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Should finger rings be removed prior to scrubbing for theatre?
Journal of Hospital Infection (2006) 62, 450–452
www.elsevierhealth.com/journals/jhin
Should finger rings be removed prior to scrubbing for theatre? N.K.R. Kelsalla, R.K.L. Griggsb, K.E. Bowkera, G.C. Bannistera,* a
Avon Orthopaedic Centre, Southmead Hospital, North Bristol NHS Trust, Westbury-On-Trym, Bristol, UK University of Bristol, Bristol, UK
b
Received 7 November 2003; accepted 1 September 2005
KEYWORDS Bacteria; Scrubbing; Jewellery; Finger rings
Summary Finger rings increase surface bacterial counts. Although scrubbing reduces these (PZ0.05), there are more bacteria under rings than on adjacent skin or the opposite hand. If rings are removed before scrubbing, bacterial counts are reduced but remain higher than on adjacent skin or the opposite hand. Ideally, finger rings should not be worn by theatre staff. However, if they are, they should be removed prior to scrubbing for surgical operations. Q 2005 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved.
Introduction The hands of operating theatre staff are one of the sources of bacteria that cause deep infection.1–4 The Association of Operating Room Nurses suggest that all jewellery should be removed before involvement in surgical procedures. 5 This practice has no bacteriological basis, although Bartlett et al. have shown that all jewellery is associated with higher surface bacterial load.6 The bacterial load around rings is higher than on other parts of fingers,7–9 but there is a paucity of studies that indicate how well this load can be reduced by scrubbing1,10 or whether it is better to remove rings altogether. The aim of this study was to measure the effect of retaining or removing finger rings on surface * Corresponding author. Tel.: C44 117 959 5795; fax: C44 117 959 5924. E-mail address: [email protected]
bacterial counts before and after scrubbing and at the end of operative procedures.
Material and methods Research Ethics Committee approval was obtained to swab the finger rings of theatre staff. Thirtytwo staff were recruited. Incomplete data were obtained on four, leaving a total of 28 subjects (nurses and surgeons). All but one were right handed, and all scrubbed with chlorhexidine gluconate (0.5%). Two of the rings were silver, two were platinum and the rest were gold. Subjects acted as their own control, thereby minimizing differences of individual skin bacterial loads. Eighteen samples were taken from each subject. On the first occasion, the ring remained in place. The ring itself, the skin directly beneath it, the skin
0195-6701/$ - see front matter Q 2005 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jhin.2005.09.002
Should finger rings be removed prior to scrubbing for theatre? Table I
Isolated bacteria
Bacteria isolated
Number of positive swabs
Coagulase-negative staphylococci Other skin flora Gram-negative cocci Pseudomonas spp. Staphylococcus aureus
150 50 9 1 4
adjacent to the ring and a similar area of skin on the ring finger of the opposite hand were all swabbed prior to the first scrub of the day, immediately following the scrub and at the end of the operative procedure. The length of scrub ranged from 3 to 6 min and the procedures ranged from 15 min to 4 h 30 min (amputation of shoulder). On the second occasion (one to 16 days later, mean eight days), the ring was removed after the first set of swabs was taken. After scrubbing, the skin beneath the (now removed) ring and that of the opposite ring finger were swabbed and this was repeated at the end of the operation. Thus a total of 18 samples was taken from each subject. Sterile dry cotton skin swabs were used to harvest bacterial samples from test areas. The swab tips were rolled along the line of the test area. Samples were stored at 2 8C prior to plating out on horse blood agar plates, pre-incubated at 37 8C for 24 h to prove sterility. The plate was inoculated and the inoculum was spread over half the plate with a sterile loop, allowing two different samples to be Table II
451
cultured per plate. The plates were then incubated for a further 18 h at 37 8C. The number of colonies was counted and classified.
Statistical analysis Data were non-parametric in distribution, and were therefore analysed by the Wilcoxon Signed Rank test. Ordinal data comparing silver rings with gold and platinum rings were analysed by Fisher’s Exact test.
Results The majority of bacteria isolated were coagulasenegative staphylococci (Table I).
Before scrubbing There were significantly higher colony counts on the skin under the ring than on the control ring finger, the ring itself or the skin adjacent to the ring (PZ0.05) (Table II).
