Infection Control Today - 06/2004: OR Topics

June 1, 2004

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. Theresponse from healthcare workers has been overwhelmingly positive.

We have gotten feedback on the updateof the Surgical Hand Antisepsis/Hand Scrubs Recommended Practice, confirmsJoan Blanchard, RN, MSS, CNOR, CIC, a perioperative nursing specialist at AORNsCenter for Nursing Practice. One of the concerns that the nurses were tellingus about was that we needed to update the RP (recommended practice) because itdidnt match Centers for Disease Control and Prevention (CDC) Hand HygieneGuidelines. It was confusing, and they thought we needed to make a statementregarding this.

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

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

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

Some members even thought the brushless scrub could be placedin the operating room (OR) itself. AORN has not stated that, Blanchardemphasizes. CDC doesnt state that, either, for an OR setting. Our concernis that the utilization of cautery or a laser increases the possibility of afire if the hand alcohol product is used in the OR. We do not recommend that youplace the dispenser in the operating room. The best place to position thebrushless 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. Theenvironments are very different.

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

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

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

Recommended Practices in Practice

Weve actually in the last couple of months switched overto 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 didend up going with the one that provided the best staff feedback; it seemed tomeet their needs the best. Its also FDA-compliant. Its weird, because thestaff are so used to socializing at the scrub sink, coming up with their plan atthe scrub sink, and its totally reduced the time it takes to complete thehand scrub and get into the operating room.

The incentive to make alcohol-based scrub products availablewas their effectiveness, observes Starkey. Also, theres some literature orresearch showing that the actual scrubbing of the hands is a) not effective andmay even be b) counter-effective, because you actually wear down the integrityof the skin, your bodys first line of defense. Theres always been somedebate about the length of scrubbing; anything over five minutes, you reallystart to wear down that skin, or potentially cause microabrasions, which mightbe an entry port for bacteria.

Introducing the waterless products required a change in thestaffs mentality, Starkey points out. All of our surgeons, all of oursurgical technologists and surgical nurses have been trained and taught that thehand scrub is effective because of the chemical and mechanical aspects, and tothrow out the window the mechanical part of it was a complete change ofpractice. 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 inhow the team functions in their pre-surgery preparation. Normally, when theyrein the operating room setting up for the cases, the surgical team knows theyvegot a good five minutes, that the surgeon will be out at the scrub sinkscrubbing for another five minutes. Now the surgeons are in the room in 30seconds, so you dont tell them to come in until youre totally ready,she adds.