National survey of hand antisepsis practices.
KEY WORDS Hand antisepsis, Postal questionnaire, Surgical scrubbing
Skin is covered with both resident and transient micro-organisms. If these micro-organisms are transferred to patient wound sites during surgery they can become pathogenic and result in surgical site infections. The purpose of hand antisepsis is to remove transient and resident bacteria and this is achieved using antiseptic agents. This practice is commonly referred to as surgical scrubbing though this term is perhaps out-of-date and confusing given the increasing use of non-scrub products such as alcohol rubs. In this article the term antisepsis is used, rather than disinfection which pertains to inanimate objects such as work surfaces.
There are a number of options within each of the components which make up hand antisepsis. These include: the selection of antiseptic agent, the method of application, the duration of the process and the use of brushes, sponges or nail picks. The following section provides a brief summary of these components.
Hand antiseptic agents and scrubbing or rubbing
The type of antiseptic agent used dictates the accompanying technique. For example aqueous based products require scrubs and alcohol-based products require rubs. Therefore in this section the agent and the technique are considered together.
Antiseptic agents are chemicals which kill and inhibit bacteria, fungi, protozoa and bacterial spores. Ideal antiseptic agents are fast acting, persistent (effective for a number of hours), cumulative (repeated exposure inhibits bacterial growth for a number of days), have a broad spectrum of activity and are safe to use.
There are three types of antiseptic solutions available for surgical hand antisepsis:
* aqueous scrubs
* alcohol rubs
* alcohol rubs with additional active ingredients.
Aqueous scrubs are water-based solutions containing active agents or ingredients. The active agents most commonly used in aqueous scrubs are chlorhexidine gluconate or povidone iodine. Removing micro-organisms from the hands with an aqueous scrub requires performing a 'surgical scrub'. Scrubbing involves wetting the hands and forearms with water, applying an aqueous scrub using either palms or sponges, rinsing under running water then repeating this process. An example of an aqueous scrub is Hibiscrub[TM]--4% chlorhexidine gluconate in an aqueous surfactant solution.
Alcohol rubs are alcohol-based solutions which are usually available in preparations of 60-90% strength. The three main alcohols used are ethanol, isopropanol and n-propanol and some rubs may contain a mixture of these. Removing micro-organisms from the hands with an alcohol rub requires performing a 'rub'. This involves a simple hand wash at the start of the day or whenever hands are visibly soiled to remove any dirt, then applying alcohol solution and allowing it to evaporate. Manufacturers recommend two applications of solution.
Alcohol rubs with additional active ingredients
These are alcohol-based solutions which contain additional active ingredients such as chlorhexidine gluconate. The active ingredient is referred to as an additional agent as the alcohol itself is an active agent. Alcohol rubs with additional active ingredients combine the rapid kill of alcohol with the persistent chemical activity of aqueous scrubs. Removing micro-organisms from hands using alcohol rubs with an additional active ingredient requires the same process as an alcohol rub. An example of an alcohol rub with additional active ingredients is Hibisol[TM]--0.5% chlorhexidine gluconate in isopropyl alcohol.
Duration of hand antisepsis
To be effective, active ingredients within antiseptic solutions need to be in contact with the skin for a minimum duration. Recommended durations for hand antisepsis are given by various associations (see Table 1).
Brushes, sponges and nail picks
During surgical scrubs, mechanical friction can be achieved using sponges, brushes and nailpicks. These are available in sterile packs and are also supplied with aqueous solution already applied.
There is some concern that excessive scrubbing and washing may cause skin damage leading to changes in normal bacterial flora, resulting in more organisms possibly increasing the risk of transferred bacteria.
Recommendations and variations in practice
Recommendations for the various components for surgical hand antisepsis have been published by numerous organisations and professional associations worldwide. For example, the Hospital Infection Society (HIS 2001), the Association for Perioperative Practice (NATN 2004), the Centers for Disease Control (Mangram 1999), the Association for Professionals in Infection Control and Epidemiology (Larson 1995), the Association of periOperative Registered Nurses (AORN 2006) and the Australian College of Operating Room Nurses (ACORN 2004).
