One hospital's clinical evaluation of brushless scrubbing

AORN Journal,  Feb, 2004  by Mara Berman

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Editor's note: AORN's "Recommended practices for surgical hand antisepsis/hand scrubs" appear on pages 416 to 431 in this issue of the Journal. AORN encourages readers to refer to this document when undertaking any evaluation of scrubbing practices in their facilities.

Brushless scrubbing is a relatively new concept. Traditional surgical scrubbing of the hands and forearms with a brush or sponge has been the policy for surgical team members for decades. Can this tradition be changed if other methods of cleansing the hands and arms before surgery prove effective? Can the traditional scrubbing practice, which mandates friction and no touching after scrubbing, be changed to a practice that is much less stringent? This paradigm shift was considered by a 380-bed acute care hospital in the southeastern United States. The hospital conducted a clinical evaluation to investigate brushless scrubbing.

BACKGROUND

Traditional surgical scrubbing has been the norm for many years. It is abrasive to the skin and may provoke allergic reactions. Compromised skin integrity may increase the chances of bacteria colonization on the hands and under the nails. In 2002, the Centers for Disease Control and Prevention said that using a brush or sponge no longer was necessary to reduce the microbial count on hands as long as an alcohol-based scrub product was used. (1) Studies show that alcohol-based solutions that contain between 60% and 95% alcohol have the greatest ability to decrease the bacterial count on hands after scrubbing compared to other agents. (2)

Brushless scrubbing is the surgical scrubbing of the hands and forearms with an antimicrobial agent without the use of a brush or sponge. The person's hands serve as the friction agent. Brushless scrubbing is believed to be less caustic and abrasive to the skin than traditional scrubbing and can aid in maintaining skin integrity, even after repeated use in the perioperative setting. (1,2) The antimicrobial agents used in conjunction with agents for persistence (eg, zinc pyrithione) have been shown to have long-lasting effects, thereby minimizing the chances of patients acquiring postoperative surgical site infections (SSIs). (3)

EVALUATION PARAMETERS

The project director at the hospital where the evaluation was conducted wanted to examine the effectiveness of brushless scrubbing to determine whether it would irritate perioperative staff members' hands and arms and whether it would result in changes in patients' postoperative SSI rates. Perioperative staff members' satisfaction with the alcohol product and their acceptance of brushless scrubbing also were investigated.

Many factors and variables contribute to the development of postoperative infections; therefore, the facility limited the evaluation to specific procedures--laminectomies, craniotomies, and colectomies. Generally, patients undergoing these procedures have fewer contributing medical problems that would make them more susceptible to postoperative SSIs.

CONDUCTING THE EVALUATION

The evaluation was conducted at a not-for-profit, 380-bed, acute care hospital that is part of the Baptist Health South Florida hospital system. There are 10 OR suites in the main hospital and four OR suites in the outpatient surgery center. To examine staff members' satisfaction and compliance with a brushless system, those who perform surgical scrubs (ie, surgeons, nurses, surgical technologists, house physicians) participated in the evaluation. To examine the potential increase in participants' skin irritation that could lead to skin infection and thus SSI in patients, information was collected postoperatively on staff members' skin breakdown, irritations/allergic reactions, pain/itching, and skin moisture. The evaluation took six months (ie, 27 weeks).

PRODUCT EVALUATED. The project director had to determine which alcohol-based brushless scrubbing agent would be used. She evaluated all available products and chose an antimicrobial agent approved by the US Food and Drug Administration (FDA). The product chosen is a 70% ethyl alcohol-based solution that contains emollients and the preservative zinc pyrithione, which enables the product to increase its persistence. According to the FDA's Tentative Final Monograph for HealthCare Antiseptic Drug Products, ethyl alcohol is classified as a category one agent, meaning it is safe and effective) The monograph for the chosen product states that it exceeds the highest requirement for antimicrobial activity for a five-day period. The director liked this product because it is used with water, as is traditional scrubbing. The hospital's infection control committee approved the use of the product in the clinical evaluation. All perioperative staff members attended an inservice program regarding the proper use of the product (Table 1).

DATA COLLECTION. Two data collection tools were developed. One was a satisfaction data collection worksheet (Table 2), and the other was an infection control data collection worksheet (Table 3). The satisfaction data collection worksheet included a three-point rating scale that staff members used to rank their skin integrity from poor to excellent. This tool was used to identify the brushless product's effects on their hands and arms after application. The infection control data collection worksheet was used to gather information about patients' development of postoperative SSIs.