Pens for marking skin prior to surgery

[Michael Wishart]

Hi all

What do other facilities use for marking skin prior to surgery? We currently use a reusable felt tip permanent marker that doesn’t appear to be cleaned in any way between each patient. This occurs prior to the surgical procedure outside of the operating room, so does not need to enter the sterile field.

Our questions revolve around whether we should source disposable pens, or try to clean the markers between each patient use. This raises the question: how do you clean a felt tip??

We did note some interesting discussions on possible cross-contamination using marking pens (eg http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2008/Dec5(4)/Pages/130.aspx ).

Any comments?

Thanks
Michael

Michael Wishart
CNC Infection Control
Holy Spirit Northside Private Hospital
627 Rode Road, Chermside, Qld 4032
t: (07) 3326 3068 | f: (07) 3607 2226
e: Michael.Wishart@hsn.org.au
w:www.holyspiritnorthside.org.au
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[Helen Newman]

Hi Michael,
We had a similar discussion about two years ago and subsequently moved to single use pens. If you are interested, I can provide the product order details off line. Our patients are marked prior to entering the operating theatre.
Helen

Helen Newman

Infection Prevention and Control CNC CICP| Infection Management and Control Service
Shellharbour and Kiama Hospitals
Tel 02 4295 2416 | Fax 02 4295 2497 | Helen.Newman@sesiahs.health.nsw.gov.au
http://www.health.nsw.gov.au

[cid:image001.jpg@01CE6139.F102B640]

Hi all

What do other facilities use for marking skin prior to surgery? We currently use a reusable felt tip permanent marker that doesn’t appear to be cleaned in any way between each patient. This occurs prior to the surgical procedure outside of the operating room, so does not need to enter the sterile field.

Our questions revolve around whether we should source disposable pens, or try to clean the markers between each patient use. This raises the question: how do you clean a felt tip??

We did note some interesting discussions on possible cross-contamination using marking pens (eg http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2008/Dec5(4)/Pages/130.aspx ).

Any comments?

Thanks
Michael

Michael Wishart
CNC Infection Control
Holy Spirit Northside Private Hospital
627 Rode Road, Chermside, Qld 4032
t: (07) 3326 3068 | f: (07) 3607 2226
e: Michael.Wishart@hsn.org.au
w:www.holyspiritnorthside.org.au
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[Lowe, Linda]

Hi Michael,

We use single use mini pre op markers for all our patients, alleviates
any possible cross – contamination issues.

Regards

Linda

Linda Lowe

Staff Development /OSH Representative

Operating Theatre

Bunbury Hospital

email: linda.lowe@health.wa.gov.au

________________________________

Behalf Of Michael Wishart
surgery

Hi all

What do other facilities use for marking skin prior to surgery? We
currently use a reusable felt tip permanent marker that doesn’t appear
to be cleaned in any way between each patient. This occurs prior to the
surgical procedure outside of the operating room, so does not need to
enter the sterile field.

Our questions revolve around whether we should source disposable pens,
or try to clean the markers between each patient use. This raises the
question: how do you clean a felt tip??

We did note some interesting discussions on possible cross-contamination
using marking pens (eg
http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2008/Dec5(4
)/Pages/130.aspx ).

Any comments?

Thanks

Michael

Michael Wishart

CNC Infection Control

Holy Spirit Northside Private Hospital

627 Rode Road, Chermside, Qld 4032

t: (07) 3326 3068 | f: (07) 3607 2226

e: Michael.Wishart@hsn.org.au

w:www.holyspiritnorthside.org.au

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[Lesley MASON]

Hello Michael

I respond for Debra as she is on leave. Here at Caboolture Hospital the
‘Codeman’ one use only sterile marker is used. No other info I’m afraid,
good luck

Lesley Mason
Acting Clinical Nurse Consultant
Infection Control & Sterilising Services
Metro North Health and Hospital Services
Caboolture Hospital

Phone 5433 8024

>>> Michael Wishart 6/4/2013 3:35 pm >>>

Hi all

What do other facilities use for marking skin prior to surgery? We
currently use a reusable felt tip permanent marker that doesnt appear
to be cleaned in any way between each patient. This occurs prior to the
surgical procedure outside of the operating room, so does not need to
enter the sterile field.

