THERE'S THE RUB Surgical staff have shown preferences based on a hand hygiene product's ease of use, consistency, fragrance and dispensing system.

The hand hygiene process is not without a debate over methods: namely, water-aided brush scrubs versus alcohol-based hand rubs. The chief question you face when deciding which to stock is whether "rubbing" with alcohol-based products works better than "scrubbing" one's hands with a brush. You can answer this question by evaluating efficacy, tolerability, staff acceptance and cost.¹

1. Efficacy
Scrubbing hands with a brush has been a long-standing practice in perioperative care. In 2002, however, the CDC published its latest hand-hygiene guidelines, which presented healthcare workers with a dramatic shift toward the preferential use of alcohol-based hand disinfectants in many settings.² AORN also endorsed the newer hand rub process as an alternative to surgical scrubs.³

The guidelines' rationale was that alcohol-based products are just as effective or more so at killing microorganisms than antibacterial soaps. They provide easier access to hand hygiene products, are easy to use, save time and are less damaging to skin than soap, water and paper towels are.

Although scrubbing is a venerable old practice, data are accumulating that show rubbing to be better at reducing bacterial burden. Loeb and colleagues conducted a randomized trial in which they compared the use of the same antibacterial soap product when administered with a brush and by rubbing.⁴ At 45 minutes after this hand preparation, the rubbing resulted in lower bacterial counts than the use of the scrub brush with the same product did.

Other studies have since compared surgical hand rubs employing alcohol-based products with traditional hand scrubs. Out of 5 studies that examined bactericidal activity, each reported that hand rubs outperformed traditional scrubs in their efficacy.

Two studies have looked at infection rate as the outcome of interest in comparing alcohol-based rubs to traditional scrubs. The first study was a pre- and post-test design in which a pediatric urologist monitored 550 consecutive surgical cases after he had switched to an alcohol-based product. He then compared the resulting infection rate with that of the last 550 cases he had performed while preparing with a traditional scrub. Although the hand preparation procedures of other members of the surgical team were not documented or controlled, this surgeon's rates of surgical site infections were very low in both phases of the study and were not significantly different when he switched to the alcohol hand rub regimen.⁵ The second study in which surgical site infection rate was the outcome included 4,387 surgical procedures. Parienti and colleagues found that scrubs and rubs were equivalent in terms of infection rates, with the rubs performing slightly better.⁶

MORE TO THE METHOD Compared to rubs, scrubs require more in the way of staff time, ancillary equipment, water use and waste disposal.

2. Tolerability
Even a small amount of damage to users' hands should be avoided, since a breakdown in skin means a potential breakdown in the most basic barrier protection. Kikuchi-Numagami and colleagues tested the irritancy of scrubbing versus rubbing with the same povidone-iodine product, discovering that there was significantly more skin moisture loss associated with scrubbing compared to rubbing.⁷

The issue of tolerability brings alcohol-based products head-to-head with rubs containing other antimicrobial agents, another choice you might face when selecting hand hygiene products. Larson and colleagues reported significantly less skin damage among OR staff who used an alcohol-based rub as compared with those who used a traditional 4% chlorhexidine gluconate scrub,⁸ a result similar to that noted by Parienti and colleagues.⁶

Skin irritation has been most commonly reported in conjunction with the use of iodophors, although chlorhexidine and other antiseptic agents have also been implicated.¹ Studies comparing hand rubs point out that alcohol-based products containing emollients, which offer skin conditioning with their disinfection, are better tolerated than other antiseptic agents or ordinary hand soaps.¹

3. Acceptability
An evaluation of the qualities of hand hygiene methods and products isn't strictly empirical, of course. Your staff's preferences must also be considered. After all, they're the front-line users who'll be working with them several times daily. In many studies, staff have shown preferences based on a hand hygiene product's consistency, fragrance and dispensing system.

A product's acceptability is a critical issue here. Healthcare workers ranked the freedom to choose the institution's hand hygiene product as the second most important feature of a hand hygiene campaign.¹ What's more, the use of inferior products can be a serious deterrent to a staff's hand hygiene compliance.

Larson found that study participants preferred waterless hand rubs to the traditional scrub process, explaining that using rubs was faster and easier than scrubbing, that donning gloves afterwards was easier and that the regular use of alcohol-based rubs proved milder on their skin.⁸

4. Cost
As with any evaluation of supplies, cost must be considered when comparing alcohol-based hand rubs and traditional brush scrubs. Not surprisingly, studies have favored the alcohol rubs on this front as well.

Taking into account the average length of a scrub or application, including the time it took for the hands to dry, as well as the average cost of a staff member's OR minute, Larson calculated that the total cost of each method per application time was about $60 for each 6-minute scrub and $20 for each 2-minute hand rub application, if manufacturers' directions were followed precisely.⁸ Although the study noted that the products' costs were similar, the shorter staff time made the alcohol rub product much more cost-effective. Additionally, Larson pointed out that each traditional scrub used 12 gallons of water and 38.6 grams of waste due to nail picks and packaging. The applications of alcohol hand rubs created only 2.1 grams of waste and no water usage.⁸

Tavolacci reported that surgical hand rubs are 67% less expensive than traditional scrubs, based on the total cost of all products used in each method — including a soap-and-water pre-wash before applying alcohol-based products, the use of the water filters often necessary to ensure water quality when traditional scrubs are used, and sterile towels.⁹ The report did not consider cost savings based on the staff time needed for each hand preparation procedure, however.

The score
You may see greater and more precise compliance with waterless hand rubs instead of brush scrubs only. To review:

• Rubs are as effective or more effective at reducing bacterial counts on hands than scrubbing.
• Rubs have been associated with equivalent or lower rates of surgical site infection.
• Skin condition after rubbing is better than it is after scrubbing.
• Some alcohol-based products contain emollients.
• Staff generally prefer hand rubs over scrubbing.
• Rubs offer major savings: staff time, ancillary equipment, water use and waste disposal costs.