Note from the Association of periOperative Nurses (AORN): Perioperative registered nurses (RNs) play a critical role in developing protocols for preoperative bathing, selecting and applying preoperative patient skin antiseptics, and facilitating appropriate hair removal when necessary. The original guideline document provides the perioperative RN 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).
- Patients should bathe or shower before surgery with either soap or an antiseptic.
- Hair removal at the surgical site should be performed only in select clinical situations.
- A multidisciplinary team including perioperative RNs, physicians, and infection preventionists should select safe and effective antiseptic products for preoperative patient skin antisepsis.
- Perioperative team members should apply the preoperative patient skin antiseptic in a safe and effective manner.
- Perioperative team members should review and follow the skin antiseptic manufacturer's instructions for use and safety data sheets (SDSs) for handling, storing, and disposing of skin antiseptics.
- Any condition requiring the use of surgical and other invasive procedures
- Surgical site infection (SSI)
Advanced Practice Nurses
To provide guidance for preoperative patient skin preparation, including preoperative patient bathing; preoperative hair removal; selection of skin antiseptics; application of antiseptics; and safe handling, storage, and disposal of antiseptics
Patients undergoing surgical and other invasive procedures
- Preoperative patient bathing with soap or antiseptic
- Preoperative hair removal (in select clinical situations only)
- Selection of safe and effective antiseptic products by multidisciplinary team
- Application of antiseptics in a safe, effective manner
- Utilization of manufacturer's instructions for the use, handling, storage, and disposal of skin antiseptics
- Bacterial load on skin
- Surgical site infections (SSIs)
- Skin irritation, allergic reaction, burn injuries, and other harms caused by skin antiseptics
- Urine iodine excretion, thyrotropin and thyroxine levels
Searches of Electronic Databases
A medical librarian conducted a systematic literature search of the databases MEDLINE®, CINAHL®, and the Cochrane Database of Systematic Reviews for meta-analyses, systematic reviews, randomized controlled and nonrandomized trials and studies, case reports, letters, reviews, and guidelines. Search terms included surgical skin preparation, skin preparation, skin prep, skin antisepsis, skin antiseptic, sterile preparation, disinfectants, local anti-infective agents, antiseptic solution, preoperative care, perioperative nursing, preoperative, surgical procedures, surgical wound infection, skin, skin care, paint, scrub, antiseptic shower, antiseptic cloth, chlorhexidine wipe, preoperative shower, preoperative wash, preoperative bathing, bathing and baths, hair removal, shaving, depilation, depilatory, nonshaved, razor, clipping, clipper, povidone-iodine, chlorhexidine, iodine, iodophors, iodine compounds, 2-propanol, alcohols, baby shampoo, isopropyl alcohol, alcohol-based, parachoroxylenol, chloroxylenol, PCMX, DuraPrep, pHisoHex, Prevantics, Hibiclens, Techni-Care, Chlora-Prep, Betadine, Betasept, PVP-I Prep, ExCel AP, Castile, iodophor, cyanoacrylates, tissue adhesives, chemical burns, skin diseases, dermatitis, skin sensitivity, surgical fires, fires, flammability, flammable, penis, vagina, mucous membrane, stoma, fingernails, nail polish, artificial nails, jewelry, body piercing, body jewelry, and subdermal implant.
The initial search, conducted on December 5, 2013, was limited to literature published in English between January 2006 and December 2013; however, the time restriction was not considered in subsequent searches. At the time of the search, the librarian also established weekly alerts on the topics included in the search and until February 2014, presented relevant alert results to the lead author.
Before the systematic search, the medical librarian had provided the lead author with a list of the citations from the 2008 revision of the Association of periOperative Registered Nurses (AORN) Recommended Practices for Preoperative Patient Skin Antisepsis for consideration for the 2014 revision. During the development of the guideline, the lead author requested additional articles that either did not fit the original search criteria or were discovered during the evidence appraisal process. Finally, the lead author and medical librarian identified relevant guidelines from government agencies and standards-setting bodies.
Excluded were non-peer–reviewed publications, studies that evaluated skin antisepsis as part of a bundle to prevent surgical site infection (SSI), and low-quality evidence when higher-quality evidence was available.
See Figure 1 in the original guideline document for a flow diagram of literature search results.
166 full-text sources were cited in the guideline.
