How to Scrub Safer

Though few outpatient surgery facility managers worry much about scrubbing, perhaps they should. Disinfection of the hands and arms is a critical defense against wound infection, as gloves are far from fail-safe preventers of microbe transmission, yet many staff members and surgeons do not do it safely. Many facilities have also failed to take advantage of new knowledge and products that allow for significantly faster and safer scrubbing. Here are some tips on making sure your staff is scrubbing effectively, efficiently, and safely.

Improve compliance
Perhaps because it is so commonplace, compliance with proper scrubbing technique breaks down frequently. Study after study shows that health care workers in all settings scrub properly only about half the time.

"In ASC settings surgeons frequently cut corners during scrubbing," says Robert Dehn, RN, Nurse Manager of the Ridgecrest, Calif. IWV Surgery Center.

Unfortunately, there are no easy answers for this problem. Studies have shown that even regular "in-services" on scrubbing improve compliance only marginally. But there are a few things that may help:
- Train new employees on proper scrubbing. The Vienna, Austria General Hospital covers their medical staffs' hands with finger-paint prior to having them scrub. Areas on the hand where paint remains helps the staff pinpoint breaks in aseptic technique.
- Do everything you can to remind your staff about proper scrubbing. An Ohio State study showed that placing brightly colored signs by each scrubbing area detailing the Center for Disease Control's scrubbing guidelines helped improve compliance.
- Remind the staff about the importance of not wearing artificial nails (it poses an increased risk for bacterial and fungal colonization) and keeping nails short (long ones are more likely to tear surgical gloves);
- Make scrubbing as easy as possible. Studies show that two-minute scrubs with any capable agent are as effective as the traditional 10-minute variety. Some of the newer scrubs even enable faster disinfection of the hands. Two such agents are Healthpoint's Triseptin, which requires only a 90-second scrub of each arm, and CareTech's Technicare, which kills virtually all bacteria within 30 seconds.

Another method to make scrubbing easier is to have your staff do a full scrub at the beginning of cases, including a thorough cleaning underneath fingernails with a brush, then use waterless antiseptic agents between cases, advises Deborah Paul-Cheadle, RN, Infection Control Nurse at Spectrum Health, Grand Rapids, Mich. Such agents include 3M's new Avagard, Metrex's Metricare Flash Foam, and Steris's Alcare. Since the antiseptic does not need to be rinsed off, it is more convenient than re-washing, she believes. A study done at the Medical College of Virginia buttresses her view; the introduction of such a system at that instituinstitution's hospital markedly improved compliance, although compliance nevertheless remained relatively poor.

Still another method is to hunt for ways to cut unnecessary requirements. Several studies show that certain scrubbing shortcuts do not affect the spread of infection. Mr. Dehn recently eliminated the requirement of scrubbing above the elbows in his center; he says he was able to determine that this made very little difference in infection control, and that surgeons were not complying anyway. In the three years since the revised protocol was put into effect, he says, there still haven't been any reported infections as the result of improper scrub technique.

Consider brushless scrubs
Although using the bristle-end of a scrub brush for under the nails may still be a good idea, most experts believe the convention of vigorously scrubbing off the uppermost layers of skin with a brush to not only be unnecessary but also unwise. "Avoid scrub brushes which can abrade the skin," says Mark Davis, MD, OR Safety Coordinator for DeKalb Medical Center in Atlanta, Ga.

The reason: Studies show that scrub brush use does not remove more bacteria than brushless scrubbing. In fact, some studies even indicate that scrubbing with a brush may be slightly less effective than scrubbing without one. Scrubbing can also be more damaging to the skin, which is a problem unto itself.

Protect your skin
Scrubbing with the bristle-end of a brush, using harsh scrubbing agents and also the practice of intentionally leaving soap residue on the hands for extra protection can all lead to dermatitis of the hands. This may be "one of the most costly problems we face," says Sharon Bottoms, RN, Surgical Services Materials Case Manager/Interim Director of the Bradley Memorial Hospital in Cleveland, Tenn.

The cost occurs because most ORs prohibit personnel with fissures on their hands from working in the OR; studies show that such wounds greatly increase the likelihood of bacterial colonization on the hands. This means the facility must pay the salary of a replacement while the staff nurse's hands heal. Also, says Mr. Dehn, "the expense of stocking lubricating lotions and hand creams to soothe skin made sore from scrubbing is considerable."

The experts recommend the following steps:
- During the initial scrub, fully rinse any soap off the hands. Leaving it on can "dry or irritate the skin," says Brenda Gregory Dawes, RN, a nurse for Florida's Morton Plant Mease Health Care Outpatient Surgery Centers.
- If you are currently using one of the harsher scrubbing agents, including 10% povidone iodine or 4% chlorhexidene gluconate, consider investigating one of the kinder, gentler scrubs now on the market. "There are a number of new scrub soaps available," says Mr. Dehn. Studies have shown some of them to be less likely to cause dryness, fissures and dermatitis. For example, Healthpoint and CareTech offer scrubs that are said to be gentle on the hands, and both Steris and Metrex offer chlorhexidine gluconate scrubs at 2% concentrations rather than 4%, also said to be less harsh.
- Rather than requiring full scrubs between cases, allow "re-entry" scrubs with the aforementioned waterless systems. Ms. Paul-Cheadle says that within two to three weeks after implementing such a product at her center, "Skin quality improved. Hands felt softer and there was less breakdown of cuticles and skin."