Interestingly, some recommendations vary between these guidelines. Table 1 provides an overview of each organisation or professional association and its recommendations for practice. However, ultimately, individual practitioners make their own choices regarding hand antisepsis. The purpose of this survey was to identify practitioners hand antisepsis practices.
This article describes a national postal questionnaire carried out to identify surgical hand antisepsis practices among perioperative practitioners. The questionnaire was sent to all 8,000 members of the Association for Perioperative Practice (AfPP) based in the UK.
The questionnaire focused on scrubs and rubs, the duration of the method of antisepsis, choice of antiseptic solution, and differences between initial, repeated and subsequent antisepsis methods. Questionnaires were piloted and revised following the comments of a group of expert practitioners. The questionnaire was designed in line with published recommendations for postal questionnaires to maximise response rates (McColl et al 2001, Edwards et al 2002). This included using a single page format, tick boxes, coloured paper, response paid envelopes and a prize draw.
Completed questionnaires were scanned electronically and data was entered onto SPSS database. Descriptive analysis was performed on returned questionnaires. Chi square tests were used for detecting any association between duration of antisepsis and two antiseptic solutions for initial, repeated and subsequent events. A chi square test is a statistical test used to identify if a relationship exists between two categorical variables.
The study was presented to the Derby Local Research Ethics Committee and the Nottinghamshire Multi-Centre Research Ethics Committee. Approval was given by the Derby Hospitals NHS Foundation Trust's Research and Development Department. In addition, AfPP gave permission for the questionnaires to be distributed to their members.
A total of 1,471 questionnaires were completed and returned giving a response rate of 18%. This compares favourably with other postal surveys conducted among AfPP members.
Method of hand antisepsis
Table 2 shows the method of hand antisepsis used for initial cases (first case of the day), repeated cases (where the practitioner removes gloves from previous case and immediately scrubs or rubs again) and subsequent cases (where the practitioner has performed hand antisepsis earlier in the day but has undertaken other activities since then).
A surgical scrub is by far the most common method (90%) for the first antisepsis of the day, although 20% of practitioners switch to using alcohol rubs for repeated cases. However, it appears that when practitioners are required to carry out subsequent scrubs they move away from alcohol rubs (from 20% to 4%) and return to the more traditional surgical scrub (74% to 87%).
Antiseptic solutions used
Table 3 identifies the antiseptic solutions used by practitioners for their first case of the day. Chlorhexidine gluconate scrub was the most popular solution (49%) followed by povidone iodine scrub (35%). Both these figures are slightly higher when practitioners who use chlorhexidine or iodine scrubs followed by an alcoholic rub are included (51% and 38% respectively).
Four per cent of practitioners used an 'other' solution. These other solutions are listed in Table 4. The product names listed in this table are transcribed verbatim from the completed questionnaires.
The reasons for choosing to use the five most common products (chlorhexidine gluconate scrub, povidone iodine scrub, alcohol rub, triclosan and 'other') are presented in Tables 5-9. The two most popular reasons for choosing to use chlorhexidine gluconate scrub--they caused the least skin reaction and were liked--were also the most popular reasons for using povidone iodine scrubs. Although surprisingly only 17% of users thought these two products were the most effective in reducing bacteria.
Alcohol rubs stood out as being considered by the practitioners who chose to use them as the most effective (50%) though only 21% of alcohol rub users liked using them. Alcohol rubs are confirmed as a newcomer to the antiseptic solution market as, unlike other mainstream products, alcohol rubs did not have a history of being 'always used'.
Skin sensitivity appeared to be the main consideration when deciding to use Triclosan and other' solutions. These solutions were considered to be kinder to skin than the mainstream products but they were rated by users as the least effective.
Duration of antisepsis
Tables 10 and 11 give the duration of antisepsis for aqueous scrubs and alcohol rubs, for initial, repeated and subsequent events. The majority of practitioners spent between three and five minutes on an initial surgical scrub and two to three minutes on a repeated scrub (91% and 78% respectively). However, the range of duration of antisepsis was more diverse for subsequent scrubs with 53% spending three minutes, 25% spending more than three minutes and 22% spending less than three minutes (see Table 10). While AfPP and HIS recommend a two minute scrub only 3% of practitioners carried out a two minute initial scrub.
