Crit Care Nurs Q

Vol. 32, No. 2, pp. 94–98

Copyright  c 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Going Around in Circles

Is This the Best Practice for
Preparing the Skin?
Karen Stonecypher, MSN, RN, CRRN

Hospital-acquired infections, which include bloodstream infections and surgical site infections, re-
sult in high rates of morbidity and mortality in the United States annually. Proper aseptic care of the
skin prior to any skin breach is of paramount importance to reduce these outcomes. The applica-
tion of the most appropriate skin preparation solution is significant but possibly not as important
as the technique employed to apply the solution itself. Historically, concentric circles were the
method of choice taught to nurses prior to any venipuncture. More recently, the back-and-forth
friction method is being promoted. There is no evidence to support either method, yet effective
reduction of infections is occurring. It is the intent of this article to address concerns for hospital-
acquired infections and offer evidence-based suggestions to improve outcomes, as one method of
skin preparation demonstrates greater efficacy. Key words: blood culture, blood stream infection,
chlorhexidine, contamination, povidone iodine, skin preparation, surgical site

T HE CENTERS FOR DISEASE CONTROL

AND PREVENTION (CDC) monitors for
hospital-acquired infections (HAIs) through-
out the United States.1 The CDC has deter-
mined that bloodstream infections (BSIs) and
surgical site infections (SSIs) are the great-
est culprits. In 2007, the CDC estimated that
1.7 million people sustained an HAI result-
ing in 99 000 deaths. This number equates
to 271 deaths per day. BSIs and SSIs were
directly responsible for 36% of all HAIs.1 Skin
preparation prior to a venipuncture or a sur-
gical procedure has been determined to be
the most common cause of infection. Normal
skin bacteria are the most common contam-
inants isolated in blood cultures. BSIs, SSIs,
and blood culture contamination are directly
related to the poor preparation of the skin
prior to the procedures.2–4 These studies sup-
port the need for best practice, as it relates
to aseptic skin preparation prior to any in-
Author Affiliation: Michael E. DeBakey VA Medical
Center, Houston, Texas.
Corresponding Author: Karen Stonecypher, MSN, RN,
CRRN, Michael E. DeBakey VA Medical Center, 2002
Holcombe Blvd, Houston, TX 77030 (Karen.
stonecypher@va.gov).
94
vasive procedure. Appropriate skin solutions
are available with different application tech-
niques utilized by means of each application
method. It is the intent of this article to ad-
dress concerns for HAIs and offer evidence-
based suggestions to improve outcomes re-
lated to solution application techniques of the
skin prior to procedures.
The 2004 National Nosocomial Infections
Surveillance report,5 which determined
that catheter-related bloodstream infections
(CRBSIs) frequently originate in intensive
care units and emergency departments, with
5.3 BSIs resulting after 1000 days of central
venous catheter insertion. According to
O’Grady et al,6 CRBSIs represent the majority
of BSIs in the United States, resulting in
250 000 infections at a cost of $6.25 billion
annually. Infections associated with central
catheter insertion total $2.3 billion, meaning
that almost $4 billion are related to peripheral
catheter insertions. The incidence of infec-
tion is frequently higher in the more acute
care patient settings where long-term central
intravenous access is necessary. Dimick
et al7 determined that additional cost could
be found in an extended length of stay in
the intensive care unit of 20 days ($70 000)

