When performing surgical hand scrub Which of the following nursing actions ensure prevention of contamination?

We are updating our policy on jewellery in the perioperative area and the ACORN standards state no rings are allowed. Is it permissible for any staff in the area to wear wedding rings as some staff (mainly recovery) are physically unable to remove their rings?

Please refer to the Perioperative attire standard. Within this standard Standards statement 8 recommends “Jewellery worn within the perioperative environment is limited to items that can be contained within the perioperative attire.”ACORN’s  rationale for this includes evidence proving that microorganisms are harboured under and within rings and it also refers to the risk of accidental traction on the ring causing avulsion of the soft tissues. This can result in injury ranging from a simple contusion injury to traumatic amputation”

In 2019 the National Health and Medical Research Council published revised Australian Guidelines for the Prevention and Control of Infection in Healthcare. The NHMRC’s recommendation see below  are built into the National Safety and Quality Health Service (NSQHS) Standards compliance with which is mandatory for Australian health service organisations. Please note that page 40 of the NHMRC Australian Guidelines for the Prevention and Control of Infection in Healthcare states “if jewellery must be worn in clinical areas it should be limited to a plain band (e.g. wedding ring) and this should be moved about on the finger during hand hygiene practices. In high-risk settings such as operating suites/rooms, any jewellery, even a plain band, should not be worn.”  In relation to your question ACORN’s recommendation is that no jewellery, including wedding rings, should be worn.

Although there is less evidence concerning the impact of jewellery on the effectiveness of hand hygiene, rings can interfere with the technique used to perform hand hygiene resulting in higher total bacterial counts. Hand contamination with infectious agents is increased with ring wearing], although no studies have related this practice to healthcare worker-to-patient transmission. The consensus recommendation is to strongly discourage the wearing of watches, rings or other jewellery during health care; however if jewellery must be worn in clinical areas it should be limited to a plain band (e.g. wedding ring) and this should be moved about on the finger during hand hygiene practices. In high-risk settings such as operating suites/rooms, any jewellery, even a plain band, should not be worn.

Do you have any information on the moments of hand hygiene in theatres?

Since November 2019 the Australian Commission on Safety and Quality in Health Care has had responsibility for the National Hand Hygiene imitative  in Australian health service organisations. There are specific obligations that health service organisations have including assessment of local hand hygiene compliance. These obligations may differ between jurisdictions and so I would also recommend you review materials specific for NSW on the Clinical Excellence Commission’s website specifically at http://cec.health.nsw.gov.au/keep-patients-safe/infection-prevention-and-control/healthcare-associated-infections/hand-hygiene  

ACSQHC’s resources for hand hygiene can be accessed free of charge at https://www.safetyandquality.gov.au/our-work/infection-prevention-and-control/national-hand-hygiene-initiative-nhhi/what-hand-hygiene

ACORN has produced a series of 12 Practice audit tools (PATs) specific to the perioperative environment. PAT 3 is for Surgical hand antisepsis, gowning and gloving. The ACORN PATs are available for purchase as a set of 12. More information is available at https://www.acorn.org.au/practiceaudittools.

I am just wondering whether ACORN has any recommendations regarding the use of surgical scrubs? I am currently looking at comparing Isopropyl Alcohol 90%  to others such as chlorhexidine and iodine to provide evidence to management in our theatres to perhaps introduce it as an alternative scrub throughout the day.

ACORN does not make recommendations regarding specific products as we appreciate that different jurisdictions and organisations have various procurement procedures in place including tenders with specific manufacturers and distributors. There are also important issues such as staff tolerance to the active ingredients in a solution used for surgical hand antisepsis. Care should be taken in selecting that solution as sensitivities may develop. Both iodine and chlorhexidine (CHG) are excellent antiseptics, the main benefit for chlorhexidine is persistence. It should be in combination with alcohol so that immediate kill is achieved (by the alcohol) and persistence (by the CHG) are attained.

As you suggest ACORN’s general recommendations are described in the Surgical hand antisepsis, gowning and gloving standard. The only stipulation is that the scrub used for surgical hand antisepsis has antimicrobial properties and is used only as per manufacturer’s instructions.

For more information you may find the National Hand Hygiene Initiative Manual useful. More information about the national hand hygience initiative is available at https://www.safetyandquality.gov.au/publications-and-resources/resource-library/national-hand-hygiene-initiative-manual

I also refer you to the 2019 Australian Guidelines for the Prevention and Control of Infection in Healthcare. The guidelines are accessible at www.nhmrc.gov.au and the following definitions are taken from it.

Surgical ABHR: Antiseptic hand rub performed preoperatively by the surgical team following the surgical pre-wash to eliminate transient flora and reduce resident skin flora. Such antiseptics often have persistent antimicrobial activity. Use should be in accordance with manufacturers’ instructions. Surgical ABHRs are often a waterless and high percent alcohol solution.