The majority of practitioners (67%) use an alcohol rub for three minutes for the first antisepsis, and between 30 seconds to three minutes for repeated and subsequent cases (95% and 88% respectively) see Table 11).
When comparing the duration of application for surgical scrubs against alcohol rubs, practitioners carried out significantly shorter durations for alcohol rubs for initial events (p-value=0.0029) repeated events (p-value <0.001) and subsequent events (p-value <0.01) (See Tables 12, 13 and 14). P-value is a measure of probability that a difference between groups during an experiment happened by chance. For example, a p-value of 0.01 (p=0.01) means that there is a one in 100 chance the result occurred by chance. The lower the p-value (<0.05), the more likely it is that the difference between groups was caused by treatment.
Additional antisepsis practices
Table 15 identifies some general practices surrounding hand antisepsis. The majority of practitioners (67%) reported using a clock rather than guessing the duration of their scrub. Though 19% said they carried out the same ritualised actions for each scrub. Sponges are used by 49% of respondents and nail brushes by 92%. Just under half the respondents washed their hands at the start of the day and only 40% claimed to wash hands when they looked dirty though 83% of practitioners reported washing their hands each time they removed their gloves.
This survey shows that the favoured method of surgical hand antisepsis is a surgical scrub using an aqueous solution of chlorhexidine gluconate or povidone iodine. A small percentage of practitioners preferred to use alternative products which they felt caused fewer skin reactions. However they considered these alternative products to be less effective in reducing bacteria than the more mainstream products.
While alcohol rubs are recommended by most organisations, with the exception of AORN, as an alternative to repeated washings only, their uptake among perioperative practitioners remains less frequent than aqueous scrubs, with maximum reported usage figures of 20%. (AORN supports the use of alcohol rubs as an alternative to initial as well as repeated antisepsis.) Alcohol rubs were predominantly found to be used for cases where practitioners carried out repeated antisepsis rather than initial or subsequent antisepsis. The duration of application for alcohol rubs is significantly shorter than surgical scrubs for all cases (initial, repeated and subsequent).
Half of the respondents used sponges. It would have been interesting to know the rationale for using, or not using, sponges but this information was not sought. Almost all respondents used nail brushes on their nails.
Non-compliance with recommended guidelines
Though guidelines have been available in the UK (NATN 2004 and HIS 2001) for several years, compliance among practitioners remains patchy.
While start of day pre-washes are recommended by AfPP, just under half the respondents washed their hands before commencing their first scrub of the day. This suggests that the compliance with this recommendation is poor. However, conversely, the majority of respondents washed their hands after removing sterile gloves. This practice is strongly advised to support basic hand hygiene and also to reduce latex sensitisation (OSHA 2006).
Though the guidelines from AfPP and HIS recommend a two minute scrub for all scrubs, the majority of initial surgical scrubs lasted for between three and five minutes with shorter durations for repeated and subsequent scrubs.
The reason for this non-compliance was not explored in the survey. However, it may be that practitioners are not aware of the recommended guidelines. Surgical scrubs used to be performed for a minimum of five minutes and it might be that practitioners find it difficult to change this practice.
Knowledge of antiseptic agents
It appears that the main reason for selecting an antiseptic agent relates to skin sensitivity and lack of reaction to the product. It is probably safe to assume that respondents using Triclosan or 'other' products did so after experiencing reactions to more mainstream products. However, it is not clear if respondents who chose to use chlorhexidine gluconate scrub did so after experimenting with povidone iodine scrubs and vice versa.
Skin sensitivity and 'liking' the product were more important than the perceived effectiveness of the product. There may be some lack of knowledge surrounding the comparative effectiveness of different antiseptic agents which needs to be addressed.
There are some issues among the recommended practices outlined in Table 1 which do not appear to be addressed. For example, while most organisations discuss the duration of the surgical scrub, contact times for alcohol rubs are not given and few organisations state if the dose of antiseptic agent is important or mention sponges. Though none of the organisations recommend specific antiseptic agents, usually stating instead that antiseptics should meet general criteria, no distinction is made between alcohol rubs and alcohol rubs containing additional active ingredients. In addition, it might be helpful for guidelines to comment on the effectiveness of different antiseptic agents.