and on the general hospital unit of 22 days
($65 000).
Historically, central catheters are inserted
by physicians and peripheral catheters are
inserted by nurses. Reduction in peripher-
ally inserted catheter infections and care of
the central catheter is directly placed on the
nurse.
Colonization of the patients’ normal skin
flora from the intravenous site often results
from bacterial migration along the catheter
shaft into the bloodstream. Aseptic skin care
at the time of catheter insertion and with
routine site care will reduce this outcome as
a target objective to reducing overall HAIs.
The creation of super bugs from the overuse
of antibiotics is on the rise. In 2004, the
CDC reported an increase in the treatment of
methicillin-resistant Staphylococcus aureus,
from 22% in 1995 to 63% in 2002.8
More than 30 million surgical procedures
are preformed in the United States annu-
ally, with 2% of these procedures resulting
in SSIs.9 Fletcher et al10 reported that SSIs
are the most common complication follow-
ing surgery, with 500 000 to 780 000 SSIs oc-
curring in the United States annually. Woods9
noted that patients with an SSI are twice as
likely to die following surgery, with 20 000
surgical deaths directly related to an SSI. In
addition, SSIs account for 38% of all infec-
tions in the surgical patient, with two-thirds
of these infections directly related to the inci-
sion. Stone et al11 placed an average cost of
$25 546 (range, $1783–$134 602) to treat one
SSI. Again, proper skin asepsis is the primary
culprit.
Blood culture collection is a fundamental
component of the medical workup for an
infection. Contamination of a blood culture
is another cost that directly affects hospital
patients. Tepus et al3 found that increased
length of stay added to hospital, laboratory,
and pharmacy costs and that the develop-
ment of antibiotic resistance has an annual
cost of $1.4 million to $1.8 million and 1450
to 2200 extra hospital days. In the 2006 study
by Zwang and Albert, Tepus et al noted that
the costs associated with one blood culture
Going Around in Circles 95
contamination were greater than $8750 per
patient. The single most common cause of
blood culture contamination is poor prepara-
tion of the skin before drawing the cultures.
Proper skin preparation prior to any break
of the skin barrier has been related to the
solution used to clean the skin, the technique
of application of the solution (concentric
circles vs back-and-forth friction), and the
length of time the solution is allowed to dry
on the surface. Tepus et al3 addressed all of
these concerns in their 2008 study. Tincture
of iodine was used for 6 months in the
emergency department on all blood cultures
collected. The solution was applied using the
recommended concentric circle technique
and allowed to dry on the skin for the recom-
mended 2 minutes. The following 6 months,
chlorhexidine gluconate was the solution of
choice. Back-and-forth friction was used to
scrub the skin surface for 30 seconds, as rec-
ommended by the manufacturer. The solution
was allowed to dry for the recommended 15
to 30 seconds. Contamination rates decreased
from 3.5% using tincture of iodine to 2.2%
using chlorhexidine. A significant statistical
difference was seen (χ 2 = 22.02, P < .0001)
using chlorhexidine gluconate.
To reduce these numbers, it is paramount
to understand the mechanism of infection
through the skin barrier and the means to pre-
vent it. The integument is the largest organ
in the body. It is a continuous protective wall
covering the entire body, which makes it the
largest protective barrier of the human body
and the first line of defense against infection.
Hebl4 reports that resident skin bacteria re-
side in hair follicles and the orifices of seba-
ceous glands. In 2005, the AACN News Prac-
tice Alerts discussed CRBSI,12 noting that 80%
of all pathogens reside in the first 5 dermal
layers of the skin, and recommended friction
to be applied with the appropriate antisep-
tic to disinfect the skin prior to catheter in-
sertion and site care. Safdar and Maki8 found
that microorganisms in the skin, pathogenic
or normal resident flora, are the major causes
of both BSIs and SSIs. Skin bacteria are known
to migrate into the bloodstream by way of
96 CRITICAL CARE NURSING QUARTERLY/APRIL–JUNE 2009
the needle-puncture site.4 This being the case,
it is of utmost importance to protect this
barrier and maintain good aseptic methods
of skin preparation. The preparation of the
skin before breaking this barrier, whether it
is for catheter placement or for a surgical pro-
cedure, is of extreme importance. Skin care
following the break to the barrier is equally
important.
Historically, the skin-cleaning technique
taught to nursing students prior to venipunc-
ture is concentric circles. This technique is
carried over to all methods of skin preparation
prior to any manipulation of the skin. Pyrek13
recommends this technique prior to a surgi-
cal incision. However, back-and-forth friction
is a new method that is gaining popularity.
To understand the rationale of concentric cir-
cles and back-and-forth friction as methods to
clean the skin before inserting a needle, it is
necessary to understand the meaning of the
2 terms.
Concentric circles are circles with a com-
mon center, such as a bull’s eye. The process
begins at the center of the circle, moving in
an outward direction cleaning approximately
2 to 3 inches around the center of the circle.
It is recommended to clean in this method
3 times, using a separate applicator each
time, disposing of the applicator after each
use. Applying pressure to the skin during this
method was never emphasized. This method
does not ensure that the same pathway is
maintained with each application, nor is
there a guarantee that the skin is now aseptic.
However, this method does ensure that the
skin has been painted with a disinfecting
solution; therefore, it is assumed to be clean.
No evidence to support this technique could
be found in the literature review.
Friction is the force applied between the
2 bodies. Back-and-forth friction at the center
of the site to be cleaned maintains pressure
outwardly for 2 to 3 inches over the same area
for the duration of the scrubbing time. Scrub-
bing the skin utilizing a disinfecting solution
in this manner for a specified length of time
will ensure cleaning through the top 5 der-
mal layers of skin. In addition, back-and-forth
scrubbing will remove the greater part of the
bacterial load that resides in the top dermal
layers of the skin, which harbor the majority
of the bacteria on the skin surface. Many stud-
ies have evaluated solutions, but only 1 study
specifically looked at the technique for the
application of the disinfecting solution.3 A
review of the literature does not reveal further
evidence to support this practice.
In 1999, the CDC supported the use of
concentric circles (moving from the center
to the periphery) as the appropriate skin-
preparation technique before breaking the
skin barrier. This technique is ranked as a
category II, meaning that this technique is sug-
gested for implementation and is supported
by suggestive clinical or epidemiological stud-
ies or a theoretical rationale.4,14 In 2000, the
US Food and Drug Administration approved
the use of 2% chlorhexidine gluconate for
patient preoperative skin preparation and
patient preinjection preparation. In 2002, rec-
ommendations were published by the CDC to
support the use of chlorhexidine gluconate–
based skin-preparation solutions prior to any
catheter insertion.6 In 2003, Moureau15 re-
ported the CDC recommendation to prepare
the skin site before inserting a central venous
access device. This report recommended
using a 2% chlorhexidine solution with a
back-and-forth friction method to apply the
solution. The US Agency for Health Care
Policy and Research outlined the use of
chlorhexidine as a grade A recommendation.
Hebl4 reports a grade A recommendation to
mean that at least 1 prospective randomized
controlled trial (RCT) has established the
quality of this solution. In addition, chlorhex-
idine was given the evidence levels of Ia
(evidence from a meta-analysis of RCT) and
Ib (evidence from at least 1 RCT). These
agencies support the use of chlorhexidine
as the most appropriate skin-preparation
solution, and the technique for solution
application is use of back-and-forth friction as
the most appropriate method.
Numerous studies have been completed in
the last few years comparing different skin-
preparation solutions and techniques. As far

