Perioperative professionals live, eat and breathe antisepsis. Perhaps no other group of healthcare professionals better understands the importance of maintaining skin integrity, or is better at consistently following hand hygiene guidelines to protect themselves and patients. That doesn't mean lapses can't occur. Even top-performing care providers might be well-served by a reminder of why cleaning and protecting skin integrity is essential to proper infection prevention.

Why it matters
According to the CDC Guideline for Hand Hygiene in Healthcare Settings, harmful pathogens can be transferred between a healthcare worker and patient if:

• organisms either present on the patient's skin or shed onto inanimate objects in close proximity to the patient are transferred to the hands of the healthcare worker;
• handwashing or hand antisepsis by the provider is inadequate, omitted entirely or the agent used for hand hygiene is inappropriate; and
• the contaminated hands of the caregiver come in direct contact with another patient or with an inanimate object that will come in direct contact with the patient.

While clinical research hasn't established a definitive relationship between hand hygiene and surgical site infections, the proper prepping of hands before surgery is consistent with common sense and standard infection prevention practices.

Hand antisepsis after removing gloves is just as important as donning gloves before surgery. Gloves obviously help prevent the transmission of bloodborne pathogens at the surgical site. They are not impervious, however, since microscopic holes can exist or tears may occur, making the exchange of pathogens between patients and providers possible.

Selecting the proper antiseptic agent for use in your facility demands an understanding of the formulation's immediate and persistent ability to reduce bacteria counts. Antiseptic agents should work quickly to kill a wide range of bacteria on the hands and have a long-lasting kill effect over several applications.

According to the World Health Organization Guidelines on Hand Hygiene in Health Care, "surgical hand preparation must eliminate the transient bacteria and significantly reduce the resident flora at the beginning of an operation and maintain the microbial release from the hands below baseline until the end of an operation." The spectrum of antimicrobial activity should be as broad as possible against bacteria and fungi. Viruses are rarely the cause of surgical wound infections.

With those principles in mind, here are the disinfectant properties of some common hand antiseptic agents.

• Plain and antimicrobial soaps. Remove soil, dirt and organic compounds from the skin. Soap's abrasiveness may in fact irritate and dry the skin, and ironically increase the bacteria count on the hands.
• Alcohols. Effective against gram-positive and gram-negative bacteria, including multi-drug resistant organisms like MRSA. Waterless alcohol gels are not recommended for cleaning hands that are visibly soiled.

A few drawbacks: Since alcohol is quick to dry and evaporate, it lacks persistence in killing germs. It also tends to dry hands. Alcohol-based rubs therefore contain emollients to negate this effect, making them in fact potentially kinder to the hands than soap and water.

• Chlorhexidine gluconate. Effective against gram-positive bacteria but demonstrates less activity against gram-negative bacteria. It lags behind alcohol in its immediate bacteria kill rate but shows significant residual activity, making it a persistent agent.
• Chloroxylenol. Commonly known as PCMX, it is more effective against gram-positive bacteria than gram-negative bacteria. Its kill rate is moderately fast, and like CHG, it has prolonged antimicrobial effects. This agent is often found in antimicrobial soaps.
• Iodophors. Demonstrate kill activity against gram-positive and gram-negative bacteria, some spore-forming bacteria, mycobacteria, viruses and fungi. According to the WHO guidelines, the most commonly used products for hand antisepsis prior to surgery are soaps containing chlorhexidine gluconate or povidone iodine.

Effective and accepted
Deciding to scrub with an antimicrobial soap or rub with an alcohol-based, waterless product is a tough call. The best agent must kill transient flora and decrease the germ load without disrupting the skin's integrity.

A segment of perioperative professionals still prefer scrubbing to rubbing. Some find comfort in traditional soap and water even though alcohol-based rubs have been shown to be more efficient and at least as effective in reducing bacteria counts.

A traditional scrub with a brush or sponge is recommended when hands are visibly soiled. Many products are available for hand scrubbing, offering choices between application with a standard brush, disposable brush or disposable sponge.

The CDC and AORN both recommend the use of alcohol rubs over traditional scrubs. AORN's hand hygiene recommendations suggest you'll get better compliance with surgical hand antisepsis by using an alcohol-based hand rub agent rather than a traditional surgical scrub.

Our perioperative staff have trialed a waterless, scrubless rub. The active ingredient is 80 percent ethanol alcohol with rich emollients to moisturize skin during use. Alcohol dries the skin when used with a product that has to be rinsed because the skin's oils are washed away.

The scrubless product that we have implemented does not require rinsing. During the rubbing action the skin's natural oils are reintroduced into the skin. It takes about 50 seconds to apply and dries very quickly. Waiting for the rub to dry is unnecessary. Our providers use the rub before the first procedure of the day and between cases. Feedback has been overwhelmingly positive. Staff acceptance is a significant factor in improving compliance. Here, alcohol-based rubs have a clear advantage over traditional scrubs. They're easy to apply, dry quickly and are less disruptive to the skin's natural protection than traditional brush scrubs.

Important reminder
Many agents are available for hand antisepsis, from traditional scrubs to waterless rubs. National and international guidelines promote a shift to alcohol-based rubs, although clinical research falls short in naming the agent most effective in preventing surgical site infections.

Regardless of which agent and method of application you decide to implement at your facility, your staff must understand the reasons behind your infection prevention practices and rededicate themselves to proper perioperative hand hygiene before each case.