Our questions revolve around whether we should source disposable pens,
or try to clean the markers between each patient use. This raises the
question: how do you clean a felt tip??

We did note some interesting discussions on possible
cross-contamination using marking pens (eg
http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2008/Dec5(4)/Pages/130.aspx
).

Any comments?

Thanks
Michael

Michael Wishart
CNC Infection Control
Holy Spirit Northside Private Hospital
627 Rode Road, Chermside, Qld 4032
t:(07) 3326 3068 | f: (07) 3607 2226
e: Michael.Wishart@hsn.org.au
w:www.holyspiritnorthside.org.au (
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)
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[Michele.Cullen@HEALTH.VIC.GOV.AU Subject: Re: Pens for marking skin prior to surgery In-Reply-To:]

[Wilkinson, Irene (Health)]

Hi all,

Is there any evidence that texta markers are a vehicle for transmission of microorganisms?
The solvents used in them would have fairly powerful antibacterial action. Isn’t the skin then well prepped before the incision is made?

Regards.

Irene Wilkinson
Manager, Infection Control Service
Communicable Disease Control Branch
SA Health
Irene.wilkinson@health.sa.gov.au

—–Original Message—–
From: ACIPC Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU] On Behalf Of Michele.Cullen@HEALTH.VIC.GOV.AU
Sent: 04 June 2013 3:40
To: AICALIST@AICALIST.ORG.AU
Subject: Re: Pens for marking skin prior to surgery

Dear Michael

Single use sterile pens for skin marking have been available for over thirty years.
Likewise reusable pens/inkwells and ink have been available and can be washed and sterilized between uses.

Regards

(Embedded (Embedded image moved to file: pic15046.jpg)
image moved
to file:
pic12667.jpg)

Michele Cullen
Infection Control Consultant | Communicable Disease Prevention and
Control | Public Health
Department of Health | 50 Lonsdale Street, Melbourne, Victoria,
3000
p. 03 9096 5094 | f. 1300 651 170
e. michele.cullen@health.vic.gov.au

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Hi all

What do other facilities use for marking skin prior to surgery? We currently use a reusable felt tip permanent marker that doesnt appear to be cleaned in any way between each patient. This occurs prior to the surgical procedure outside of the operating room, so does not need to enter the sterile field.

Our questions revolve around whether we should source disposable pens, or try to clean the markers between each patient use. This raises the
question: how do you clean a felt tip??

We did note some interesting discussions on possible cross-contamination using marking pens (eg
http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2008/Dec5
(4)/Pages/130.aspx ).

Any comments?

Thanks
Michael

Michael Wishart
CNC Infection Control
Holy Spirit Northside Private Hospital
627 Rode Road, Chermside, Qld 4032
t: (07) 3326 3068 | f: (07) 3607 2226
e: Michael.Wishart@hsn.org.au
w:www.holyspiritnorthside.org.au
Please consider the environment before printing this email

WARNING : This email contains information, which is CONFIDENTIAL, and that maybe subject to LEGAL PRIVILEGE. This e-mail and any attachments to it (the “Communication”) is confidential and is for the use only of the intended recipient, and may not duplicated or used by any other party without the express consent of the sender. The Communication may contain copyright material of St Vincent’s Health & Aged Care(“SVHAC”), or any of its related entities or of third parties. If you are not the intended recipient of the Communication, please notify the sender immediately by return e-mail, delete the Communication, and do not read, copy, print, retransmit, store or act in reliance on the Communication. Any views expressed in the Communication are those of the individual sender only, unless expressly stated to be those of SVHAC. SVHAC does not guarantee the integrity of the Communication, or that it is free from errors, viruses or interference. Thank-you.

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[Lynley King]

Hi All,

I would still prefer to mark the leg then have the wrong one amputated.
Happens more often then you might think!

Just a thought.

And if the leg is being amputated what is the risk of infection following surgery?
And as the leg is being amputated (usually due ti infection) isn’t the site left at increased risk anyway?

