Infection Control Today - 06/2004: OR Topics

AORN Surgical Scrub Update
Appropriate Hygiene for the New Millennium

By Kathy Dix

Earlier this year, the Association of periOperative Registered Nurses (AORN) released updated guidelines on the proper procedures for surgical scrubs. The response from healthcare workers has been overwhelmingly positive.

We have gotten feedback on the update of the Surgical Hand Antisepsis/Hand Scrubs Recommended Practice, confirms Joan Blanchard, RN, MSS, CNOR, CIC, a perioperative nursing specialist at AORNs Center for Nursing Practice. One of the concerns that the nurses were telling us about was that we needed to update the RP (recommended practice) because it didnt match Centers for Disease Control and Prevention (CDC) Hand Hygiene Guidelines. It was confusing, and they thought we needed to make a statement regarding this.

AORN had waited to release the updated version because the AORN Standards, Recommended Practices and Guidelines comes out at the beginning of each year, so it made sense to include the recommended surgical scrub practices with that publication. Thus, in the fall of 2003, It was put on the AORN Web site for member input and feedback, Blanchard explains. The RP does follow very closely with the CDC guidelines. We have gotten positive feedback from our membership.

The guidelines were then included in the annual book, and also published in the February 2004 issue of AORN Journal. We started getting feedback as soon as the members got their journal and could see that we had addressed the CDC Hand Hygiene Guidelines, Blanchard recalls. The draft of a new recommended practice goes on our AORN Web site for review once it has been updated. We know what the responses are almost immediately. What we dont know is the response from the member who doesnt get online and review recommended practices. Putting the final draft in the AORN Journal reaches all of our members. They, of course, also get the final draft of the RP in their new Standards, Recommended Practices, and Guidelines.

There were some misconceptions when the draft of the guidelines was first released. I think what people initially thought of the alcohol products was that you would not have to wash your hands anymore, Blanchard says. We are following CDCs guidelines, which basically state you have to remove debris from your hands, especially when youre coming in from the outdoors. An important point is using the nail files to clean under your nails; that is an area of high microbial collection. Handwashing remains a key part of caring for patients; you wash your hands between patients, before using the alcohol hand preparation, after going to the bathroom, before lunch, between procedures, and any other time you need to.

Some members even thought the brushless scrub could be placed in the operating room (OR) itself. AORN has not stated that, Blanchard emphasizes. CDC doesnt state that, either, for an OR setting. Our concern is that the utilization of cautery or a laser increases the possibility of a fire if the hand alcohol product is used in the OR. We do not recommend that you place the dispenser in the operating room. The best place to position the brushless scrub is in the scrub sink area.

However, there was a reason for the misunderstanding, she points out. I think the confusion came from CDCs guidelines stating that you could put the alcohol product in a patient room. That is very different than putting an alcohol dispenser in an OR. The environments are very different.

The new guidelines differ from the previous version in only one main aspect: The previous AORN recommendations dealt basically with surgical hand scrub with a brush, says Blanchard. That is still part of the recommended practice if ORs choose to use that method. The previous recommended practice did not have the emphasis on the alcohol products that is in the 2004 update.

One of the main changes at AORN is the number of phone calls they receive about what their position is on the brushless system since the updated CDC guidelines were published. Basically, people wait to see what AORN is going to publish, because we do a lot of research and review a lot of different practices before we put new recommendations out. It is also important to get members feedback before the new RPs go out, Blanchard says.

The Recommended Practices Committee has been studying this for over a year because the RP was due for an update, she adds. It was time to update the RP to be in line with the CDC Hand Hygiene Guideline. I think weve ended up with a good recommended practice. Technology is wonderful; it creates new procedures and processes. As these procedures and processes improve, AORN will shift based on the research and references in the field. If its a real shift in practice patterns, then it needs to be addressed.

Recommended Practices in Practice

Weve actually in the last couple of months switched over to the alcohol-based brushless and waterless product, says Amie Starkey, RN, a nurse clinician, operating rooms, at William Beaumont Hospital in Royal Oak, Mich. We trialed two different companies with very similar products, but did end up going with the one that provided the best staff feedback; it seemed to meet their needs the best. Its also FDA-compliant. Its weird, because the staff are so used to socializing at the scrub sink, coming up with their plan at the scrub sink, and its totally reduced the time it takes to complete the hand scrub and get into the operating room.

The incentive to make alcohol-based scrub products available was their effectiveness, observes Starkey. Also, theres some literature or research showing that the actual scrubbing of the hands is a) not effective and may even be b) counter-effective, because you actually wear down the integrity of the skin, your bodys first line of defense. Theres always been some debate about the length of scrubbing; anything over five minutes, you really start to wear down that skin, or potentially cause microabrasions, which might be an entry port for bacteria.

Introducing the waterless products required a change in the staffs mentality, Starkey points out. All of our surgeons, all of our surgical technologists and surgical nurses have been trained and taught that the hand scrub is effective because of the chemical and mechanical aspects, and to throw out the window the mechanical part of it was a complete change of practice. But by showing the documentation and the research thats been done, they couldnt help but buy into it.

The shorter time to scrub in has made quite a difference in how the team functions in their pre-surgery preparation. Normally, when theyre in the operating room setting up for the cases, the surgical team knows theyve got a good five minutes, that the surgeon will be out at the scrub sink scrubbing for another five minutes. Now the surgeons are in the room in 30 seconds, so you dont tell them to come in until youre totally ready, she adds.

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