Surgical hand preparation: The process of eliminating transient and reducing resident flora prior to surgery. This comprises removal of hand jewellery, performing hand hygiene with liquid soap if hands are visibly soiled, removing debris from underneath fingernails and scrubbing hands and forearms using a suitable antimicrobial formulation

I just wanted to clarify something from the standard for surgical hand antisepsis. It states in there that surgical hand scrub and surgical hand rub should not be used sequentially. What is the rationale behind this? I am unable to access the full text article that is referenced for this statement. Medical staff in particular in our facility are doing this regularly, doing a traditional scrub then applying the waterless hand rub. We are hoping to change their practice but know they will want some more information.

This is an interesting question and it has been asked of ACORN on at least one other occasion in the past 12 months which has prompted ACORN to revise the wording of the recommendation. In our new 16th edition of the ACORN Standards those sections of the standard have been re-worded to:

"3.11 Do not combine surgical hand scrub and alcohol-based surgical hand rub sequentially as using surgical hand scrub and washing may result in moist hands and moisture may dilute the antimicrobial properties of the surgical hand rub. Surgical hand scrub may also enhance skin irritation and dryness.

3.12 Generally, hand washing prior to applying an alcohol-based surgical hand rub is not necessary and it may dilute the effectiveness of the surgical hand rub and can predipose users' hands to irritation. However, if hands are visibly soiled or dirty, they should be washed with a non-antimicrobial soap before surgical hand preparation and must be completely dry before applying the alcohol-based surgical hand rub solution."

The other important information is that if two different types of antimicrobial agents are used sequentially the first may reduce the efficacy of the second. These rationales are well described in the Kampf article1. Also please check the World Health Organization. Guidelines on hand hygiene in health care. First global patient safety challenge: Clean care is safe care. Geneva: WHO; 2009. as it also helps explain this recommendation.

1. Kampf G, Löffler H. Dermatological aspects of a successful introduction and continuation of alcohol-based hand rubs for hygienic hand disinfection. J Hosp Infect. 2003;55(1):1-7. doi:10.1016/s0195-6701(03)00223-8

In the "Surgical hand antisepsis, gowning and gloving" standard section 3.5 where it says that surgical antiseptic hand scrub agents and alcohol base surgical hand rub should not be used sequentially does this mean that if you do your 5 min scrub at the start of the day using antimicrobial hand-wash the following hand washes after that cannot be a 90 second Skinman alcohol hand rub? It must be a 3 min washes continuing using the chosen antimicrobial hand wash? If we chose to use the 90 second Skinman alcohol antiseptic hand rub we must use that at the start of the day in-replace of our 5 min scrub and continue to use that all day for the sequential washes?

ACORN’s recommendation is:

3.5 Antimicrobial surgical hand scrub agents and alcohol-based surgical hand rub agents should not be combined sequentially2,p.153. If you choose to use a surgical hand scrub you must continue using that same antiseptic for all subsequent scrubs.

ACORN’s recommendation makes no mention of a specific duration as we are aware that in all cases manufacturer’s IFUs should be followed and they may differ depending on which agent is used. The statement states that if you start your first scrub of the day using a scrub agent (solution A) then you cannot change to a different agent for your subsequent scrubs. Simply put you must continue to use Solution A for the remaining scrubs for the day. This is because of incompatibilities between surgical scrub and alcohol-based rubs solutions that render the agents to be less effective. This recommendation is based on WHO’s recommendation World Health Organization. Guidelines on hand hygiene in health care. First global patient safety challenge: Clean care is safe care. Geneva: WHO; 2009 See page 153. Page 153 reads:

" H. When using an alcohol-based surgical handrub product with sustained activity, follow the manufacturer’s instructions for application times. Apply the product to

dry hands only (IB). Do not combine surgical hand scrub and surgical handrub with alcohol-based products sequentially (II)."

You may also wish to undertake further discussions with your local perioperative leaders and your infection control team. ACORN will never provide manufacturer-specific advice. Instead you should seek a recommendation and gaurantee from the manufacturer that your proposed use of hand hygiene solutions is optimal, safe and does not reduce patient or staff safety. Please appreciate that ACORN’s recommendations are necessarily broad and over-arching whereas you may have specific local or jurisdictional obligations that override ACORN’s recommendations.

I am wanting clarification on the new standards of scrubbing, my understanding of the standard is that we no longer have to do a first 5 minute scrub of the day. I read it as you can simply arrive and use the alcohol scrub rub and then gown and glove, without any real hand washing.

ACORN is not sure what you mean by the term “real hand washing”. The current NHMRC national infection control guidelines use the term “surgical hand preparation”. Please review their recommendations on page 176 which I have reproduced below.

"Hand hygiene for surgery

Surgical hand preparation should reduce the release of skin bacteria from the hands of the surgical team for the duration of the procedure; in case of an unnoticed puncture of the surgical glove that releases bacteria to the open wound. Surgical hand preparation must eliminate the transient and reduce the resident flora. There are special surgical scrub formulations available for use, although any product used within Australia should preferably be listed on the Australian Register of Therapeutic Goods (ARTG). Current WHO guidelines recommend the use of an alcohol-based formulation for preoperative surgical hand preparation, given its superior antimicrobial efficacy compared to other methods. Specific policies and procedures on products and methods of surgical hand preparation should be developed locally."