Weighting According to a Rating Scheme (Scheme Given)
I: Randomized controlled trial (RCT) or experimental study, systematic review of all RCTs
II: Quasi-experimental study, systematic review of quasi-experimental studies or combination of quasi-experimental and RCTs
III: Non-experimental studies, qualitative studies, systematic review of non-experimental studies, combination of non-experimental, quasi-experimental, and RCTs, or any or all studies are qualitative
IV: Clinical practice guidelines, position or consensus statements
V: Literature review, expert opinion, case Report, community standard, clinician experience, consumer experience, organizational experience (quality improvement, financial)
Review of Published Meta-Analyses
Systematic Review with Evidence Tables
Articles identified in the search were provided to the project team for evaluation. The team consisted of the lead author and three evidence appraisers. The lead author divided the search results into topics and assigned members of the team to review and critically appraise each article using the Association of periOperative Registered Nurses (AORN) Research or Non-Research Evidence Appraisal Tools as appropriate. 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.
The collective evidence supporting each intervention within a specific recommendation was summarized, and the Association of periOperative Registered Nurses (AORN) Evidence-Rating Model was used to rate the strength of the evidence. Factors considered in the review of the collective evidence were the quality of evidence, the quantity of similar evidence on a given topic, and the consistency of evidence supporting a recommendation. The evidence rating is noted in brackets after each intervention.
1: Strong Evidence: Interventions or activities for which effectiveness has been demonstrated by strong evidence from rigorously-designed studies, meta-analyses, or systematic reviews, rigorously-developed clinical practice guidelines, or regulatory requirements
- Evidence from a meta-analysis or systematic review of research studies that incorporated evidence appraisal and synthesis of the evidence in the analysis
- Supportive evidence from a single well-conducted randomized controlled trial
- Guidelines that are developed by a panel of experts, that derive from an explicit literature search methodology, and include evidence appraisal and synthesis of the evidence.
1: Regulatory Requirement: Federal law or regulation
2: Moderate Evidence: Interventions or activities for which the evidence is less well established than for those listed under "1: Strong Evidence"
- Supportive evidence from a well-conducted research study
- Guidelines developed by a panel of experts which are primarily based on the evidence but not supported by evidence appraisal and synthesis of the evidence
- Non-research evidence with consistent results and fairly definitive conclusions
3: Limited Evidence: Interventions or activities for which there are currently insufficient evidence or evidence of inadequate quality.
- Supportive evidence from a poorly conducted research study
- Evidence from non-experimental studies with high potential for bias
- Guidelines developed largely by consensus or expert opinion
- Non-research evidence with insufficient evidence or inconsistent results
- Conflicting evidence, but where the preponderance of the evidence supports the recommendation
4: Benefits Balanced with Harms: Selected interventions or activities for which the Association of periOperative Registered Nurses (AORN) Recommended Practices Advisory Board (RPAB) is of the opinion that the desirable effects of following this recommendation outweigh the harms.
5: No Evidence: Interventions or activities for which no supportive evidence was found during the literature search completed for the recommendation.
- Consensus opinion
A formal cost analysis was not performed and published cost analyses were not reviewed.
External Peer Review
Internal Peer Review
The Guideline for Preoperative Patient Skin Antisepsis has been approved by the Association of periOperative Registered Nurses (AORN) Guidelines Advisory Board. It was presented as a proposed guideline for comments by members and others. The guideline is effective August 15, 2014.
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 in the original guideline document, as applicable. Also see the original guideline document for the systematic review and discussion of evidence.
Reduction in the risk of the patient developing a surgical site infection (SSI) by removing soil and transient microorganisms at the surgical site. Refer to the original guideline document for more information concerning benefits of specific interventions.
- The harms of preoperative patient bathing with an antiseptic may include skin irritation, allergic reaction, or unnecessary treatment with antiseptics.
- The benefits of a 4% chlorhexidine gluconate (CHG) shampoo may not outweigh the potential harms of CHG causing injury by contact with the eyes, ears, or mouth.
- Neonates, especially extremely premature neonates, are at an increased risk for skin irritation and chemical burns of the skin from both CHG and alcohol-based skin antiseptics.
- The harms of leaving the hair in place at the surgical site may include risk of fire. The risk of fire may be minimized by confining the hair with a water-soluble gel and non-metallic ties or with braids for longer hair.
- Some patients are susceptible to iodism from preoperative skin antisepsis with iodine and iodophor-based antiseptics. A literature review recommended minimizing neonatal iodine exposure because of the risk of significant iodine overload and severe transient hypothyroidism, especially in premature neonates with increased skin permeability and immature thyroid glands.
