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Survey: Brushless Scrubs Catching On
Many who use the new alcohol-based products say scrub times and skin problems have decreased while infection rates have stayed the same.
Dianne Taylor
Publish Date: October 10, 2007   |  Tags:   Infection Prevention

Are brushless and waterless scrubs catching on in your facility? They certainly are in surgical facilities across the country, according to our recent online survey. More than half of the 142 administrators from last month's hand hygiene panel say they've changed their scrub practices during the past five years to include alcohol-based brushless products. As you might have guessed, the reasons why include preservation of skin integrity, better scrubbing compliance, between-case efficiency and excellent safety. Here's a look at what we found out.

The switch to brushless
Seventy percent of our panel (n=90) now use an alcohol-based, water-aided or a waterless, brushless scrub after the first scrub of the day, and another 9 percent (n=12) give OR personnel a choice between brushless and traditional scrubs.

This reflects a clear change in scrubbing practices; more than half of our panel say they use fewer brush-based scrubs than they did five years ago, and 17 percent say they have gone completely brushless.

"We have switched. One-hundred percent of our staff nurses now use an alcohol-rub product for the surgical scrub," says Bevie Swanson, BSN, director of nursing with the North Platte Surgery Center in Nebraska. "We have encouraged physicians to do the same by presenting them with infection control documentation on alcohol products."

A hospital-based ambulatory surgery program director makes a point to say you won't find any brushes in her department. Her staff can choose between a waterless scrub and a water-activated scrub.

The great majority of our panelists who made the switch to brushless say they gained the confidence to do so after the Centers for Disease Control (CDC) and the Association of periOperative Registered Nurses (AORN) released hand hygiene guidelines. Both documents endorse alcohol-based hand rubs for surgical hand antisepsis, specifically those approved for surgical hand antisepsis and offer persistent antimicrobial activity.

Outpatient Surgery Reader Survey

Waterless vs. water-aided
Of the 90 panelists who use a brushless product for between-case scrubs, 60 percent use a waterless product and 40 percent use a water-aided, brushless scrub. The reasons for going brushless, they say, are user satisfaction and improved skin integrity, which lead to better compliance with scrubbing protocols.

Brenda Kathman, surgical services manager with Mallard Pointe Surgical Center in Watertown, S.D., says her surgeons no longer rush their between-case scrubs because they don't have to use brushes for five minutes. Instead, they use a waterless, brushless rub.

"Having a waterless alternative has increased staff and physician satisfaction as well as a reported decrease in problems with cracked, dry and chapped hands," says Jennifer Misajet, RN, BBA, director of surgical services with Banner North Colorado Medical Center in Greeley, Colo.

At Treasure Valley Hospital in Boise, Idaho, the staff's skin had nearly everything to do with a switch to brushless surgical scrubs. Less than a month after the changeover, staff complaints of skin breakdown all but disappeared, says OR manager Wade Houser, RN, BA. His OR personnel use a waterless scrub between cases and pre-wash only when gross contamination is evident or suspected.

Some facilities have had to modify their infection control policies and prove that brushless scrubs wouldn't compromise infection control standards. The Southcoast Health System in New Bedford, Mass., monitored breaks in aseptic technique, post-op infections and glove changes for six months to satisfy the infection control committee. "But it was unnecessary," says A.E. Lyn Ames, RN, MS, CNOR, CNAA, director of perioperative services. "There was, is and never has been any change in the infection rate associated with the surgical hand scrub."

The experience of Lana Entringer, BSN, nurse-manager with the Boise VA Medical Center in Idaho, is similar: "With the new alcohol-based products, the times for scrub are decreased and skin problems have decreased. Infection rates continue to stay low and are not affected by this change."

And at the Renaissance Center for Plastic Surgery in Shavertown, Pa. - where OR personnel use a brushless, waterless scrub for all cases - improvements in turnover time have been notable. "Turnover between cases is much faster, and this greatly adds to the efficiency of the surgery center, saves costs and reduces down time without compromising patient safety," says Francis J. Collini, MD, medical director of the center.

Role of traditional scrubs
Still, most of our panelists haven't eliminated traditional brushed scrubs altogether. For many, these products - like those containing a chlorhexidine gluconate- or PCMX-impregnated brush - still play an important role in the following circumstances:

  • First scrub of the day. About two-thirds of our panel still use a traditional scrub for the first scrub of the day to ensure hand antisepsis and eliminate gross contamination carried in from the outside. Of the remaining one-third, 18 percent use a water-aided brushless scrub, 8 percent use a waterless brushless scrub, and 9 percent offer a choice between traditional and brushless products for the first scrub of the day.
  • Implant cases. Several of our panelists say they still require traditional brushed scrubbing before any case involving an implant. "In the past, personnel used a traditional scrub for all cases. Now, we use the alcohol-based waterless foam for second cases as long as no implants are used," says one Dallas-based facility manager.
  • After multiple brushless scrubs. "Several of our surgeons use a traditional scrub every third case, as they feel the brushless scrub accumulates and make gloves harder to don," says Denise Adams, RN, BSN, ambulatory surgery coordinator with the Baltimore Washington Eye Center in Glen Burnie, Md.

Outpatient Surgery Reader Survey

Choice remains important
Regardless of these changes, most facilities continue to offer their OR personnel a choice of traditional and brushless scrub products. Several panelists say the potential for allergic reactions or sensitivities to certain ingredients necessitates this. However, the overriding reason is that some still prefer a traditional scrub every time they scrub. Change, they say, takes time and can't be forced, especially upon surgeons.

"We changed our practice based on research. Our infection control epidemiologist strongly endorsed and supported the change. He worked with us to present the research findings with the surgeon leadership. The expectation with implementation was that all staff would use the alcohol/ CHG product," says one hospital-based education coordinator. Reality has been somewhat different. Despite posting the research, about half of the staff still scrubs with the brush and uses iodophor or CHG. And although the facility designated the alcohol-based scrub as the product of choice, surgeons can still use what they prefer.

Surgical Scrubbing Tips

As an AORN perioperative nursing specialist, I receive many questions about proper surgical scrubbing practices. Here are what I consider to be the six most important surgical scrubbing tips, based on the questions I receive and the common misconceptions underlying them:

  • Perform a traditional brushed scrub for the first scrub of the day. This will ensure hand antisepsis and elimination of gross contamination brought in from the outside.
  • Use only products that are FDA-approved for surgical scrubbing. Some alcohol-based, waterless products are not indicated for this purpose.
  • Follow all of the manufacturer's guidelines, including application time.
  • Always start at the hands and work to the elbows, no matter what type of surgical scrub product you are using.
  • Remove all jewelry before pre-washing and scrubbing.
  • Report any skin conditions that may result from hand products to your health coordinator.

- Joan Blanchard, RN, MSS, CNOR, CIC

Ms. Blanchard ([email protected]) is perioperative nursing specialist with the AORN Center for Nursing Practice.