Scrubbing in is fundamental to any infection prevention protocol and a mandatory practice before participating in a surgical procedure. But how closely do you look at this part of your facility's daily, perhaps even hourly, routine? Don't take it for granted: Take a look at infection control experts' advice on increasing your surgical scrub efficiency.

Can you save time scrubbing?
You can't put your gloves on until your scrub is complete, but can you speed that process? "Well, you're limited by how much you can do that and still follow what's required," says Mary C. Wilson, BSN, RN, CNOR, a clinical preceptor at West Virginia University Hospitals in Morgantown, W.Va. "To do it safely, there's a minimum amount of time it's going to take."

"It's not something I'd advise taking a short cut on," says Terry Burger, RN, BSN, CIC, CNA, BC, director of infection control and prevention for the Lehigh Valley Health Network in Allentown, Pa. But, she notes, "it's said that if you truly washed your hands the entire time required every time it was indicated, it would fill an entire 8-hour shift."

While infection prevention authorities recommend a thorough, traditional brush scrub for the first scrub of the day, and perhaps following a break if the hands have become significantly soiled, not all of your scrubs during the day must be traditional. "Save some time and save some skin by using a brush-free product throughout the day," says Ms. Burger.

"Brushless is usually a faster process," says Ms. Wilson, whether you're using water-aided or waterless products. While their manufacturers' directions — which she recommends consulting — frequently require that their use follow an initial traditional brush scrub, brushless products demand less effort on subsequent scrubs.

She notes, however, that both brush and brushless methods are commonly used throughout the day at her hospital's scrub sinks. "We have not been able to get entirely away from standard brushes," she says. After their initial traditional scrub, about two-thirds to three-fourths of her staff switch to a brushless and waterless product, but the others use the brush method every time. "Some because alcohol doesn't agree with them, and some because it's the way they always did it," she says.

One additional advantage that waterless scrubs have over traditional ones is that they're self-timing, says Lynn Cromer, BSN, MT, CIC, of the Duke University Infection Control Outreach Network in Durham, N.C., and spokeswoman for the Association for Professionals in Infection Control and Epidemiology. For a traditional scrub, she says, you're either watching the clock as you scrub for 3 to 5 minutes or counting a set number of strokes for each part of your hands and arms, after which you dry off with a sterile towel. "With waterless, you rub it in and let it dry," she says. "That's a plus: It's easy to know when you're done. When it's dry, you're ready to go."

"Waterless is the way of the future," says Ms. Cromer. She says she can imagine a clinical future in which the alcohol-based brushless solutions are acceptable for the initial and all subsequent scrubs for surgical personnel, although she admits we're not there yet.

"What it's going to take is time, until there's strong evidence out there that this is as good as a traditional scrub," she says. "Waterless products have not been out that long." But continuing clinical studies "will build up a level of confidence that this is an acceptable practice."

When should you re-examine your scrub?
When your surgical supplies work, you tend to stick with them. But sometimes it may become necessary to give another scrub product a look. If your scrub sinks are stocked only for traditional brush scrubs, for instance, you may want to consider brushless products. Or if a new product with new claims, such as the addition of improved skin conditioners, has been introduced. Or if infection prevention authorities announce changes to their hand hygiene guidelines.

Sometimes, however, the product continues to work, but at the expense of your surgical staff. "If you're hearing any kind of complaints about skin integrity, or employees report dermatitis on their hands, it may be related to your scrubs," says Ms. Cromer. "The products that are used for surgical scrubs are harsh on skin in general. A brush just adds injury to that. They're not always good for surgical workers' skin."

"Scrubbing hands can cause harm to hands," agrees Ms. Burger. "And we hold them out as portals for infection due to the breakdown in skin integrity." Since hand antisepsis and skin care should not be mutually exclusive, it's important for surgical facilities to find workable solutions, whether by relying less on the brush or finding brushless products that are easier on the hands, in order to make compliance less painful.

Should it come time to consider changing your scrub products, start by reviewing the clinical data on each product's efficacy. "Trust the data," says Ms. Wilson. "There's no other way to know exactly how effective a product is." Also, she says, make sure that each of the products you plan to trial is FDA-approved and has also received the blessing of your facility's infection prevention personnel. "The infection control department wouldn't let us trial something they didn't want in use in our hospital."

How should scrubs be trialed?
When trialing hand scrubs, Ms. Cromer recommends that you introduce the products to only a portion of the staff, for use among one group or specialty, and not to the entire staff at once. This will let you monitor infection rates and compare the results of the new product against the one already in use during the two weeks to a month that the trial team is determining a scrub's usability.

In addition to assessing a scrub product's epidemiological effectiveness, make sure you also take into account how well your staff, and their skin, tolerate it. When judging the results of a trial, says Ms. Wilson, watch for reports of skin irritation and ask your trial team whether they experienced any sensitivity after repeated use. "It's no good to get a product that only a percentage of your staff can use, while everyone else breaks out," she says.

Keep an eye out for any other usage comments and concerns as well, she says. "Were there just outright problems with some products? Did one make hands too sticky or too slippery?" asks Ms. Wilson. "If just one person says something, maybe that's not a reason to eliminate a product, but if it's a consistent theme, that may be cause for reconsideration."

Despite the budget imperative to standardize your supplies and streamline your inventory, you may still have to stock a choice of products. "People always have a preference," says Ms. Burger. "There's not one particular product that works for everybody. Everybody's got different hand issues." That's why she thinks it's important to respond to physician and staff preferences, and to offer different scrub products. Adds Ms. Cromer, "If you don't give reasonable choices, it may impede the practice" and lead to less-than-vigilant compliance.

How can you ensure compliance?
"In the OR, probably more than any other place in the hospital, there's an acute awareness of sterile consciousness," says Ms. Burger. If you've systematically educated employees when they come on board and have selected a scrub product that's acceptable to a majority of your staff, you shouldn't see many problems with compliance.

Still, says Ms. Cromer, "a lot of times we do things in a hurry." Perhaps the most common error in surgical scrubbing is failing to thoroughly visualize and cover each part of the hand and forearm, she says.

Ms. Wilson says that she conducts monthly audits, surreptitiously observing staffers at the scrub sink, among other practices, for compliance. If any post-audit education is necessary, the method depends on the prevalence of the problem. "If everyone but one person is compliant, I'll discuss the problem with the individual," she says. "If it's more than that, it'll be addressed through a staff meeting and perhaps more frequent audits."

Lastly, make sure your infection prevention protocol is up to date with your current methods. If you've recently switched scrub products, says Ms. Cromer, you've read the manufacturer's directions and follow them to the letter. But does your protocol reflect those directions? Make sure it's written up in accordance with the new specifics.