Recommended practices for surgical hand: antisepsis/hand scrubs - Recommended Practices

AORN Journal, Feb, 2004

The following recommended practices were developed by the AORN Recommended Practices Committee and have been approved by the AORN Board of Directors. They were presented as proposed recommended practices for comment to members and others. These recommended practices are effective Jan 1, 2004.

These recommended practices are intended as achievable recommendations representing what is believed to be an optimal level of practice. Policies and procedures will reflect variations in practice settings and/or clinical situations that determine the degree to which the recommended practices can be implemented.

AORN recognizes the numerous types of settings in which perioperative nurses practice. These recommended practices are intended as guidelines adaptable to various practice settings. These practice settings include traditional ORs, ambulatory surgery units, physicians' offices, cardiac catheterization suites, endoscopy suites, radiology departments, and all other areas where surgical and other invasive procedures may be performed.

PURPOSE. Microorganism transfer from the hands of health care workers to patients is an important factor in health care-associated (ie, nosocomial) infections and has been recognized since the observations of Semmelweis and others more than 100 years ago. (1) Skin is a major potential source of microbial contamination in the surgical environment. Hand hygiene is a critical step in preventing infections and the spread of infections, is of critical importance for the entire health care team, and remains the most effective and least expensive measure to prevent the transmission of microorganisms and health care-associated infections. It is the single most important step in the prevention of infections. (2) The term general hand hygiene refers to decontamination of the hands by one of two methods--hand washing with either an antimicrobial or plain soap and water or use of an antiseptic hand rub. (3)

The term surgical hand antisepsis refers to the antiseptic surgical scrub or antiseptic hand rub performed before donning sterile attire preoperatively. Although scrubbed members of the surgical team wear sterile gloves, the skin of their hands and forearms should be cleaned preoperatively to significantly reduce the number of microorganisms. The moist environment underneath surgical gloves can promote microorganism proliferation on the hands of the wearer. Both surgical and examination gloves can fail during a procedure. Choice of surgical hand antiseptic/scrub agents should be limited to those that are US Food and Drug Administration (FDA) compliant, have a documented ability to kill organisms immediately upon application, provide antimicrobial persistence to reduce regrowth of microorganisms, and have a cumulative effect over time. (3) The purpose of surgical hand antisepsis/hand scrubs is to

* remove debris and transient microorganisms from the nails, hands, and forearms;

* reduce the resident microbial count to a minimum; and

* inhibit rapid rebound growth of microorganisms.

PERIOPERATIVE NURSING VOCABULARY. The perioperative nursing vocabulary is a clinically relevant and empirically validated standardized language. This standardized language consists of the Perioperative Nursing Data Set and includes perioperative nursing diagnoses, interventions, and outcomes. The expected outcome of primary importance to this recommended practice is outcome 10 (O10), "The patient will be free of signs and symptoms of infection." (4)

RECOMMENDED PRACTICE I

All personnel should practice general hand hygiene.

1. Hand hygiene immediately before and after patient contact remains the most cost-effective and simplest measure for health care workers to prevent cross contamination in the health care setting. (5) General hand hygiene should be performed before and after patient contact, after removing gloves, any time there is a possibility that there has been contact with blood or other potentially infectious materials, before and after eating, and after using a restroom. (3) Wearing gloves is not a substitute for hand hygiene. (6) Hands are a major source of transient flora and, therefore, a major vector of cross contamination in health care. Health care workers should avoid contact with surfaces that are potentially contaminated, such as equipment and other inanimate objects in the patient care setting (see "Recommended practices for standard and transmission-based precautions"). (7)

2. Fingernails should be kept short, clean, and healthy. The subungual region harbors the majority of microorganisms found on hands. Removal of debris underneath fingernails requires the use of a disposable, single-use nail cleaner under running water. Additional effort may be necessary for longer nails. The risk of tearing gloves can increase if fingernails extend past the fingertips. Long fingernails may cause patient injury during the moving or positioning process. (8-12) Ideal nail length has been described as not extending beyond the fingertips. (13) Polish, if used, should not be chipped. Studies have found no increase in microbial growth related to wearing freshly applied nail polish, but chipped nail polish may support the growth of larger numbers of organisms on fingernails. (3,9,12) There is concern, however, that individuals who spend considerable time and money on maintaining their nails may be less inclined to perform a vigorous surgical scrub to protect their nails. If this occurs, there could be a detrimental effect of bacterial growth on the hands, not from the polish itself, but from a change in hygienic practices. Available data indicate that nail polish that has been obviously chipped or worn for more than four days harbors greater numbers of bacteria. (9,12) This time frame may suggest a guide for changing polish so that nails remain well manicured. Individuals who choose to wear nail polish in the surgical setting should be guided by surgical conscience. (8,9,12)