Getting armed for battle – The perioperative challenge

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The Role of Surgical Hand Scrub and Hand Antisepsis in Preventing Infection

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Surgical hand antisepsis plays a significant role in preventing healthcare associated infections and surgical site infections and the subsequent morbidity, mortality, and cost associated with them.
Hand washing is known to be the single most important action in preventing infection. The hands of healthcare providers carry microorganisms identified as sources of microbial contamination.^1,2 For healthcare providers, the skin flora isolated from the hands can include coagulase-negative staphylococci (CNS), micrococci, Staphylococcus aureus, a-hemolytic streptococci, yeasts, fungi, lipophilic corynebacteria, large-colony diphtheroids, and other gram-positive and gram-negative bacteria.^2,6 Some of these same organisms, notably S. aureus and CNS, are also the leading causes of surgical site infections.
To help combat this problem, hand antisepsis is performed to remove or destroy transient microorganisms and for surgical scrubbing, to remove or destroy transient microorganisms and reduce resident flora.³ Hand antisepsis and surgical scrub agents have been refined over the years, offering increasingly effective and broader spectrum microbial kill, first with povidone-iodine and hexachlorophene, and later, chlorhexidine gluconate.
Unfortunately, the effects of frequent scrubbing and hand washing can also damage the skin’s integrity.^1–3,5–10
Healthy skin needs to be soft, pliable, and hydrated to maintain its barrier function.¹¹ Fatty acids found in the stratum corneum help the skin maintain its barrier by preventing dehydration.¹¹ Additionally, these fatty acids have fungicidal and bactericidal activity important to modulating the balance of flora on the skin.¹¹ Yet, many of today’s antiseptic scrub agents, although highly effective against a broad spectrum of infectious organisms, compromise the integrity of the skin’s natural barrier by dehydrating and defatting the skin, resulting in a loss of moisture, pliability, and integrity.^{1–3,6,10,16–21} The consequenceof damaged skin on the hands of health careproviders is that damaged skin can harbor large numbers of microorganisms, shed greater numbers of these microorganisms because of increased desquamation of dry skin, and become a deterrent to good hand washing practices.^1–3,6,8,10 Damaged hands are very prevalent among health care professionals because of frequent hand washing with harsh agents.^10,19,20
Based on surveys of operating room nurses at the Association of periOperative Registered Nurses (AORN) 1996 and 1997 conferences, approximately 75% of nurses reported having problems with their hands including: dry, scaly, cracked skin; red blotchy skin; or stinging.²² The frequency of hand washing/scrubbing and the soap/ antimicrobial agent used were among the most common reasons cited for damaged skin.²²
To address this problem, the focus of hand antisepsis is shifting to incorporate maintaining the skin’s health and integrity as a preventative measure against infection.^2–4 AORN, in their most recent guidelines, call for the following criteria when selecting an antimicrobial surgical hand scrub:
The surgical hand scrub agent should:

• contain a non-irritating antimicrobial preparation


• significantly reduce microorganisms on intact skin


• be broad spectrum


• be fast acting


• have a persistent effect¹
  

* ACORN also highlight that the skin antiseptic criteria shall “have a cumulative action” as well as “have minimal detrimental effects on the skin”. (ACORN Standards for Perioperative Nursing 2014-2015 Asepsis and Clinical. Standard: Scrubbing, Gowning and Gloving.)
Because many surgical scrub and hand antisepsis agents increase the damage to hands as well as the risk for contamination, leaders in infection control now call for increased emphasis on maintaining the skin’s natural barrier as an adjunct to antimicrobial activity in preventing infection.^2,10
Recognised Active Ingredients Provide Immediate, Persistent and Cumulative Activity
3M™ Avagard™ Antiseptic Hand Rub Healthcare professional hand antiseptic and for surgical hand disinfection(Chlorhexidine Gluconate 1% w/w in Ethanol absolute 61% w/w) contains two proven active ingredients to provide immediate, persistent and cumulative activity needed in a surgical hand antiseptic: alcohol for fast immediate broad spectrum kill and chlorhexidine gluconate for persistent and cumulative activity. As a trusted global leader, 3M infection prevention has fundamentally laid the foundation for infection prevention in the perioperative environment: from pre-operative to intra-operative to post-operative. Backed by a broad portfolio of perioperative solutions, 3M collaborates with customers to help facilities manage surgical site infections (SSI) and hospital acquired infections (HAI) risk factors, to improve patient outcomes, improve staff safety and manage costs.
References
1. Association of Operating Room Nurses. 1999 standards, recommended practices, and guidelines: recommended practices for surgical hand scrubs. AORN J. 1999; Apr:249–254.
2. Larson E, Norton Hughes CA, Pyrek JD, Sparks SM, Cagatay EU, Bartkus JM. Changes in bacterial flora associated with skin damage on hands of health care personnel. Am J Infect Control. 1998; 26:513–521.
3. Larson EL. APIC guideline for handwashing and hand antisepsis in health care settings. Am J Infect Control. 1995; 23:251–269.
4. Hobson DW. Surgical hand washing: new products for the next millennium Surg Serv Manage. 1998; 4:36–43.
5. Wheelock SM, Lookinland S. Effect of surgical hand scrub time on subsequent bacterial growth. AORN J. 1997; 65:1087–1098.
6. Larson E, Leyden JJ, McGinley KJ, Grove GL, Talbot GH. Physiologic and microbiologic changes in skin related to frequent handwashing. Infect Control. 1986; 7:59–63.
7. Steere AC, Mallison GF. Handwashing practices for the prevention of nosocomial infection. Ann Intern Med. 1975; 83:683–690.
8. Meers PD, Yeo GA. Shedding of bacteria and skin squames after handwashing. J Hyg Camb. 1978; 81:99–105.
9. Larson E, Killien M. Factors influencing handwashing behavior of patient care personnel. Am J Infect Control. 1982; 10:93–99.
10. Larson E, Friedman C, Cohran J, Treston-Aurand J, Green S. Prevalence and correlates of skin damage on the hands of nurses. Heart Lung. 1997; 26:404–412.
11. Marples MJ. The Ecology of Human Skin. Springfield, Ill: Charles C. Thomas, 1965.
12. Rabussay D, Korniewicz DM. The risks and challenges of surgical glove failure. AORN J. 1997; 66:867–888.
13. Emori TG, Gaynes RP. An overview of nosocomial infections, including the role of the microbiology laboratory. Clin Microbiol Rev. 1993; 6:428–442.
14. Martone WJ, Jarvis WR, Culver DH, Haley RW. Incidence and nature of endemic and epidemic nosocomial infections. In: Bennet JV, Brachman PS, eds. Hospital Infections, 3rd ed. Boston, Mass: Little, Brown and Co, 1992:577–96.
15. Mangram AJ, Horan TC, Peason ML, et al. Guideline for prevention of surgical site infection, 1999. From the Hospital Infections Program, National Center for Infectious Diseases, CDC, 1999; 27:97–134.
16. Newman JL, Seitz JC. Intermittent use of an antimicrobial hand gel for reducing soap-induced irritation of health care personnel. Am J Infect Control. 1990; 18:194–200.
17. Mitchell KG, Rawluk DJR. Skin reactions related to surgical scrub up: results of a Scottish survey. Br J Surg. 1984; 71:223–224.
18. Hassing JH, Nater JP, Bleumink E. Irritancy of low concentrations of soap and synthetic detergents as measured by skin water loss. Dermatologica. 1982; 164:314–321.
19. Kligman AM. The biology of the stratum corneum. In: Montagna W, Lobbitz WE, eds. The Epidermis. New York, NY: Academic Press; 1964:387–433.
20. Klauder JV, Gross BAL. Actual causes of certain occupation dermatosis. Arch Dermatol Syph. 1951; 63:1–23.
21. Kirk JE. Handwashing: quantitative studies on skin lipid removal by soaps and detergents based on 1500 experiments. Acta Derm Venereol. 1966; (suppl):1–183.
22. Data on file, 3M Health Care. AORN surveys.
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