Skin Cleansing Prior to Elective Surgery
Many institutions have incorporated a skin
cleansing - often referred to as “preoperative
bathing” - protocol to reduce microbial load
on the skin for patients undergoing elective
surgery. In fact, guidelines from influential
organizations such as AORN and the CDC recommend cleansing with an antiseptic prior to
surgery as a component of a broader strategy
to reduce Surgical Site Infections (SSI)¹, ².
There are a variety of actives than be used for
skin cleansing, including: regular bar soap, antimicrobial soap, chlorhexidine gluconate, or po-vidone iodine. Chlorhexidine gluconate (CHG)
has emerged as one of the preferred options
for its broad spectrum efficacy and persistence.
The mechanical action of scrubbing with CHG
helps to cleanse the skin, and rinsing removes
debris, while maintaining a layer of CHG on the
skin that has persistent antimicrobial effects.³
Questions remain about best practices for
implementing CHG skin cleansing protocols.
Some of the most common questions include:
• How many times should a patient cleanse?
• How can surgical teams enhance patient
compliance with cleansing instructions?
The following sections explore best practices for addressing these questions.
Number of Cleanses
The optimal number of CHG cleanses has yet
to be established, but 2 or more (e.g. night
before and morning of surgery) is common
practice. Examples of cleansing recommen-
dations are available in Figure 1:
A study supporting CDC recommenda-
tions of at least one shower prior to surgery
comments on CHG’s cumulative effects:
“chlorhexidine gluconate-containing prod-
ucts require several applications to attain
maximum antimicrobial effect, so repeated
showers are usually indicated.”²
Just as guidelines vary, cleansing protocols
vary across hospitals and sometimes even
within a hospital. To reap the benefits of a
CHG skin cleansing program, it is important
1) choose the protocol that aligns with your
facility’s goals, and 2) drive consistency with
that protocol through staff education.
Enhancing Patient Compliance with
Patient compliance with CHG skin cleansing
instructions is a common concern. When
patients cleanse at home, they lack the supervision of their surgical team, which makes it difficult to verify whether they cleansed correctly
or even cleansed at all. In a recent market
research study, 55% of Nurses and Infection
Preventionists were only “Somewhat Confident” that their patients were complying with
skin cleansing instructions.⁵ The problem is that
hospitals have invested in these programs, and
if compliance is low, neither the patient nor the
hospital experiences the full benefits.
Addressing this challenge requires an
understanding of the barriers to patient
compliance. Patients have a lot on their mind
prior to surgery, and even the best intentioned
patients may not follow their surgical team’s
instructions correctly. A recent research report
on patient adherence to medication identifies
the root causes of patient non-compliance⁶:
• Inadequate knowledge reasons for treatment
• Misunderstanding of treatment instructions
Effective patient education and clear
communication may help overcome these
challenges. When a patient receives skin
cleansing instructions, they need to know
why this is important, how to use these
products, and be reminded to cleanse.
In addition to implementing educational programs with patients, product choice can also
help enhance your skin cleansing program.
CHG skin cleansing products typically come
in two categories: bottles of CHG liquid or
CHG-impregnated cloths. Both are effective for
killing bacteria on the skin. Some CHG bottle
manufacturers also offer kits that include cloths
and other materials for cleansing. Kits that
provide everything in one place are convenient
for patients and staff and may make it easier
to be compliant with guidelines and instruc-
tions. For example, the Aplicare® 4% CHG
Skin Cleansing kit provides all of the materials
needed for 2 cleanses (aligning with AORN
guidelines) and has a number of tools avail-
able (like visual, bilingual instructions) to help
patients understand the cleansing instructions.
Choosing products that are easy to use can reduce confusion and help hospitals implement
successful CHG skin cleansing programs.
Kim LaFreniere is an Associate Research Fellow,
R&D, at Clorox Professional Products Company
with extensive healthcare and R&D experience in
product development and technical services. She
is an active member of the Association for Professionals in Infection Control and Epidemiology
(APIC), the Association of periOperative Registered Nurses (AORN) and the Michigan Society
for Infection Prevention and Control. She holds
a doctorate degree in Analytical Chemistry from
Iowa State University and a bachelor’s degree in
Chemistry from the University of Michigan.
AORN Recommended Practices for Preoperative Patient
Skin Antisepsis (2012) Preoperative Standards and Recommended Practices: 445-463.
² Mangram, A., et. al. GUIDELINE FOR PREVENTION OF
SURGICAL SITE INFECTION, 1999. INFECTION CONTROL
AND HOSPITAL EPIDEMIOLOGY Vol. 20. No. 4. pg. 247-
278. Centers for Disease Control and Prevention. (CDC).
³ Edmiston, Charles E. Evidence for Using Chlorhexidine
Gluconate Preoperative Cleansing to Reduce Risk of Surgical Site Infection. AORN Journal, Vol. 92, No. 5, 2010.
⁴ IHI Project JOINTS (website accessed March, 2012):
⁵ Aplicare/Clorox Healthcare Market Research conducted
December 2013. N=87 Infection Preventionists and
⁶ Forissier, T., et al. Capgemini Consulting. Patient Adherence: The Next Frontier in Patient Care. Vision & Reality,
9th Edition (2011).
For more information about Aplicare and
Clorox Healthcare products for skin cleansing
By Kim LaFreniere, PhD
Figure 1: Common Guidelines & Protocols
AORN ¹ 2 cleanses with CHG
CDC ² At least one shower
with an antiseptic
IHI – Project JOINTS ⁴ 3 cleanses with CHG