Just curious.

Lynley

ICP
Alice Springs Hospital
CAHN

Sent from mikala, the iPad!

On 05/06/2013, at 11:56, Michael Wishart wrote:

> Hi Irene
>
> Good question, some aspects of which has already been discussed in the literature, but with conflicting opinions.
>
> http://www.medpagetoday.com/MeetingCoverage/ICAAC-IDSA/11440
>
> http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2008/Dec5(4)/Pages/130.aspx
>
> Some of those referred studies seem to indicate different brands will act differently. The most interest finding I saw was that in one study, MRSA remained on all types of felt tips tested.
>
> So, the question remains: is it possible to transfer microorganisms via felt tip pens? Without doing a full study on whichever brand of felt tip pen we chose, I would be reluctant to say a definite yes for all different marking pens.
>
> Should we rely solely on antiseptic skin prep prior to the procedure? I think would much depend on where the site was marked… I have seen limbs marked prior to surgery well below where the area was be prepped with antiseptic.
>
> At the very least, the body of the marking pens should be wiped over between uses to avoid transfer of MRO’s onto the hands of whoever handles it, as these pens have direct contact with patients. Carrying a marking pen for the purpose of limb marking in one’s pocket ‘until it runs dry’ seems to be asking for problems (and not just from staining of the pockets from ink!).
>
> More discussion on this would be appreciated. I recognise that sterile marking pens have been used within the sterile field for a long time, but should we use these same disposable sterile markers for pre-operative limb marking as required for safe-site surgery protocols?
>
> Cheers
> Michael
>
> Michael Wishart
> CNC Infection Control
> Holy Spirit Northside Private Hospital
> 627 Rode Road, Chermside, Qld 4032
> t: (07) 3326 3068 | f: (07) 3607 2226
> e: Michael.Wishart@hsn.org.au
> w:www.holyspiritnorthside.org.au
> Please consider the environment before printing this email
>
>
>
> —–Original Message—–
> From: ACIPC Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU] On Behalf Of Wilkinson, Irene (Health)
> Sent: Wednesday, 5 June 2013 12:03 PM
> To: AICALIST@AICALIST.ORG.AU
> Subject: Re: Pens for marking skin prior to surgery
>
> Hi all,
>
> Is there any evidence that texta markers are a vehicle for transmission of microorganisms?
> Th

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[Michael Wishart]

Hi Lynley

If this was only about amputation of infected limbs and digits which were then discarded, it would be less concerning. But safe surgery protocols now require us to mark every site and side for every surgical procedure that has laterality (except mucous membrane areas, basically). So your professional athletes having joint surgery, your women having breast surgery, the diabetic patient having foot amputation for chronic infection: they all need the correct site marked. We obviously want to do everything we can to reduce risks of infection in all of our patients.

That is what the question is aimed at: what is the risk, and what should we do to minimise such risk?
Apologies if this sounds dictatorial, but I feel we need to focus on why we are discussing this.

Cheers
Michael

Michael Wishart
CNC Infection Control
Holy Spirit Northside Private Hospital
627 Rode Road, Chermside, Qld 4032
t: (07) 3326 3068 | f: (07) 3326 3523
e: Michael.Wishart@hsn.org.au
w:www.holyspiritnorthside.org.au
Please consider the environment before printing this email

________________________________________

Hi All,

I would still prefer to mark the leg then have the wrong one amputated.
Happens more often then you might think!

Just a thought.

And if the leg is being amputated what is the risk of infection following surgery?
And as the leg is being amputated (usually due ti infection) isn’t the site left at increased risk anyway?

Just curious.

Lynley

ICP
Alice Springs Hospital
CAHN

Sent from mikala, the iPad!

