Waterless ‘surgical scrub’ protocol

[Michael Wishart]

Hi all

I am wondering if anyone has developed a full protocol for waterless ‘surgical scrub’ that covers issues like hand hygiene post toilet breaks, meal breaks, ward rounds, etc, prior to further waterless agent use. Our current protocol merely recommends a full social hand wash with soap and water prior to the first waterless surgical skin antisepsis of the day (or when hands are visibly dirty), but does not address any of the above scenarios. We have different observed behaviours amongst clinicians currently, but it has been difficult to find guidelines addressing these issues.

Also, does anyone enforce a social hand wash with soap and water AFTER every procedure (ie after removal of gloves and other PPE)?

I find it amazing that professional bodies for operating room professionals in Australia have not addressed these issues to date.

Thanks for any help or discussion on this.

Cheers
Michael

Michael Wishart
Infection Control Coordinator
Holy Spirit Northside Private Hospital
627 Rode Road, Chermside, Qld 4032
t: (07) 3326 3068 | f: (07) 3607 2226
e: Michael.Wishart@svha.org.au
w:www.holyspiritnorthside.org.au
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[Matthias Maiwald (KKH)]

Hi Michael,

Some of the answers to your questions follow by logical extension from the 2009 WHO Hand Hygiene Guidelines (surgical hand preparation is covered in pages 54-60), although not quite in the format that you are looking for. WHO states that it is not necessary to wash hands before the surgical preparation unless they are visibly dirty (p. 56 bottom). It may then be up to an individual organisation to adapt the guidelines for its institutional use, e.g. to make sure that no one who has e.g. returned from a toilet break ‘slips through the cracks’ (i.e. to err on the stricter side).

Note that contrary to some statements that I have seen — and this should, of course, not affect the general recommendation to wash if hands are visibly dirty — it is reassuring to know that alcohol is able to cope with small (!) amounts of organic dirt/contamination:

Larson E, Bobo L. Effective hand degerming in the presence of blood. J Emerg Med. 1992 Jan-Feb;10(1):7-11.
http://www.ncbi.nlm.nih.gov/pubmed/1629595

It needs to be re-emphasised that it is important to keep the hands and forearms wet with alcohol — by liberally applying it — during the entire hand preparation procedure. Recommendations by some manufacturers/organisations to use ridiculously small amounts, e.g. ~6 mL for the entire procedure, including forearms, are outright dangerous and put patients at risk.

I have discussed this aspect in a previous letter to the editor:

Maiwald M. Technique is important for alcohol-based surgical hand antisepsis. Healthcare Infection, 2012; 17: 106-107.
http://dx.doi.org/10.1071/HI12028

The importance of applied volume is also being shown in a recent article by the Kampf group:

Kampf G, Ostermeyer C. Small volumes of n-propanol (60%) applied for 3 minutes may be ineffective for surgical hand disinfection. Antimicrob Resist Infect Control. 2014 Apr 24;3:15. doi: 10.1186/2047-2994-3-15. eCollection 2014.
http://www.ncbi.nlm.nih.gov/pubmed/24822090

Note that due to methodological issues with testing standard EN 12791 (the one used by Kampf), the volumes in that paper are only needed to cover the hands, not the forearms (this is not well explained in the article). For a real surgical hand preparation, one needs extra volume above what is stated in the Kampf paper to cover the forearms, too.

Best regards, Matthias.

—
Matthias Maiwald, MD, FRCPA
Consultant in Microbiology
Adj. Assoc. Prof., Natl. Univ. Singapore
Department of Pathology and Laboratory Medicine
KK Women’s and Children’s Hospital
100 Bukit Timah Road
Singapore 229899
Tel. +65 6394 8725 (Office)
Tel. +65 6394 1389 (Laboratory)
Fax +65 6394 1387

Hi all

I am wondering if anyone has developed a full protocol for waterless ‘surgical scrub’ that covers issues like hand hygiene post toilet breaks, meal breaks, ward rounds, etc, prior to further waterless agent use. Our current protocol merely recommends a full social hand wash with soap and water prior to the first waterless surgical skin antisepsis of the day (or when hands are visibly dirty), but does not address any of the above scenarios. We have different observed behaviours amongst clinicians currently, but it has been difficult to find guidelines addressing these issues.

Also, does anyone enforce a social hand wash with soap and water AFTER every procedure (ie after removal of gloves and other PPE)?

I find it amazing that professional bodies for operating room professionals in Australia have not addressed these issues to date.

Thanks for any help or discussion on this.

Cheers
Michael

Michael Wishart
Infection Control Coordinator
Holy Spirit Northside Private Hospital
627 Rode Road, Chermside, Qld 4032
t: (07) 3326 3068 | f: (07) 3607 2226
e: Michael.Wishart@svha.org.au
w:www.holyspiritnorthside.org.au
Please consider the environment before printing this email

[http://www.interactivejam.com.au/images/ACIPC-conference.jpg]

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