The survey shows that most practitioners differentiate between repeated and subsequent antisepsis by eschewing alcohol rubs and returning to aqueous scrubs. However, none of the published recommendations make any distinction between repeated and subsequent scrubs. Recommendations should clarify if there is indeed a difference and whether, or not, they require to be treated differently. Further evidence of the lack of clarity over subsequent scrubs was the confusion regarding the duration of antisepsis for subsequent scrubs. While practitioners clustered around a three to five minute initial scrub and a two to three minute repeated scrub, scrub times for subsequent scrubs ranged across the spectrum.
A further comment relates to the knowledge of manufacturers' instructions. While most of the recommended guidelines refer the practitioner to manufacturers' instructions, only half the practitioners were aware of manufacturers' recommendations regarding dosage (Table 15). Some work may be needed to make practitioners more aware of manufacturers' instructions or professional organisations should provide this information.
Some progress has been made in the ritualised practice of the surgical scrub, with shorter times and a move towards alcohol rubs. However, full compliance with recommended guidelines has yet to be established. While practitioners need to become more aware of guidelines, the guidelines themselves need to be updated and address outstanding issues.
This study was funded by the 2005 Siobhan Rankin Award. The authors would like to thank all the practitioners who took part in the study by completing and returning questionnaires.
ACORN 2004 ACORN Standards O'Halloran Hill, Australian College of Operating Room Nurses
AORN 2006 Standards, Recommended Practices and Guidelines Denver, Association of periOperative Registered Nurses
Edwards P, Roberts I, Clarke M et al 2002 Increasing response rates to postal questionnaires: systematic review British Medical Journal 324 1183-1194
HIS 2001 Behaviours and Rituals in the Operating Theatre Hospital Infection SocietyAvailable from: www.his.org.uk/_db/_documents/Rituals-02.pdf [accessed 29 June 2006]
Mangram AJ 1999 Guidelines for prevention of surgical site infection Infection Control and Hospital Epidemiology 20 (4) 247-278
McColl E, Jacoby A, Thomas L et al 2001 Design and use of questionnaires Health Technology Assessment 5 (31) 1-266
NATN 2004 NATN Standards and Recommendations Harrogate, NATN
OSHA 2006 Latex AllergyAvailable from: http://www.osha.gov/SLTC/etools/hospital/hazards/late x/latex.html [accessed 26 June 2006]
Judith Tanner BN, MPhil, PhD
Professor of Clinical Nursing Research, De Montfort University and University Hospitals Leicester
Chris Blunsden RGN
Acting Theatre Manager, Derby City General Hospital
Apostolos Fakis BSc, MSc
Medical Statistician, Derby Hospitals NHS Foundation Trust
Table 1 Recommended hand antisepsis practices HIS AfPP Start of day - Wash with plain pre-wash antimicrobial solution (sic) before beginning surgical scrub Aqueous - Should meet scrub general solutions criteria for antiseptics Alcohol Acceptable Acceptable rubs alternative to alternative to repeated repeated washing washing. Are not appropriate when hands are visibly contaminated Dose/ - 5mls at each amount of application solution Brushes Not Not necessary recommended (except for nails) Sponges - - Nail pick For first case For first case Duration Two minutes is Two minutes is of sufficient sufficient. aqueous Adhere to scrub manufacturer's instructions Duration - - of alcohol rub AORN CDC Start of day Wash with plain or - pre-wash antimicrobial soap before beginning first scrub Aqueous