On 05/06/2013, at 11:56, Michael Wishart wrote:

> Hi Irene
>
> Good question, some aspects of which has already been discussed in the literature, but with conflicting opinions.
>
> http://www.medpagetoday.com/MeetingCoverage/ICAAC-IDSA/11440
>
> http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2008/Dec5(4)/Pages/130.aspx
>
> Some of those referred studies seem to indicate different brands will act differently. The most interest finding I saw was that in one study, MRSA remained on all types of felt tips tested.
>
> So, the question remains: is it possible to transfer microorganisms via felt tip pens? Without doing a full study on whichever brand of felt tip pen we chose, I would be reluctant to say a definite yes for all different marking pens.
>
> Should we rely solely on antiseptic skin prep prior to the procedure? I think would much depend on where the site was marked… I have seen limbs marked prior to surgery well below where the area was be prepped with antiseptic.
>
> At the very least, the body of the marking pens should be wiped over between uses to avoid transfer of MRO’s onto the hands of whoever handles it, as these pens have direct contact with patients. Carrying a marking pen for the purpose of limb marking in one’s pocket ‘until it runs dry’ seems to be asking for problems (and not just from staining of the pockets from ink!).
>
> More discussion on this would be appreciated. I recognise that sterile marking pens have been used within the sterile field for a long time, but should we use these same disposable sterile markers for pre-operative limb marking as required for safe-site surgery protocols?
>
> Cheers
> Michael
>
> Michael Wishart
> CNC Infection Control
> Holy Spirit Northside Private Hospital
> 627 Rode Road, Chermside, Qld 4032
> t: (07) 3326 3068 | f: (07) 3607 2226
> e: Michael.Wishart@hsn.org.au
> w:www.holyspiritnorthside.org.au
> Please consider the environment before printing this email
>
>
>
> —–Original Message—–
> From: ACIPC Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU] On Behalf Of Wilkinson, Irene (Health)
> Sent: Wednesday, 5 June 2013 12:03 PM
> To: AICALIST@AICALIST.ORG.AU
> Subject: Re: Pens for marking skin prior to surgery
>
> Hi all,
>
> Is there any evidence that texta markers are a vehicle for transmission of microorganisms?
> Th

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[Wilkinson, Irene (Health)]

Thanks Michael for this discussion and the links to the articles you supplied below.

In the second article, which is a good review of the current literature on the topic, one study was noted that conducted laboratory experiments on 31 permanent markers and 30 surgical site markers (presumably specifically marketed as such). The authors seeded the tips of the pens with MRSA and then used them to inoculate agar plates at various times up to 3 weeks post-seeding. The article summarises their findings thus:

“Results showed that MRSA did not survive on the permanent marking pens after 15 minutes from inoculation; however, the MRSA survived up to 3 weeks on the surgical marking pens. The authors theorized that MRSA did not survive on the permanent marking pens because the ink contained isopropyl alcohol and ethanol but was able to survive on the surgical marking pens because the ink contained water as the main solvent.”

What this says to me is that if surgical marking pens are used, then it is imperative that they are single patient use. On the other hand, the risk of cross-contamination by reusing a permanent marker (such as a texta) is minimal if not re-used within 15 minutes. Of course, there are other considerations such as the potential toxicity of the permanent ink, durability of the marking, etc.

Regards,
Irene

Irene Wilkinson
Manager, Infection Control Service
SA Health
Irene.wilkinson@health.sa.gov.au

—–Original Message—–

Hi Lynley

If this was only about amputation of infected limbs and digits which were then discarded, it would be less concerning. But safe surgery protocols now require us to mark every site and side for every surgical procedure that has laterality (except mucous membrane areas, basically). So your professional athletes having joint surgery, your women having breast surgery, the diabetic patient having foot amputation for chronic infection: they all need the correct site marked. We obviously want to do everything we can to reduce risks of infection in all of our patients.

That is what the question is aimed at: what is the risk, and what should we do to minimise such risk?
Apologies if this sounds dictatorial, but I feel we need to focus on why we are discussing this.

Cheers
Michael

Michael Wishart
CNC Infection Control
Holy Spirit Northside Private Hospital
627 Rode Road, Chermside, Qld 4032
t: (07) 3326 3068 | f: (07) 3326 3523
e: Michael.Wishart@hsn.org.au
w:www.holyspiritnorthside.org.au
Please consider the environment before printing this email

________________________________________

Hi All,

I would still prefer to mark the leg then have the wrong one amputated.
Happens more often then you might think!