- Fragile skin or tissue, burns, and open wounds are at a high risk for skin injury during preoperative patient skin antisepsis. Vigorous skin antisepsis in areas of malignancy may potentially spread cancer cells.
- Flammable skin antiseptics are a fuel source and pose a fire hazard. The prevention of pooling of flammable skin antiseptics and allowing for the complete drying of the antiseptic to minimize the fire hazard is supported by published guidance. Disposal of unused flammable skin antiseptics must be handled in a manner to decrease the risk of fire and in accordance with local, state, and federal regulations.
- Refer to the original guideline document for additional discussion of potential harms of specific interventions. Also refer to Table 2 in the original guideline document for considerations and cautions for use of specific skin antiseptics.
- The presence of hair may contraindicate the use of flammable antiseptics according to manufacturers' instructions for use. A flammable antiseptic for preoperative skin antisepsis is contraindicated when the procedure involves an ignition source (e.g., electrosurgical unit [ESU], laser) and the solution is unable to dry completely in hair. According to the Centers for Medicare and Medicaid Services (CMS), alcohol-based skin antiseptics that wick into the patient's hair result in prolonged drying times. No evidence was found that describes the length or amount of hair that constitutes a fire risk during use of alcohol-based skin antiseptics.
- See Table 2 in the original guideline document for contradictions of specific preoperative skin antiseptics
- These recommendations represent the Association's official position on questions regarding optimal perioperative nursing practice.
- No attempt has been made to gain consensus among users, manufacturers, and consumers of any material or product.
- Compliance with the Association of periOperative Registered Nurses (AORN) guideline is voluntary.
- AORN's recommendations are intended as achievable and represent what is believed to be an optimal level of patient care within surgical and invasive procedure settings.
- Although they are considered to represent the optimal level of practice, variations in practice settings and clinical situations may limit the degree to which each recommendation can be implemented.
An implementation strategy was not provided.
Mobile Device Resources
Staff Training/Competency Material
|Wood A, Conner R. Guideline for preoperative patient skin antisepsis. In: 2015 guidelines for perioperative practice. Denver (CO): Association of periOperative Registered Nurses (AORN); 2014. p. 43-66. [166 references]|
Not applicable: The guideline was not adapted from another source.
Association of periOperative Registered Nurses - Professional Association
Association of periOperative Registered Nurses (AORN)
Association of periOperative Registered Nurses (AORN) Recommended Practices Advisory Board
Lead Author: Amber Wood, MSN, RN, CNOR, CIC, CPN, Perioperative Nursing Specialist AORN Nursing Department Denver, Colorado
Contributing Author: Ramona Conner, MSN, RN, CNOR, Manager, Standards and Guidelines, Denver, Colorado
Team Members: Deborah S. Hickman, MS, RN, CNOR, CRNFA, Renue Plastic Surgery, Brunswick, Georgia; Melanie L. Braswell, DNP, RN, CNS, CNOR, Indiana University Health Arnett, Lafayette, Indiana; Judith R. Garcia, MHSS, MS, BSN, RN, CNOR, Perioperative Department, Ohio State University Wexner Medical Center James Cancer Hospital and Solove Research Institute, Columbus, Ohio; J. Hudson Garrett Jr, PhD, MSN, MPH, FNP-BC, Director, Clinical Affairs, PDI Healthcare, Atlanta, Georgia; Lisa Spruce, DNP, RN, ACNS, ACNP, ANP, CNOR, Director of Evidence-based Perioperative Practice, AORN, Inc., Denver, Colorado
No financial relationships relevant to the content of this guideline have been disclosed by the authors, planners, peer reviewers, or staff.
This is the current release of the guideline.
This guideline meets NGC's 2013 (revised) inclusion criteria.
Available for purchase from the Association of periOperative Registered Nurses (AORN) Web site .
The following is available:
- Patient skin antisepsis evidence table. Denver (CO): Association of periOperative Registered Nurses; 2014. 29 p. Available from the Association of periOperative Registered Nurses (AORN) Web site .
Additional implementation tools, including clinical FAQ's, webinars, online learning modules, videos, community discussions and journal articles are available from the AORN Web site .
In addition, an AORN Guidelines for Perioperative Practice eBook mobile app is available for purchase from the AORN Web site .
This NGC summary was completed by ECRI Institute on January 9, 2015. The information was verified by the guideline developer on February 25, 2015.
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