Sterility and use of surgical site markers

AORN Journal,  Nov, 2007  by George Allen

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Journal of the American College of Surgeons August 2007

The Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery, which has been endorsed by more than 40 professional medical organizations, includes a preoperative verification process, marking the surgical site with an indelible marker, and taking a time out immediately before starting the procedure. Potential contamination of the surgical field with ink from a surgical marker or from the mechanical abrasion caused by marking the skin with a pen or marker has raised concerns of surgeons from different specialties. Indeed, it is not known if bacteria can be trapped under the ink of a marker and therefore not be affected by the surgical preparation, potentially contaminating the surgical site. The purpose of this self-controlled, single-cohort study was to determine whether preoperative site markers trap pathogens and shield them from surgical preparation, thereby affecting bacterial colony counts from the epidermis in actual surgical wounds.

Thirty adult patients scheduled to have elective, upper-extremity surgery by the same surgeon at a university hospital center in Loma Linda, California, were enrolled in the study. Excluded were patients with open wounds, cellulitis, and active or chronic infection.

Marking of the surgical site was completed in accordance with the Universal Protocol guidelines. For each patient, one-half of the planned incision site was marked with a nonsterile, indelible marker and the other half of the incision site was left unmarked. The involved upper extremity was then prepped. A single incision was made, beginning in the unmarked area and continuing through the marked area of the incision site.

Two aerobic cultures then were taken. The first swab was taken from the edges of the unmarked incision area, and the second swab was taken from the edges of the incision area that had been marked. The cultures were labeled and transferred to the microbiology laboratory to be grown on blood agar plates in a controlled setting for 72 hours. The cultures were analyzed by a blinded observer and identified as either negative or positive.

FINDINGS. After 72 hours, all 60 cultures were assessed as negative regardless of the swab site (ie, marked or unmarked). Because all the cultures were negative, no statistical analysis was necessary.

CLINICAL IMPLICATIONS, The authors concluded that the practice of surgical marking does not increase the risk of surgical field contamination. Perioperative nurses and managers should be confident that marking the surgical site does not contaminate the surgical field and should vigorously enforce the requirement to mark the surgical site as an effective component in preventing wrong site surgery.

Editor's note: The Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery is a registered trademark of the Joint Commission, Oakbrook Terrace, IL.

Cullan DB II, Wongworawat MD. Sterility of surgical site marking between the ink and the epidermis. J Am Coil Surg. 2007;205(2):319-321.

GEORGE ALLEN

PHD, RN, CNOR, CIC

DIRECTOR OF INFECTION CONTROL

DOWNSTATE MEDICAL CENTER

BROOKLYN, NY

COPYRIGHT 2007 Association of Operating Room Nurses, Inc.
COPYRIGHT 2008 Gale, Cengage Learning