Manufacturers’ instructions for use are critical and for waterless surgical hand preparation they should be followed. Further the American AORN recommend that:

“A standardized surgical hand scrub with a soap (antimicrobial agent), nonabrasive sponge, and water does not have to be the first surgical hand scrub of the day before an alcohol-based surgical hand rub product is used, unless it is recommended in the manufacturer's instructions for use. The surgical hand scrub reduces the transient and resident flora of the hands, which also may reduce health care-associated infections. A standardized surgical hand scrub using an alcohol-based hand rub product will decrease transient and resident flora on the hands. Hand washing does however need to be performed before the first surgical hand scrub of the day”.

AORN recommends hand washing before the first surgical hand scrub. Hand washing is defined by the ACSQHC National Hand Hygiene Initiative User Manual as the application of soap and water to the surface of the hands. The soap could be plain or antimicrobial. A critically important step is that before any surgical hand preparation is applied the healthcare worker’s hands must be dry. When the hands are dry and only then the surgical hand scrub using the skin antiseptic can be performed for the first surgical scrub. As per the ACORN Standards “The skin antiseptic used for the first surgical hand scrub of the day should continue to be used for subsequent scrubs because the beneficial, cumulative or sustained effects of skin antiseptics differ.”

Can you please define sequential in relation to the use of hand scrub and hand rub. We are undertaking our yearly assessments and want to ensure that if they do a 5 minute scrub, gown and glove they can then demonstrate practically use of the a specific product and go on to use their scrub/rub of choice for the rest of the day.

ACORN’s use of the word “sequential” is no different from its everyday usage ie. following in a logical order or sequence.

ACORN’s recommendation regarding hand hygiene and the sequence of hand hygiene solutions is as per the current standard:

"3.5 Antimicrobial surgical hand scrub agents and alcohol-based surgical hand rub agents should not be combined sequentially 2,p.153. If you choose to use a surgical hand scrub you must continue using that same antiseptic for all subsequent scrubs."

ACORN’s recommendation makes no mention of a specific duration as we are aware that in all cases manufacturer’s IFUs should be followed and they may differ depending on which agent is used. The statement states that if you start your first scrub of the day using a scrub agent (solution A) then you cannot change to a different agent for your subsequent scrubs. Simply put you must continue to use Solution A for the remaining scrubs for the day. This is because of incompatibilities between surgical scrub and alcohol-based rubs solutions that render the agents to be less effective. This recommendation is based on WHO’s recommendation World Health Organization. Guidelines on hand hygiene in health care. First global patient safety challenge: Clean care is safe care. Geneva: WHO; 2009 See page 153

Page 153 reads: "H. When using an alcohol-based surgical handrub product with sustained activity, follow the manufacturer’s instructions for application times. Apply the product to dry hands only (IB). Do not combine surgical hand scrub and surgical handrub with alcohol-based products sequentially (II)."

Gowning and gloving

As we can not source our usual 6.5 gloves from our current supplier our hospital is sourcing other companies. I have been asked what reference ACORN use for gloves I am presuming its reference the AS/NZS standard. I can not find any other reference in the Standards

Unfortunately, your question is vague and non-specific regarding the type of glove ie. non-sterile, sterile or reusable utility gloves you are enquiring about. Regardless please note that all ACORN recommendations for infection control are consistent with the requirements and recommendations included in the Australian Guidelines for the Prevention and Control of Infection in Healthcare (2019). Please refer to section 3.3 Personal protective equipment for glove-specific recommendations.

The document is available at https://www.nhmrc.gov.au/about-us/publications/australian-guidelines-prevention-and-control-infection-healthcare-2019

Hi, just want to check with you as have always used the open gloving technique as this is what evidence says is the superior technique in unassisted gloving. The evidence is a randomised trial that was published in 2003, the gold standard of clinical research, and until now there is still no randomised trial conducted to challenge this evidence. May I know what is your take on this?

I have checked the current edition of the ACORN Standards and note that on page 317 in the Surgical hand antisepsis, gowning and gloving ACORN’s advice is as follows:

Surgical scrub team members have a duty to: 
4.7 use the closed gloving method as the preferred method for donning surgical gloves. This method assists in maintaining an aseptic field by allowing members of the surgical scrub team to don gloves in a manner consistent with the principles of aseptic technique58. 

The reference underpinning this recommendation is

Jones C, Brooker B, Genon M. Comparison of open and closed staff-assisted glove donning on the nature of surgical glove cuff contamination. Aust N Z J Surg 2010;80(3):174–177.

Is there a standard regarding the pre scrub prior to using 90 second hand alcoholic rubs for Perioperative surgical scrubs? 

ACORN has addressed questions similar to this several times recently and in multiple public forums. There was a recent FB post about it. It was discussed in the first edition of our newsletter “The Oak”. It is also contained in the Clinical FAQs page on ACORN’s website. Here are the links that will help you:   https://www.acorn.org.au/clinicalfaqs  

https://www.acorn.org.au/asap