When the Centers for Disease Control and Prevention and the Association of periOperative Registered Nurses endorsed alcohol-based hand rubs for surgical hand antisepsis, many surgical facility managers had questions. Are rubs really worth integrating into the surgical protocol? Are they truly effective under gloves? Are there significant product differences? Should the surgical team pre-wash or just stick with more traditional soap-and-water techniques? Whether you're already rubbing before surgery, or are still contemplating the role of rubs for surgical hand antisepsis, here are three steps toward surgical rub success.

Step 1: Product selection
All alcohol-based rubs are not created equally. When selecting a rub for surgical hand antisepsis, say experts, look for these three features:

• Immediate antimicrobial kill. Rubs can contain different forms, combinations and concentrations of alcohols, all of which can influence antimicrobial strength. Most rubs contain isopropanol, ethanol, n-propanol or a combination thereof, and at different concentrations. Unfortunately, as with patient skin preps, it can be difficult to compare the efficacy of different products because the Food and Drug Administration regulations governing all surgical scrub products are vague and provisional, and test conditions vary.

Several factors can help you wade through this landscape. Currently, the FDA categorizes 60 percent to 95 percent ethanol as safe and effective, but has not classified isopropanol or n-propanol as safe and effective. Manufacturers using these two ingredients should be able to show you data proving that their products meet the efficacy criteria outlined in the FDA's Tentative Final Monograph. It might also help to know that n-propanol 60 percent is the reference standard for all alcohol-based hand rubs in Europe, where the efficacy criteria are much more stringent than the FDA's, and European practitioners have used n-propanol-containing hand rubs for many years. Second, says G'nter Kampf, a researcher with Bode Chemie GmbH & Co., ethanol 75 percent to 85 percent, isopropanol 70 percent to 80 percent, and n-propanol 60 percent to 80 percent offer equivalent efficacy against bacteria. (Bode Chemie is a German manufacturer of an 80-percent ethanol-based rub.) Higher concentrations of alcohol can slightly hinder efficacy because some water is needed to facilitate denaturing of the antimicrobial proteins.

• Persistence. For surgical hand antisepsis, experts recommend using only rubs with antimicrobial persistence. According to the TFM, that means rubs must continue to kill microbes under gloves for at least six hours after application and provide cumulative antimicrobial action as you continue to use the rubs over time. Since it is volatile and evaporates, alcohol alone is not persistent; alcohol-based surgical rubs must therefore be specially formulated or contain additional, longer-acting ingredients (like chlorhexidine gluconate) to prolong the rub's antimicrobial effect. As a result, rubs that might be perfectly appropriate for bedside use might not qualify for surgical hand antisepsis. "The demands of the OR are not the same as the demands arising from brief patient visits," says Jean Jacques Parienti, MD, lead author of a 16-month Journal of the American Medical Association study in which he compared SSI rates after rubbing or scrubbing. "You need documented long-term efficacy under the glove because heat, moisture, duration and potential for glove puncture create an environment that is ripe for microbial growth."
• Dermal compatibility. Importantly, modern alcohol rubs contain emollients, and they do not cause skin irritation, as the harsher first-generation alcohol rubs did. "Concerns about dermal intolerance of alcohol should no longer stand in the way of using these products, because research consistently shows that the modern emollient-containing formulations are better tolerated than antiseptic soaps," says Dr. Parienti. In Dr. Parienti's JAMA study, skin irritation and dryness declined significantly when practitioners crossed over from the traditional water-aided scrub to the waterless surgical rub. Today's challenge, then, is finding the formulation that does the best job of pleasing and protecting the majority of your practitioners. Says Dr. Parienti: "It's like a recipe for a cake. Each rub may contain the same basic ingredients, yet each one will taste different. These products are not all the same."

Step 2: Practitioner acceptance
User acceptance is the second step toward surgical rub success, and experts emphasize that practitioners react subjectively ' and thus, sometimes with high variability ' to different alcohol-based surgical rubs. "User acceptance may be a key factor irrespective of objective factors," says Dr. Kampf. "It can be influenced by things like smell, the feeling on the skin and drying speed." Dr. Parienti adds that perfumes and colorants, in particular, can cause negative subjective reactions.

