Surgical hand antisepsis; hand lotions and creams; gel overlays as artificial nails; benchmarking

AORN Journal, April, 2007 by Mary Ogg, Carol Petersen

QUESTION: My hospital has been using an alcohol-based, surgical hand-rub product for the last two years. Initially, staff members and surgeons were adhering to the manufacturer's directions for proper application, but now, most are not using the product correctly. At the beginning of the day, they are not washing their hands with soap and water before starting the alcohol-based, surgical hand-rub process, nor are they cleansing their fingernails between procedures. Furthermore, before gowning and gloving they only apply a small amount of the product on their palms and rub their hands together without rubbing the product up their wrists or arms. Is this acceptable? What does AORN recommend?

ANSWER: Using a waterless, hand-rub product in the manner you describe is not recommended. AORN recommends following the manufacturer's written instructions for maximum effectiveness. A standardized protocol should be developed that includes the following steps.

* Before beginning surgical hand antisepsis, prewash hands and forearms with soap and water to remove any debris. Using a nail cleaner, clean the subungual areas of both hands under running water. Rinse the hands and forearms and dry thoroughly with a paper towel.

* Following the manufacturer's directions, dispense the recommended amount of the surgical hand-rub product and apply it to hands and forearms.

* Repeat the product application process if required by the manufacturer's directions.

* Rub hands together until they are completely dry. (1)

The habits that staff members have developed for the surgical scrub are poor practice. The practice they are performing is akin to hand hygiene rather than surgical hand antisepsis. Hand hygiene is considered routine decontamination with plain or antimicrobial soap and water or an antiseptic hand-rub product. Surgical hand antisepsis is defined as preoperative preparation of surgical team members' hands and arms to eliminate transient bacteria and reduce resident hand flora. (1) Surgical hand antiseptics that comply with US Food and Drug Administration (FDA) regulations and are approved by the facility's infection control personnel should be used according to manufacturers' directions.

Barriers to proper surgical hand antisepsis include lack of knowledge of proper product usage, forgetfulness, and insufficient time to complete the standardized protocol. A multifaceted approach to education, motivation, and system changes such as the following will help improve compliance with proper surgical hand antisepsis. (2)

* Place a manufacturer's poster outlining correct use of the alcohol-based surgical hand-rub product by the scrub sink.

* Provide inservice training programs presented by an infection control practitioner and the manufacturer's clinical educator.

* Ask an infection control practitioner to perform pre-education and posteducation cultures of staff members' hands.

* Involve key surgeons and other personnel who perform surgical hand-rub antisepsis correctly in providing re-education, observing the techniques used by other personnel, and offering feedback to personnel regarding their technique.

* Implement a contest for best compliance.

* Place posters showing proper technique in the lounge or on educational bulletin boards.

Preventing surgical site infections is an important endeavor for the entire surgical team. AORN's "Recommended practices for surgical hand antisepsis/hand scrubs" (1) and the "Guideline for prevention of surgical site infections" (3) from the Centers for Disease Control and Prevention both emphasize the importance of effective surgical hand antisepsis, which includes using an FDA-approved antimicrobial agent and a proper scrubbing or application technique of adequate duration to prevent surgical site infections.

QUESTION: With the combined effects of the colder, dryer weather and frequent hand washing and scrubbing, our OR staff members are having trouble with cracked and dry skin and cuticles. Staff members have tried various over-the-counter hand lotions and creams. One nurse brought in the hoof cream that she uses on her horses. It has become extremely popular with the staff members. Is it acceptable to use this type of product?

ANSWER: Over-the-counter hand lotions or creams may not be compatible with surgical glove material or hand-hygiene products and should be used with caution. The surfactants in hand-wash products provide cleansing action, but the cleansing effects of surfactants also break down the epidermal layer of the skin, the barrier between the health care worker and the patient. In the OR, repeated hand washing and scrubbing and wearing of gloves can increase epidermal breakdown. Damaged skin can cause bacterial shedding and increase the risk of infection. Skin moisturizing products are an important component in maintaining skin health and in preventing dryness, discomfort, and dermatitis. (4,5)

Hand-care products should be evaluated for use in the health care setting before they are used. Selection of hand lotions should