Just a thought.

And if the leg is being amputated what is the risk of infection following surgery?
And as the leg is being amputated (usually due ti infection) isn’t the site left at increased risk anyway?

Just curious.

Lynley

ICP
Alice Springs Hospital
CAHN

Sent from mikala, the iPad!

On 05/06/2013, at 11:56, Michael Wishart wrote:

> Hi Irene
>
> Good question, some aspects of which has already been discussed in the literature, but with conflicting opinions.
>
> http://www.medpagetoday.com/MeetingCoverage/ICAAC-IDSA/11440
>
> http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2008/Dec5(4)/Pages/130.aspx
>
> Some of those referred studies seem to indicate different brands will act differently. The most interest finding I saw was that in one study, MRSA remained on all types of felt tips tested.
>
> So, the question remains: is it possible to transfer microorganisms via felt tip pens? Without doing a full study on whichever brand of felt tip pen we chose, I would be reluctant to say a definite yes for all different marking pens.
>
> Should we rely solely on antiseptic skin prep prior to the procedure? I think would much depend on where the site was marked… I have seen limbs marked prior to surgery well below where the area was be prepped with antiseptic.
>
> At the very least, the body of the marking pens should be wiped over between uses to avoid transfer of MRO’s onto the hands of whoever handles it, as these pens have direct contact with patients. Carrying a marking pen for the purpose of limb marking in one’s pocket ‘until it runs dry’ seems to be asking for problems (and not just from staining of the pockets from ink!).
>
> More discussion on this would be appreciated. I recognise that sterile marking pens have been used within the sterile field for a long time, but should we use these same disposable sterile markers for pre-operative limb marking as required for safe-site surgery protocols?
>
> Cheers
> Michael
>
> Michael Wishart
> CNC Infection Control
> Holy Spirit Northside Private Hospital
> 627 Rode Road, Chermside, Qld 4032
> t: (07) 3326 3068 | f: (07) 3607 2226
> e: Michael.Wishart@hsn.org.au
> w:www.holyspiritnorthside.org.au
> Please consider the environment before printing this email
>
>
>
> —–Original Message—–
> From: ACIPC Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU] On Behalf Of Wilkinson, Irene (Health)
> Sent: Wednesday, 5 June 2013 12:03 PM
> To: AICALIST@AICALIST.ORG.AU
> Subject: Re: Pens for marking skin prior to surgery
>
> Hi all,
>
> Is there any evidence that texta markers are a vehicle for transmission of microorganisms?
> Th

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[Lynley King]

Hi Michael,

No worries.
We use disposable markers, one use only as about 40% of our clients are colonised with nmMRSA long before they get near a hospital.
I have seen, however, the only healthy kidney removed and the wrong limbs operated on and removed so just want to remind us all of the bigger picture.
I have also had the reason for not marking the limb as the lack of the ‘correct’ pen.
May well be a local issue but always worth keeping it in mind when educating staff!

The articles are certainly interesting. Sometimes you are damned if you do and damned if you don’t.

Always an interesting and informative site.

Kind regards,
Lynley

Sent from mikala, the iPad!

On 05/06/2013, at 19:26, Michael Wishart wrote:

