The aim  
The total amount of infections among total knee arthoplasty patients by orthopedic in Central hospital of Central Finland was too high.
The whole perioperative procedure was surveyed in operating room (OR). 
Perioperative disinfection was one of the components which was surveyed and there was need for change. In Finland the disinfection is commonly performed with plain 80% ethanol. The disinfection was done by lifting straight leg with too wet swaps, beginning from toes to ankle continuing over knee down to hip focusing to one-way draws and runoff directions of ethanol liquid and this was done too many times. By evidence-based guidelines this was not the right way to perform disinfection. 

Method 
The skin disinfection procedure in OR was inspected by infection control nurse for several times and discussed together with the orthopedic team before the change was made. 
At the beginning of April 2018 colored alcohol-chlorhexidine gluconate 2% (CHG) with ready-to-use applicator (Chloraprep®) was taken in action with elective knee joint surgery as WHO nowadays strongly recommends. A new disinfection guideline with pictures and the manufacturer´s instructions was made and orthopedic OR nurses were educated with new method by infection control nurse. The new instruction is to start from incision site with curved knee, proceed to peripheral areas.

Conclusion
The new preoperative disinfection method has been used several months now. Outset was challenging. This demanded new thinking from OR nurses and attitude to change old habits and the way to do disinfection. The disinfection with applicator was totally new and different way to do it. There was rebellion against the new guideline, but with determined guidance it is now found good, practical and easy to use.

Nowadays this method has been implemented to all knee and hip surgery.



Maija-Liisa Lauritsalo
Registered Infection Control Nurse, Perioperative Nurse 
Central Hospital of Central Finland, Jyväskylä, Finland
maija-liisa.lauritsalo@ksshp.fi
+358142695577

The change of preoperative desinfection in knee joint surgery