After scrubbing Colony counts at all sites were significantly reduced by scrubbing (PZ0.05). There were significantly more bacteria on the skin under the ring than the control finger (PZ0.025) and the skin over which the ring had been worn before being removed (PZ0.05). There were significantly more bacteria
Comparative colony counts Ring
Colony counts Before scrubbing, wearing ring Median 0 Range 0–100 After scrubbing, wearing ring Median 0 Range 0 After operative procedure, wearing ring Median 0 Range 0–1001 Before scrubbing, not wearing ring Median Range After scrubbing, not wearing ring Median Range After operative procedure, not wearing ring Median Range
Beneath ring
Skin next to ring
Opposite hand
4 0–1001
1 0–510
0 0–1004
0 0–101
0 0–10
0 0–15
0 0–23
0 0–54
0 0–2
1 0–500
0 0–14
0 0–18
0 0
0 0–4
0 0–1001
452 on the skin over which the ring had been worn before removal than in the control finger (PZ0.05).
After the operative procedure Colony counts on the skin under the retained rings were significantly higher than on the control finger (PZ0.01), but there was no difference when the ring had been removed before scrubbing.
Ring type There was only one positive culture from the 28 samples taken from and adjacent to the two silver rings (3.6%), compared with 31% of the gold and platinum rings (PZ0.01) and 17% of the control fingers (not significant).
Discussion This study indicates that it is preferable for operating theatre personnel to remove their finger rings before surgical procedures. Rings reduce the effectiveness of scrubbing and increase glove microtears around the base of the finger.11,12 If silver rings are worn, there are measurably fewer bacteria than under gold or platinum rings. Indeed, the antiseptic properties of silver showed a trend to lower colony counts than on control fingers. If gold and platinum rings are worn, they should be removed before scrubbing as this reduces colony counts on a digit that is more likely to tear gloves and expose patients to bacterial contamination.
N.K.R. Kelsall et al.
Acknowledgements The authors wish to thank Gavin Bartlett for advice on methodology.
References 1. Arrowsmith VA, Maunder JA, Sargent RJ, et al. Removal of nail polish and finger rings to prevent surgical infection. The Cochrane Library. Oxford: Update Software; 2002 [Issue 1]. 2. Gould D. Nurses hands as vectors of hospital acquired infection: a review. J Adv Nurs 1991;16:1216—1225. 3. Lidwell OM, Lowbury EJI, Whyte W, et al. The effect of ultraclean air in operating rooms in deep sepsis in the joint after hip or knee replacement: a randomised study. BMJ 1982;285:10—14. 4. Whyte W, Hodgson R, Tinkler J. The importance of airborne bacterial contamination in wounds. J Hosp Infect 1982;3: 123—135. 5. Association of Operating Room Nurses. Recommended practices for surgical hand scrub. AORN J 1988;69:842 [see also p. 845, 846, 848—850]. 6. Bartlett GE, Pollard TCB, Bowker KE, et al. Effect of jewellery on surface bacterial counts of operating theatres. J Hosp Infect 2002;52:68—70. 7. Salisbury DM, Hutfilz P, Treen LM, et al. The effect of rings on microbial load of health workers hands. Am J Infect Control 1997;25:24—27. 8. Hoffman PN, Cooke EM, McCarville MR, et al. Microorganisms isolated from skin under wedding rings worn by staff. BMJ 1985;290:206—207. 9. Jacobson G, Thiele JE, McCune JH, et al. Handwashing: ring wearing and number of micro-organisms. Nurs Res 1985;34: 186—188. 10. Bernthal E. Wedding rings and hospital acquired infection. Nurs Stand 1997;11:44—46. 11. Nicolai P, Aldam CH, Allen PW. Increased awareness of glove perforation in major joint replacement. J Bone Joint Surg 1997;79:371—373. 12. Larson E. Handwashing: it is essential even when you use gloves. Am J Nurs 1989;89:934—939.
www.elsevierhealth.com/journals/jhin
Should finger rings be removed prior to scrubbing for theatre? N.K.R. Kelsalla, R.K.L. Griggsb, K.E. Bowkera, G.C. Bannistera,* a
Avon Orthopaedic Centre, Southmead Hospital, North Bristol NHS Trust, Westbury-On-Trym, Bristol, UK University of Bristol, Bristol, UK
b
Received 7 November 2003; accepted 1 September 2005
KEYWORDS Bacteria; Scrubbing; Jewellery; Finger rings
Summary Finger rings increase surface bacterial counts. Although scrubbing reduces these (PZ0.05), there are more bacteria under rings than on adjacent skin or the opposite hand. If rings are removed before scrubbing, bacterial counts are reduced but remain higher than on adjacent skin or the opposite hand. Ideally, finger rings should not be worn by theatre staff. However, if they are, they should be removed prior to scrubbing for surgical operations. Q 2005 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved.
