madness in the operating theatre

It was a few years ago that the High Impact Intervention – Care bundle to prevent surgical site infection guidance was issued. Just to remind everyone that the aim was to reduce the incidence and consequences of surgical site infection (SSI).

It all links together – surgical site infections increase hospital stay, are unpleasant and potentially dangerous to the patient, often requires additional healthcare expense and usually leads to the use of an antibiotic. We are constantly told that overuse of antibiotics lead to resistance, hospital beds are expensive and the patient should be our main consideration.

The high impact change within the Intra-operative phase is:

“Patient’s skin has been prepared with 2% chlorhexidine gluconate in 70% isopropyl alcohol solution and allowed to air dry”

That is simple enough isn’t it – and in the care bundle audit, successful achievement of this high impact change will be recorded.

On Friday, I think I had one of the most disappointing and frustrating discussions with a senior nurse in charge of an operating theatre. It went a little bit like this:

“I see that you aren’t using a 2% chlorhexidine in 70% IPA solution as indicated in the High Impact Intervention – care bundle to prevent surgical site infection.”

“No we use a 2.5% v/v solution in alcohol instead.”

“Why is that?”

“Because it is a stronger solution and it is less expensive than the licensed 2% solution.”

“In fact it is weaker. If you reread the label it is 2.5% v/v of a 20% chlorhexidine gluconate solution – meaning that it is only 0.5% chlorhexidine.”

“Does that matter?”

“Yes. It means that you have been completing the care bundle audit incorrectly and using a solution that is less effective. You are also routinely adding a red-staining solution to the product which is not covered in the label – so you should have been dealing with this off-label use of a medicinal product.”

“What does that all mean?”

“Well – you have been saving some money, using a product weaker than suggested by the high impact intervention document and telling porkie pies on the audit sheet. What’s more you have been using it off-label, without assessing the risk or informing your patients.”


“And although the evidence is limited to a poster, when this research is fully published, it is highly likely that you have contributed to an increase in surgical site infections.”

It is a little difficult to offer advice at this point. And to be honest, I am not sure how the department/hospital has got them into this position. It looks like a systemic failure, but who am I to comment. I am not sure where this fits within the Code of Practice on the prevention and control of infections, CQC monitoring and the new patient safety agenda. It is a mess – an opportunity to save a few quid without the proper assessment that comes before writing policies and taking action.

I am rarely at a loss – its madness!


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