For these reasons, say experts, perform a trial and evaluate all of these factors, as well as the product's tackiness. Some thicker formulations might build up faster than others, causing practitioners to feel uncomfortable and wash more often. Washing removes the superficial sebum layer and the product's emollients, and can predispose skin to irritation. Applying alcohol to irritated skin creates a burning sensation. "When this occurs, practitioners tend to blame the alcohol, so they keep washing, and this removes the emollients in the rub, further breaks down the skin and ultimately promotes a vicious circle of washing, rubbing and irritation," says Dr. Kampf. Skin is best protected, and alcohol rubs are better accepted, say experts, when practitioners wash hands only when necessary (see step 3) and use professional skin-care lotions before they go home.

"Personnel should be reminded that it is neither necessary nor recommended to routinely wash hands after each application of an alcohol-based rub," adds Dr. Kampf.

Step 3: Proper protocol
As with any infection control measure, the third step to success is proper adherence to protocol. Here are some important elements of any surgical rub protocol:

• Wash away dirt, rub away microbes. Because alcohol-based rubs effectively kill microbes, they can replace traditional surgical scrubbing and provide a quick kill between intraop glove changes. The rubs do not, however, remove organic debris or dirt, so a pre-washing protocol is important. The specific protocol is somewhat controversial and to some degree remains a matter of discretion. There is, though, one clear point of agreement: Experts universally recommend pre-washing whenever hands are soiled ' whether visibly or not ' so hands are clean before rub application. That is, you should pre-wash before the first scrub of the day; after surgery when the hands have become visibly soiled with organic material such as blood or bodily fluids; after leaving and upon re-entering the surgical ward; and after using the restroom. This was the basic protocol in Dr. Parienti's study, and his results suggest the importance of pre-washing before the first case of the day. Dr. Parienti recorded a lower SSI rate when practitioners pre-washed before the first case of the day (5.9 percent SSI rate without pre-washing compared to 3.6 percent with pre-washing).

"It is possible there were more emergency procedures in the higher SSI group, which have a higher inherent infection risk," he says. "But still, this underscores the importance of handwash in the hand-rubbing protocol," he says. "However, whether facilities require pre-washing before every single surgical scrub, as suggested in the CDC hand hygiene guidelines, is up to them."

• Pre-wash with non-antimicrobial soap. When you pre-wash, the CDC and other experts advise doing so with a non-antimicrobial soap. Antimicrobial action is not needed because the intent of the wash is to remove soil, not bacteria, and a milder soap will help preserve skin integrity. In Dr. Parienti's study, practitioners specifically performed a one-minute handwash with non-antimicrobial soap and brush cleaning of the subungual space. "The choice of non-antiseptic soap will be very important to keep the advantage of better tolerance of alcohol-based rubs over traditional scrubbing," he says.
• Think dry before and after rubbing. When you pre-wash, be sure to dry arms and hands thoroughly and apply rubs only on dry, clean skin. Dr. Kampf says moisture can hinder efficacy by diluting the rub and making skin more susceptible to irritation. Then, after rubbing, it is just as important to be sure hands are completely dry before donning gloves in order to ensure efficacy and easy gloving.
• Follow the manufacturer's instructions. Ask an expert for advice, and they'll inevitably stress the importance of following the manufacturer's instructions. Otherwise, you cannot guarantee efficacy, because efficacy is dependent on contact time, volume, and, again, whether hands are wet. One study cited in the CDC guidelines documented that 1mL of alcohol is substantially less effective than 3mL, and if you get insufficient coverage, you get insufficient efficacy. If hands feel dry after rubbing hands together for 10 seconds to 15 seconds, say the guidelines, you didn't use enough rub. Further, advises Joan Blanchard, RN, MSS, CNOR, CIC, a perioperative nursing specialist with the AORN Center for Nursing Practice, always start at the hands and work down to the elbows no matter what type of product you are using. Importantly, add experts, be sure to allow the rub to dry on its own and don't towel it off.

Offer a selection
The very good news about surgical rubs is that they tend to promote compliance, as research has shown (see "SSI Rates After Rubbing or Scrubbing"). This may be very important in the surgical arena, as research also shows that compliance with scrubbing protocols tends to be poorer among surgeons than nurses. Those who have experience with surgical rubs, however, strongly advise against forcing change on the surgical team. Rather, they say, obtain and understand the manufacturer's testing data, conduct product trials, present the findings, advocate for the patient and continue to offer a choice.

A recent Outpatient Surgery survey of 142 facility managers shows that the vast majority do offer several options for this very reason, and because the potential for allergic reactions or sensitivities also necessitates choice. Concludes Dr. Parienti: "After our study was over, some surgical personnel went back to a water-aided scrub simply because that's what they preferred, especially the older ones, and one nurse had a reaction to the alcohol. Choice is an important element of promoting compliance."