Should meet Should meet scrub general criteria general criteria solutions for antiseptics for antiseptics Alcohol May be used for Are discussed but rubs routine no decontamination. recommendations Are not are given appropriate if hands are visibly soiled Dose/ Dispense - amount of according to solution manufacturer's instructions Brushes Not necessary For first case only to clean nails Sponges Can be used - Nail pick Yes - Duration A timed scrub or Suggests that two of a stroke counted minutes as aqueous method may be effective as ten scrub used. With minutes but specific products optimum three-four minutes as duration not effective as five known minutes. Practitioners should follow manufacturer's written instructions Duration Requires a - of alcohol shorter duration rub than acqueous scrubs ACORN Start of day - pre-wash Aqueous Should meet scrub general criteria for solutions antiseptics Alcohol If using an rubs alcohol based hand rub, use as per manufacturer's recommendations Dose/ Sufficient solution amount of to ensure adequate solution skin coverage Brushes - Sponges - Nail pick For first case Duration Five minute scrub for of first case of the day, aqueous three minute scrub scrub for subsequent cases Duration - of alcohol rub Hospital Infection Society (HIS;) Association for Perioperative Practice (AfPP); Association of Perioperative Registered Nurses (AORN); Centers for Disease Control (CDC); Australian Colleger of Operating Room Nurses (ACORN) Table 2 Methods used for surgical hand antisepsis Scrub Scrub plus rub Rub Initial 1309 (90%) 145 (9%) 9 (>1%) Repeated 1090 (74%) 78 (5%) 283 (20%) Subsequent 1277 (87%) 126 (8%) 62 (4%) Scrub or rub Total Initial 2 (>1%) 1465 Repeated 16 (1%) 1467 Subsequent 5 (>1%) 1470 Table 3 Which antiseptic solution do you use for your first case of the day? Antiseptic solution Number of practitioners Chlorhexidine gluconate scrub 729 (49%) Povidone iodine scrub 513 (35%) Alcohol rub 14 (>1%) Chlorhexidine gluconate scrub plus alcohol rub 38 (2%) Povidone iodine scrub plus alcohol rub 44 (3%) Chlorhexidine gluconate or povidone iodine scrub 22 (2%) Chlorhexidine gluconate scrub or alcohol rub 4 (>1%) Chlorhexidine gluconate scrub or povidone iodine 1 (>1%) scrub plus alcohol rub Triclosan rub 52 (3%) Other * 55 (4%) Total 1472 Other * details are listed in Table 4 Table 4 'Other' antiseptic solutions identified in Table 3 Antiseptic solution * Number of practitioners Aloe vera soap 1 Antibacterial hand wash 1 Aquagel 1 Aquasept and alcohol 2 Baktoln and sterillium 4 Chlorex and aloe vera 1 Clarex 1 Cutan soap 1 Dermol 3 Desdermen 1 Johnsons soap 1 Lever line 1 Mediscrub 3 PCMX 8 PEMOC 1 PMX 2 Savlon 1 Soap 12 Soap and alcohol scrub 5 Total number 55 * names of products are reproduced verbatim from responses on questionnaire sheet Table 5 I use chlorhexidine gluconate scrub because ... Reason Number of practitioners n = 729 Causes the least skin reaction 406 (56%) I like it best 270 (37%) I've always used 183 (25%) It is the most effective in reducing bacteria 124 (17%) It is listed on our theatre policy 83 (11%) Only solution available 6 (>1%) Table 6 I use povidone iodine scrub because ... Reason Number of practitioners n = 512 Causes the least skin reaction 358 (70%) I like it best 143 (28%) I've always used it 89 (17%) It is the most effective in reducing bacteria 87 (17%) It is listed on our theatre policy 47 (9%) Only solution available 1 (>1%) Table 7 I use alcohol hand rub for initial antisepsis because ... Reason Number of practitioners n = 14 Causes the least skin reaction 9 (64%) It is the most effective in reducing bacteria 7 (50%) I like it best 3 (21%) It is listed on our