Perioperative Hand Hygiene:

Perioperative Hand Hygiene:
The Challenge of Integrating Rinseless Products in the OR

By Michael Garvin, MHA

The healthcare industry is rapidly adopting alcohol-based products throughout the hospital. Based on research from key hand hygiene experts such as Elaine Larson, RN, PhD, from Columbia University College of Nursing, there is growing interest among infection control practitioners (ICPs) to evaluate these alcohol-based products for hand hygiene use.

In addition, the Centers for Disease Control and Prevention (CDC) recently published its hand hygiene recommendations strongly supporting the use of alcohol-based products for improved infection control practices. The use of alcohol products is gaining wide acceptance within the patient-care arena. The challenge facing ICPs and operating room (OR) managers is how the new products fit into the perioperative surgical scrub procedures.

The CDC's guidance for the use of surgical scrub procedures is provided by the agency's new hand hygiene guidelines. Speaking at a news conference at the 2002 annual meeting of the Infectious Disease Society of America, Dr. Julie Gerberling, director of the CDC, stated, "What we are advocating is a comprehensive approach to hand hygiene. Certainly if the hands of the healthcare workers are soiled, they need to wash with soap and water, and gloves are still recommended for situations where people have contact with blood or other body fluids or when they're conducting sterile procedures."

This being said, there is confusion and concern among ICPs with regard to how hand hygiene is addressed in the OR vs. other patient-care areas. The purpose of this article is to attempt to set the discussion parameters for the use of alcohol-based products in the surgical arena.

The introduction of alcohol-based hand antiseptics has changed the way clinicians are implementing and maintaining hand hygiene as a part of infection control procedures. In both the inpatient and clinical environment, the pace in which the clinician sees patients has increased dramatically during the past 20 years, while the practice of proper hand hygiene has decreased.

The time it takes to wash hands and the somewhat inconvenient location of sinks impact overall productivity and compliance. The studies that support the use of alcohol-based hand antiseptics as a substitute for hand washing indicate they are as effective as traditional handwashing if the solution is applied thoroughly and uniformly. It is also widely believed by industry leaders that the convenience and ease of use of alcohol-based products will increase compliance.

Within the surgical environment, compliance does not have the same challenges.

"I think that most ICPs understand that the hand hygiene issues facing OR staff is different from what faces the staff in clinics and inpatient floors," says Dr. Victoria Steeleman of the University of Iowa Hospitals and Clinics. "On the floors, access to handwashing sinks continues to be a problem. That is hardly ever the case in the OR. On the floors, you could have a doctor seeing five patients an hour with handwashing between every patient. In the OR, patient turnover is rarely that fast and the limiting factor on getting to the next patient is more the set-up of the room."

The question arises whether the same dynamics are at work in the OR setting. Should the same conversion toward alcohol-based products take place in that area? Obviously, time is always a precious commodity in any sector of the healthcare-delivery process. This is no less the case in the OR than in other patient-care areas. Yet the similarities between the patient room or clinic and the OR are more difficult to define once one gets beyond the time issue.

The reluctance of many OR directors to readily adopt alcohol-based surgical hand scrubs is an indication that even if the new hand antiseptics are as good as the traditional surgical hand scrub techniques, there are other environmental dynamics that come into play. In fact, utilizing the traditional scrubbing technique allows the clinician to remove gross particles from the skin and under the nails, which provides a compelling reason for the decision to retain some scrubbing or mechanical agitation in the surgical hand scrub procedure.

"We are recommending a 3-minute wash to remove materials from the hands," says Mary Claire Cook, surgical services nurse manager at the University of Washington Medical Center. "Nurses and surgeons may have been playing with the dog or working in the garden before coming to the OR. We want to make sure that gross contamination is taken care of. The alcohol-based products can then be used as needed following the wash."

Although it is recognized that the 10-minute scrub with a brush is not necessary, there is sound reason and common sense for continuing with some sort of mechanical agitation. There is still a strong belief among clinicians in the surgical setting that a brush/sponge should still be used for the first scrub of the day, or any time the hands become visibly soiled. Using a brush/sponge provides the mechanical action needed to eliminate environmental dirt and debris. This will also help ensure that nails are thoroughly cleaned, as nails are recognized areas that harbor transient bacteria. Procedures can then be supplemented throughout the day with an alcohol-based surgical hand scrub product.

Another issue that is adding confusion to the industry is what one should look for in a surgical hand scrub antiseptic. The Food and Drug Administration (FDA) states that products considered to be surgical scrubs must show characteristics that include immediate kill, broad-spectrum activity and persistence up to six hours and residual activity over time.

