Understanding Surgical Hand Antisepsis


In the paper, Low Adherence With Waterless Surgical Hand Antisepsis, authors Lawton Seal, PhD, of Healthpoint, Ltd., and Shanta Modak, PhD, and Cenk Cayci, MD, both of the Department of Surgery at the College of Physicians and Surgeons at Columbia University, describe how a survey was undertaken with operating room (OR) nursing personnel to better understand the level of adherence of the revised guidelines, obstacles to adoption, and limitations of current products.


Based on the evidence that alcohol-based hand rubs are more effective than water-based soaps, the Centers for Disease Control and Prevention (CDC) revised its prevention guidelines on hand hygiene with the objective to improve the low level of compliance among healthcare personnel.1 Reports indicate implementation of a waterless hand rub saves time and reduces dermal irritation with the same clinical outcomes. The Association of periOperative Registered Nurses (AORN), recognizing the environmental challenge the OR setting presents, revised OR hand hygiene antisepsis guidelines in 2004.


1. Adoption of waterless alcohol-based hand rub 

  • A waterless alcohol-based hand rub product was available for surgical and antisepsis in 81.9 percent (610/745) of the institutions represented by the respondents 

  • Familiarity with AORN Guidelines 

  • 42.9 percent (282/658) of respondents indicated they were only somewhat familiar or less with AORN guidelines for use of waterless alcohol-based hand rub agents 

2. Performance of prewash 

  • 74.7 percent (438/586) of respondents were non-adherent to AORN guidelines for prewash 

  • Reasons cited for not performing a prewash included: not clinically needed (57.4 percent, 301/524); time constraints (11.3 percent, 59/524); did not like the effect on their skin (9.2 percent, 48/524) 

3. Application of waterless alcohol-based hand rub 

  • 39.8 percent (219/550) of respondents used less than the amount of waterless product indicated in the products labeling; 84.0 percent (184/219) used fewer than 3 pump applications because they think it is not clinically needed; 11.0 percent (24/219) used less based on hand-feel or impact on their hands 

  • 31.1 percent (169/543) did not rub until dry as per AORN Guidelines and manufacturers written directions 

  • 24.9 percent (134/538) of respondents reported utilizing a towel to aid drying; 83.7 percent (108//129) reported using a towel in order to speed the drying process; 16.3 percent (21/129) reported dislike of hand-feel as the reason for towel drying 

4. Hand-feel experience with waterless alcohol-based hand rub 

  • 76.6 percent (406/530) of respondents reported difficulty donning gloves with waterless alcohol-based hand rub 

  • 61.1 percent (310/507) reported difficulty in re-gloving after utilizing a waterless alcohol-based hand rub for surgical hand antisepsis 

  • 68.3 percent (355/520) reported having experienced slipping (defined as when hands/fingers move or slide within the glove); 14.4 percent (52/361) indicated they towel dried or used less product during scrub to avoid slipping


While the results of this survey indicate waterless alcohol-based hand rub agents are widely used by perioperative nurses, it suggests that in many instances they are not being used properly. Reasons for this low level of adherence may be a combination of factors including:

  • Low understanding of AORN guidelines and manufacturers directions 

  • Time constraints within the OR setting 

  • Level of satisfaction of available products 

It appears that there is less-than-complete understanding of AORN guidelines and product labeling for the use of waterless alcohol-based hand rub products. This is evidenced by the low level of prewash prior to utilization of a waterless alcohol-based hand rub, variation in the amount of waterless product applied, and the use of a towel to aid drying. Use of less than the specified amount of product whether from application of fewer than the three pumps specified in the manufacturers written directions or product removal via a towel-aided drying process increases the risk that the desired level of antimicrobial antisepsis may not be maintained.

Time constraints were the major reason cited for not rubbing the hand rub into the hands and forearms until completely dry, and to a lesser extent the reason for not performing a prewash. It is well documented that increased time constraints negatively impact adherence to OR guidelines.

Formulation of available products was also noted as an issue. In particular, difficulties related to donning/wearing surgical gloves were reported. As hand-feel issues were mentioned as reasons for using a towel and applying less product, they appear to contribute to non AORN-compliant usage of waterless products.


While waterless alcohol-based hand rub agents are widely used in the OR, the results of this survey indicate they are not always being used properly. This potentially compromises their efficacy. To improve adherence to AORN guidelines and maintain the desired level of antisepsis in the OR, the following is suggested for nurse managers:

  • Proactively monitor for inappropriate application of waterless alcohol-based hand rub products 

  • Educate and reinforce of AORN guidelines as they pertain to the use of surgical hand antisepsis 

  • Recognize that formulation of the product can affect adherence and select waterless alcohol-based hand rub products accordingly


1. Boyce JM and Pittet D. Guideline for hand hygiene in healthcare settings. Morb Mortal Wkly Rep. 2002;51(RR16):1-44

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