theatre policy 2 (14%) Only solution available 1 (7%) I've always used it 0 (0%) Table 8 I use triclosan because ... Reason Number of practitioners n = 52 Causes the least skin reaction 48 (92%) I like it best 15 (29%) I've always used it 6 (11%) It is the most effective in reducing bacteria 1 (2%) It is listed on our theatre policy 0 (0%) Only solution available 0 (0%) Table 9 I use other' products because * ... Reason Number of practitioners n = 55 Causes the least skin reaction 40 (72%) I like it best 8 (15%) I've always used it 2 (4%) It is the most effective in reducing bacteria 5 (9%) It is listed on our theatre policy 6 (11%) Only solution available 3 (5%) * 'other' products are listed in Table 4 Table 10 Duration of surgical scrubs 30 sec 1 min 2 min Initial 0(0%) 11 (>1%) 43 (3%) Repeated 3(>1%) 72 (6%) 238 (22%) Subsequent 9(>l%) 52 (4%) 211 (17%) 3 min 4 min 5 min Initial 414 (32%) 170 (13%) 604 (46%) Repeated 587 (56%) 74 (7%) 87 (8%) Subsequent 665 (53%) 95 (8%) 196 (16%) 6-10 min Don't know Total Initial 52 (4%) 6 (>1%) 1300 Repeated 7 (>1%) 8 (>1%) 1076 Subsequent 15 (1%) 9 (>1%) 1252 Table 11 Duration of alcohol rubs 30 sec 1 min 2 min Initial 0 1 (11%) 1 (11%) Repeated 47 (18%) 99 (37%) 70 (26%) Subsequent 10 (16%) 22 (35%) 8 (13%) 3 min 4 min 5 min Initial 6 (67%) 1 (11%) 0 Repeated 38 (14%) 1 (>1%) 1 (>1%) Subsequent 15 (24%) 2 (3%) 2 (3%) 6-10 min Don't know Total Initial 0 0 9 Repeated 1 (>1%) 10 (4%) 276 Subsequent 1 (>2%) 2 (3%) 62 Table 12 Duration of initial antisepsis (scrubs and rubs) Initial antisepsis 30 sec 1 min 2 min Surgical scrubs 0 (0%) 11 (>1%) 43 (3%) Alcohol Rubs 0 1 (11%) 1 (11%) Initial antisepsis 3 min 4 min 5 min Surgical scrubs 414 (32%) 170 (13%) 604 (46%) Alcohol Rubs 6 (67%) 1 (11%) 0 Initial antisepsis 6-10 min Don't know Total Surgical scrubs 52 (4%) 6 (>1%) 1300 Alcohol Rubs 0 0 9 Table 13 Duration of repeated antisepsis (scrubs and rubs) Repeated antisepsis 30 sec 1 min 2 min Surgical scrubs 3 (>1%) 72 (6%) 238 (22%) Alcohol Rubs 47 (18%) 99 (37%) 70 (26%) Repeated antisepsis 3 min 4 min 5 min Surgical scrubs 587 (56%) 74 (7%) 87 (8%) Alcohol Rubs 38 (14%) 1 (>1%) 1 (>1%) Repeated antisepsis 6-10 min Don't know Total Surgical scrubs 7 (>1%) 8 (>1%) 1076 Alcohol Rubs 1 (>1%) 10 (4%) 276 Table 14 Duration of subsequent antisepsis (scrubs and rubs) Subsequent antisepsis 30 sec 1 min 2 min Surgical scrubs 9 (>1%) 52 (4%) 211 (17%) Alcohol Rubs 10 (16%) 22 (35%) 8 (13%) Subsequent antisepsis 3 min 4 min 5 min Surgical scrubs 665 (53%) 95 (8%) 196 (16%) Alcohol Rubs 15 (24%) 2 (3%) 2 (3%) Subsequent antisepsis 6-10 min Don't know Total Surgical scrubs 15 (1%) 9 (>1%) 1252 Alcohol Rubs 1 (2%) 2 (3%) 62 Table 15 Surgical hand antisepsis practices Statement Respondents who agreed I guess the duration of my scrub 471/1419 (33%) I watch a clock during my scrub 959/1425 (67%) I don't bother about time focus on actions 267/1397 (19%) I use a sponge on my hands and arms 702/1429 (49%) I use a nail brush on my nails 1347/1454 (92%) I am not aware how much solution I use 553/1410 (39%) I use the manufacturers recommended dose 775/1381 (56%) I wash my hands before the 1st scrub of the day 693/1466 (47%) I wash my hands before subsequent scrubs 242/1463 (16%) I wash my hands before alcohol hand rubs 229/283 (80%) I wash my hands when they look dirty 586/1465 (40%) I wash my hands every time I remove my gloves 1231/1468 (83%)
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|Title Annotation:||CLINICAL FEATURE|
|Author:||Tanner, Judith; Blunsden, Chris; Fakis, Apostolos|
|Publication:||Journal of Perioperative Practice|
|Date:||Jan 1, 2007|
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