> Hi Lynley
>
> If this was only about amputation of infected limbs and digits which were then discarded, it would be less concerning. But safe surgery protocols now require us to mark every site and side for every surgical procedure that has laterality (except mucous membrane areas, basically). So your professional athletes having joint surgery, your women having breast surgery, the diabetic patient having foot amputation for chronic infection: they all need the correct site marked. We obviously want to do everything we can to reduce risks of infection in all of our patients.
>
> That is what the question is aimed at: what is the risk, and what should we do to minimise such risk?
>
> Apologies if this sounds dictatorial, but I feel we need to focus on why we are discussing this.
>
> Cheers
> Michael
>
> Michael Wishart
> CNC Infection Control
> Holy Spirit Northside Private Hospital
> 627 Rode Road, Chermside, Qld 4032
> t: (07) 3326 3068 | f: (07) 3326 3523
> e: Michael.Wishart@hsn.org.au
> w:www.holyspiritnorthside.org.au
> Please consider the environment before printing this email
>
> ________________________________________
> From: ACIPC Infexion Connexion [AICALIST@AICALIST.ORG.AU] on behalf of Lynley King [lynleyk@TPG.COM.AU]
> Sent: Wednesday, 5 June 2013 7:15 PM
> To: AICALIST@AICALIST.ORG.AU
> Subject: Re: Pens for marking skin prior to surgery
>
> Hi All,
>
> I would still prefer to mark the leg then have the wrong one amputated.
> Happens more often then you might think!
>
> Just a thought.
>
> And if the leg is being amputated what is the risk of infection following surgery?
> And as the leg is being amputated (usually due ti infection) isn’t the site left at increased risk anyway?
>
> Just curious.
>
> Lynley
>
> ICP
> Alice Springs Hospital
> CAHN
>
>
>
>
> Sent from mikala, the iPad!
>
> On 05/06/2013, at 11:56, Michael Wishart wrote:
>
>> Hi Irene
>>
>> Good question, some aspects of which has already been discussed in the literature, but with conflicting opinions.
>>
>> http://www.medpagetoday.com/MeetingCoverage/ICAAC-IDSA/11440
>>
>> http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2008/Dec5(4)/Pages/130.aspx
>>
>> Some of those referred studies seem to indicate different brands will act differently. The most interest finding I saw was that in one study, MRSA remained on all types of felt tips tested.
>>
>> So, the question remains: is it possible to transfer microorganisms via felt tip pens? Without doing a full study on whichever brand of felt tip pen we chose, I would be reluctant to say a definite yes for all different marking pens.
>>
>> Should we rely solely on antiseptic skin prep prior to the procedure? I think would much depend on where the site was marked… I have seen limbs marked prior to surgery well below where the area was be prepped with antiseptic.
>>
>> At the very least, the body of the marking pens should be wiped over between uses to avoid transfer of MRO’s onto the hands of whoever handles it, as these pens have direct contact with patients. Carrying a marking pen for the purpose of limb marking in one’s pocket ‘until it runs dry’ seems to be asking for problems (and not just from staining of the pockets from ink!).
>>
>> More discussion on this would be appreciated. I recognise that sterile marking pens have been used within the sterile field for a long time, but should we use these same disposable sterile markers for pre-operative limb marking as required for safe-site surgery protocols?
>>
>> Cheers
>> Michael
>>
>> Michael Wishart
>> CNC Infection Control
>> Holy Spirit Northside Private Hospital
>> 627 Rode Road, Chermside, Qld 4032
>> t: (07) 3326 3068 | f: (07) 3607 2226
>> e: Michael.Wishart@hsn.org.au
>> w:www.holyspiritnorthside.org.au
>> Please consider the environment before printing this email
>>
>>
>>
>> —–Original Message—–
>> From: ACIPC Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU] On Behalf Of Wilkinson, Irene (Health)
>> Sent: Wednesday, 5 June 2013 12:03 PM
>> To: AICALIST@AICALIST.ORG.AU
>> Subject: Re: Pens for marking skin prior to surgery
>>
>> Hi all,
>>
>> Is there any evidence that texta markers are a vehicle for transmission of microorganisms?
>> Th
>
> Messages posted to this list are solely the opinion of the authors, and do not represent the opinion of ACIPC.
>
> Archive of all messages are available at http://aicalist.org.au/archives – registration and login required.
>
> Replies to this message will be directed back to the list. To create a new message send an email to aicalist@aicalist.org.au
>
> To send a message to the list administrator send an email to aicalist-request@aicalist.org.au.
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> You can unsubscribe from this list be sending ‘signoff aicalist’ (without the quotes) to listserv@aicalist.org.au
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> Messages posted to this list are solely the opinion of the authors, and do not represent the opinion of ACIPC.
>
> Archive of all messages are available at http://aicalist.org.au/archives – registration and login required.
>
> Replies to this message will be directed back to the list. To create a new message send an email to aicalist@aicalist.org.au
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