelines from government agencies, professional organizations, and standards-setting bodies.

Search terms included administration (cutaneous), administration (topical), alcohol, anti-infective agents (local), antiseptic cloth, antiseptic shower, antiseptic solution, antisepsis, artificial nails, baby shampoo, bathing, benzalkonium chloride, Betadine, Betasept, body jewelry, body piercing, burns (chemical), care bundle, castile, cesarean section, chemical burns, ChloraPrep, chlorhexidine*, chlorhexidine alcohol, chlorhexidine wipe, chloroxylenol, clipp*, ClipVac, cost-benefit analysis, cross infection, depilat*, delivery of health care (integrated), dermatitis, disinfectant, Duraprep, ExCel AP, fingernails, fires, flammab*, Hyamine, hair removal, health care delivery (integrated), Hibiclens, impaired wound healing, infection prevention, iodine compounds, iodophors, jewelry, local anti-infective agents, male genitalia, mucous membrane, nail polish, nails, nasal cavity, nasal decolonization, nonshaved, Nozin, open wound, parachloroxylenol, patient care bundles, PCMX, penis, perioperative nursing, pHisoHex, post-natal infection, povidone-iodine, practice guidelines, practice guidelines as topic, preoperative antisepsis, preoperative bathing, preoperative care, preoperative shower, preoperative wash, program evaluation, prosthetic joint infection, PVP-I prep, quality improvement, razor, scrotum, shaving, shellfish, skin antisep*, skin paint, skin prep, skin scrub, skin sensitivity, sterile prep solution, sterile preparation, surgery (operative), surgical fires, surgical patients, surgical procedures, surgical procedures (operative), surgical site infection, surgical skin preparation, surgical wound infection, tape, Techni-Care, total joint replacement, treatment outcome, triclosan, vacuum hair, vagina, vaginal cleansing, vaginal irritation, vaginal vault, vaginitis, wound infection, ZuraGard, and 2-propanol.

Included were research and non-research literature in English, complete publications, and publications with dates within the time restriction when available. Excluded were non-peer-reviewed publications and older evidence within the time restriction when more recent evidence was available. Editorials, news items, and other brief items were excluded. Low-quality evidence was excluded when higher-quality evidence was available, and literature outside the time restriction was excluded when literature within the time restriction was available (Figure 1).

Figure 1
Flow Diagram of Literature Search Results

Flow Diagram of Literature Search Results

Adapted from Moher D, Liberati A, Tetzlaff J, Atman DG; The PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA Statement. PLoS Med. 2009;6(6):e1000097.

Articles identified in the search were provided to the project team for evaluation. The team consisted of the lead author and one evidence appraiser. The lead author and the evidence appraiser reviewed and critically appraised each article using the AORN Research or Non-Research Evidence Appraisal Tools as appropriate. A second appraiser was consulted in the event of a disagreement between the lead author and the primary evidence appraiser. The literature was independently evaluated and appraised according to the strength and quality of the evidence. Each article was then assigned an appraisal score. The appraisal score is noted in brackets after each reference as applicable.

Each recommendation rating is based on a synthesis of the collective evidence, a benefit-harm assessment, and consideration of resource use. The strength of the recommendation was determined using the AORN Evidence Rating Model and the quality and consistency of the evidence supporting a recommendation. The recommendation strength rating is noted in brackets after each recommendation.

Note: The evidence summary table is available at http://www.aorn.org/evidencetables/.

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