Flammable hand scrubs; people who should count; draping; OR music; inserting central venous catheters - Clinical Issues

AORN Journal,  Nov, 2002  by Dorothy Fogg

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Question: We are considering changing to one of the alcohol-based hand scrub agents to replace the traditional surgical scrub in our facility. The product we are considering has an emollient component, and the manufacturer claims that it is gentle on the skin. Some staff members are opposed to making this change. They are concerned about flammability of the alcohol in the product. I know these products have been used in Europe for some time and more recently in the United States as general hand cleansing products. Are there any reports of fire associated with these products?

Answer: Although alcohol-based products have been used in health care settings for general hand hygiene without incident for some time, the American Journal of Infection Control recently reported an incidence of flash fire associated with the use of an alcohol-based hand antiseptic agent. (3) The fire occurred when a spark of static electricity ignited the alcohol-based hand gel on the hand of a health care worker who had just removed a 100% polyester gown. The health care worker put the premeasured amount of alcohol-based hand gel in the palm of her hand from a wall-mounted dispenser. She then removed the 100% polyester gown, placed it on a metal surface, and began rubbing the gel onto both hands. While her hands were damp, she pulled open a metal sliding door, heard an audible static spark, saw a flash of light, and experienced spontaneous flames on the palm of one hand. After the incident, the palm showed redness but no blisters. Flames singed the hair on her arm.

The product in use was advertised to contain 70% ethanol. Upon examination after the incident, the product was found to contain 73.7% ethanol, which was within the manufacturing specifications for the product. Polyester fibers are known to accumulate static charges because of the low moisture content of the fiber. Polyester garments may produce thousands of volts (V) of electrical charge when surfaces of the gown rub against each other or against garments worn under the gown. A rapid discharge of static electricity of less than 1,000 V is sufficient to damage some electronic equipment.

Flash fires associated with use of alcohol-based hand hygiene products can have potentially severe consequences for health care workers and their patients. Health care workers should ensure complete drying or evaporation of the product before engaging in other activities. Other risk reduction strategies include maintaining the ambient humidity within recommended limits (4) and avoiding use of 100% polyester gowns and drapes. If polyester gowns and drapes are used, they should have an antistatic carbon fiber or an antistatic finish.

Question: During some procedures in our OR, it is difficult for the circulating nurse to perform the count with the scrub person when closure begins. The circulating nurse may be assisting the anesthesia care provider, getting blood from the storage refrigerator down the hall, speaking on the phone to a nurse in the postanesthesia care unit (PACU) to notify him or her of special patient needs, or performing a variety of other tasks. When there are two scrub persons, they perform the count with each other. Recently, the RN first assistant (RNFA) assisting with a procedure objected to the two scrub persons performing the count. Neither of them was an RN. Instead, our RNFA insisted that she count with one of the scrub persons. Is it acceptable for two scrub persons to perform the count? What if one of the scrub persons is an RN? Does that make a difference? Can or should the RNFA count with the scrub person? Who should sign the count on the surgical record?

Answer: AORN's "Recommended practices for sponge, sharp, and instrument counts" recommend that items be counted "audibly and viewed concurrently by two individuals, one of whom should be a registered nurse." (1) It is not acceptable, however, for two scrub persons to perform the count regardless of whether one or both are RNs. As scrub persons, it would be impossible to prepare the sponges for counting that have been discarded from the sterile field. The same would be true for sharps and instruments that may have been removed from the field for any reason. The RNFA would suffer the same handicap if attempting to perform the count procedure. Additionally, it is not within the role of the RNFA to simultaneously assist the surgeon and perform other nursing tasks normally performed by other personnel. The AORN "Revised position statement on the RN first assistant" clearly states, "The RN first assistant does not concurrently function as a scrub nurse." (2) It would be equally impossible for the RNFA who is scrubbed for the procedure to concurrently function as a circulating nurse. Finally, the assigned circulating nurse is accountable for all nursing care provided to and for the patient during the intraoperative period, including the sponge, sharp, and instrument counts. He or she must sign the surgical record indicating that the counts were correct or incorrect. In authenticating, by signature, a count in which he or she did not participate, the assigned circulating nurse may be opening the door to personal liability and serious disciplinary action by the board of nursing should the patient suffer an unfavorable outcome.