You probably think about anything but scrubbing while prepping your hands for surgery. Will the case start on time? Is that instrument tray back from central sterile? Did my youngest daughter really just get her driver's license? It's understandable to let your mind wander while standing in front of the scrub sink, performing a task you've done thousands of times. But that doesn't mean it's acceptable. Take this opportunity to refocus on how you and your surgeons must care for the hands that care for your patients.

Scrub or rub?
In contrast to the traditional hand wash, surgical hand scrubbing must reduce both transient and resident flora and inhibit growth of new bacteria under surgical gloves, says Anita Buono, RN, MSN, CNOR, NE-C, clinical nurse manager of surgical services at the Bethlehem, Pa., campus of St. Luke's Hospital. She says the antiseptic properties of surgical hand scrubs are critically important if your gloves puncture or tear. Even microscopic breaches in a glove's protective material can increase infection risks for you and your patients.

You have 2 basic choices when it comes to preparing your hands for work in the sterile field: scrub with antimicrobial soap or rub with an alcohol-based, waterless product. Both are acceptable options, as evidence-based research and AORN and CDC guidelines have yet to identify one particular product and technique as superior to another, says Ms. Buono.

In fact, a 2008 Cochrane Review (www.ncbi.nlm.nih.gov/pubmed/18254046) conducted by English researchers attempted to determine the effects of surgical hand antisepsis on the number of surgical site infections in patients. "Alcohol rubs used in preparation for surgery by the scrub team are as effective as aqueous scrubbing in preventing SSIs but there is no evidence to suggest that any particular alcohol rub is better than another," says the report. It further states that there is no evidence regarding the positive antimicrobial effects of equipment such as brushes and sponges, although new guidelines aimed at reducing surgical site infections during orthopedic cases released by the Association of Professionals in Infection Control and Epidemi-ology and AORN suggest abrasive scrub brushes may damage the skin, increasing infection risks.

AORN recommends a traditional scrub when your hands are visibly soiled. While Ms. Buono's staff varies in their preferences for scrubs or rubs, most prefer the mechanical friction provided by a brush scrub before their first case of the day. After that, Ms. Buono says their loyalties are divided.

Frontline flexibility
Marian LeCoultre, RN, CNOR, clinical nurse manager of the OR at St. Luke's Allentown campus, says the initial surgical scrub begins with a routine washing of the hands and arms, as well as a cleaning under the fingernails with an approved nail pick (see "Essential Elements of the 5-Minute Scrub"). After completely drying the hands and arms, staff at St. Luke's choose from 3 traditional surgical hand scrub products: povidone-iodine, chlorhexidine gluconate and chloroxylenol (PCMX). They can also opt for an alcohol-based, waterless surgical hand rub, which is applied to dry hands and arms. This product must be allowed to air-dry prior to gowning and gloving, warns Ms. LeCoultre.

While researchers and policymakers have yet to crown a hand prep champion, CHG is gaining traction in facilities as the scrubbing agent of choice due to the immediate and persistent properties of its active ingredients, says Ms. Buono. But it's rare that a healthcare organization would tell you which product you have to use, she adds.

Giving your staff the flexibility to choose between a few hand prep options is especially important for employees with sensitivities to certain agents. Negative skin reactions associated with repetitive hand hygiene include dry, cracking and flaking skin, and in rare instances, allergic contact dermatitis, according to Bridget McEnrue, RN, manager of infection control at the Bethlehem campus of St. Luke's.

She says St. Luke's provides its employees with a hospital-approved hand lotion to help care for dry skin. "But today's surgical rubs are formulated with emollients to counteract the drying nature of the products' alcohol base," says Ms. Buono. Scrubbing agents, on the other hand, tend to burn dry, cracked hands, making the use of soothing hand lotion essential for nurses and surgeons who prefer traditional scrubs. Just be sure to check the manufacturers' directions on the lotions you use to be sure the formulas won't break down surgical glove material and that they're compatible with the hand hygiene products in use throughout your facility.