back as 1999, Mimoz et al16 found statistical
significance (P = .004) when comparing the
skin preparations of 5% chlorhexidine in alco-
hol with aqueous 10% povidone-iodine used
prior to blood culture collection. The study
of Mimoz et al16 was significant as it was the
only RCT of solution preparations until more
recently. Tepus et al3 compared the concen-
tric circle technique using tincture of iodine
with the back-and-forth friction technique us-
ing chlorhexidine. A statistically significant
(χ 2 = 22.02, P < .0001) decrease in blood cul-
ture contamination rates was shown using 2%
chlorhexidine and 70% alcohol preparation
solution in comparison with the use of tinc-
ture of iodine. Suwanpimolkul et al17 reported
on a meta-analysis of 8 RCTs and the CDC
guidelines to support the use of chlorhexidine
gluconate as the antiseptic agent of choice for
the prevention of vascular catheter–related
infections.
Skin is the primary barrier of the human
body. As such, it is adventitious to protect this
barrier from bacterial invasion in the delivery
of healthcare. The US Food and Drug Admin-
istration and the CDC recommend the use
of chlorhexidine gluconate before inserting
a central or a peripheral intravenous catheter
and before a surgical incision. Studies in
the last 10 years have supported the use of
chlorhexidine gluconate for skin asepsis be-
fore drawing blood cultures. The application
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Going Around in Circles 97
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