ICPs and hospital purchasing professionals must carefully review the scientific findings supporting a product's claim of both kill efficiency and persistence. As long as the claims meet the performance required and as long as the scientific data supports performance, it makes little difference what components are used to achieve that performance.

One last area of consideration when choosing one of the newer surgical hand scrub products is should the product be a rinseless or water-aided (rinsed) alcohol-based antiseptic. Both have advantages, including ease of use and convenience; however, ICPs and the OR surgical staff are encouraged to monitor methodology and compliance. The one concern with these newer products is that the ease of use and convenience will lead to complacency, which could ultimately lead to an increase in surgical site infections.

So, is a logical approach to perioperative hand-hygiene protocol a "blended" system using traditional handwashing and alcohol-based products? Rita McCormick, senior infection control practitioner at the University of Wisconsin Hospitals and Clinics, believes so.

"There are surgeons who would not feel comfortable in not scrubbing for a case. The term 'scrubbing for a case' is ingrained into our industry language and psyche. However, alcohol-based products could prove very helpful in reducing the wear and tear on the hands of the OR professional."

Hand hygiene efforts in the OR have found a new ally in maintaining compliance. The alcohol-based hand antiseptic products are making it easier to ensure that disease is not transmitted. Yet the OR poses a unique challenge on how best to use these new products. A "blended" approach seems to allow staff to remove any gross contamination from their hands, while the alcohol-based products provide an easy-to-implement, second-tier protection to help hands stay clean.

Michael Garvin, MHA, is a safety consultant for the University of Iowa Hospital and Clinics.

Hand Hygiene Guidelines Fact Sheet

According to the Centers for Disease Control and Prevention (CDC), improved adherence to hand hygiene (i.e., handwashing or use of alcohol-based hand rubs) has been shown to terminate outbreaks in healthcare facilities, to reduce transmission of antimicrobial resistant organisms (e.g., methicillin resistant Staphylococcus aureus) and reduce overall infection rates.

In October 2002, the CDC released guidelines to improve adherence to hand hygiene in healthcare settings. In addition to traditional handwashing with soap and water, the CDC is recommending the use of alcohol-based handrubs by healthcare personnel for patient care because they address some of the obstacles that healthcare professionals face when taking care of patients.

Handwashing with soap and water remains a sensible strategy for hand hygiene in non-health care settings and is recommended by the CDC and other experts.

When healthcare personnel's hands are visibly soiled, they should wash with soap and water.

The use of gloves does not eliminate the need for hand hygiene. Likewise, the use of hand hygiene does not eliminate the need for gloves. Gloves reduce hand contamination by 70 percent to 80 percent, prevent cross-contamination and protect patients and health care personnel from infection. Handrubs should be used before and after each patient just as gloves should be changed before and after each patient.

When using an alcohol-based handrub, apply product to the palm of one hand and rub hands together, covering all surfaces of hands and fingers, until hands are dry. Note that the volume needed to reduce the number of bacteria on hands varies by product.

Alcohol-based handrubs significantly reduce the number of microorganisms on skin, are fast acting and cause less skin irritation.

Healthcare personnel should avoid wearing artificial nails and keep natural nails less than one quarter of an inch long if they care for patients at high risk of acquiring infections (e.g. patients in intensive care units or in transplant units).

When evaluating hand hygiene products for potential use in healthcare facilities, administrators or product selection committees should consider the relative efficacy of antiseptic agents against various pathogens and the acceptability of hand hygiene products by personnel. Characteristics of a product that can affect acceptance and therefore usage include its smell, consistency, color and the effect of dryness on hands.

As part of these recommendations, CDC is asking healthcare facilities to develop and implement a system for measuring improvements in adherence to these hand hygiene recommendations. Some of the suggested performance indicators include: periodic monitoring of hand hygiene adherence and providing feedback to personnel regarding their performance, monitoring the volume of alcohol-based handrub used/1,000 patient days, monitoring adherence to policies dealing with wearing artificial nails and focused assessment of the adequacy of healthcare personnel hand hygiene when outbreaks of infection occur.

Allergic contact dermatitis due to alcohol handrubs is very uncommon. However, with increasing use of such products by healthcare personnel, it is likely that true allergic reactions to such products will occasionally be encountered.

Alcohol-based handrubs take less time to use than traditional hand washing. In an eight-hour shift, an estimated one hour of an ICU nurse's time will be saved by using an alcohol-based handrub.

Source: CDC and