Introduction The hands of operating theatre staff are one of the sources of bacteria that cause deep infection.1–4 The Association of Operating Room Nurses suggest that all jewellery should be removed before involvement in surgical procedures. 5 This practice has no bacteriological basis, although Bartlett et al. have shown that all jewellery is associated with higher surface bacterial load.6 The bacterial load around rings is higher than on other parts of fingers,7–9 but there is a paucity of studies that indicate how well this load can be reduced by scrubbing1,10 or whether it is better to remove rings altogether. The aim of this study was to measure the effect of retaining or removing finger rings on surface * Corresponding author. Tel.: C44 117 959 5795; fax: C44 117 959 5924. E-mail address: [email protected]
bacterial counts before and after scrubbing and at the end of operative procedures.
Material and methods Research Ethics Committee approval was obtained to swab the finger rings of theatre staff. Thirtytwo staff were recruited. Incomplete data were obtained on four, leaving a total of 28 subjects (nurses and surgeons). All but one were right handed, and all scrubbed with chlorhexidine gluconate (0.5%). Two of the rings were silver, two were platinum and the rest were gold. Subjects acted as their own control, thereby minimizing differences of individual skin bacterial loads. Eighteen samples were taken from each subject. On the first occasion, the ring remained in place. The ring itself, the skin directly beneath it, the skin
0195-6701/$ - see front matter Q 2005 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jhin.2005.09.002
Should finger rings be removed prior to scrubbing for theatre? Table I
Isolated bacteria
Bacteria isolated
Number of positive swabs
Coagulase-negative staphylococci Other skin flora Gram-negative cocci Pseudomonas spp. Staphylococcus aureus
150 50 9 1 4
adjacent to the ring and a similar area of skin on the ring finger of the opposite hand were all swabbed prior to the first scrub of the day, immediately following the scrub and at the end of the operative procedure. The length of scrub ranged from 3 to 6 min and the procedures ranged from 15 min to 4 h 30 min (amputation of shoulder). On the second occasion (one to 16 days later, mean eight days), the ring was removed after the first set of swabs was taken. After scrubbing, the skin beneath the (now removed) ring and that of the opposite ring finger were swabbed and this was repeated at the end of the operation. Thus a total of 18 samples was taken from each subject. Sterile dry cotton skin swabs were used to harvest bacterial samples from test areas. The swab tips were rolled along the line of the test area. Samples were stored at 2 8C prior to plating out on horse blood agar plates, pre-incubated at 37 8C for 24 h to prove sterility. The plate was inoculated and the inoculum was spread over half the plate with a sterile loop, allowing two different samples to be Table II
451
cultured per plate. The plates were then incubated for a further 18 h at 37 8C. The number of colonies was counted and classified.
Statistical analysis Data were non-parametric in distribution, and were therefore analysed by the Wilcoxon Signed Rank test. Ordinal data comparing silver rings with gold and platinum rings were analysed by Fisher’s Exact test.
Results The majority of bacteria isolated were coagulasenegative staphylococci (Table I).
Before scrubbing There were significantly higher colony counts on the skin under the ring than on the control ring finger, the ring itself or the skin adjacent to the ring (PZ0.05) (Table II).
After scrubbing Colony counts at all sites were significantly reduced by scrubbing (PZ0.05). There were significantly more bacteria on the skin under the ring than the control finger (PZ0.025) and the skin over which the ring had been worn before being removed (PZ0.05). There were significantly more bacteria
Comparative colony counts Ring
Colony counts Before scrubbing, wearing ring Median 0 Range 0–100 After scrubbing, wearing ring Median 0 Range 0 After operative procedure, wearing ring Median 0 Range 0–1001 Before scrubbing, not wearing ring Median Range After scrubbing, not wearing ring Median Range After operative procedure, not wearing ring Median Range
Beneath ring
Skin next to ring
Opposite hand
4 0–1001
1 0–510
0 0–1004
0 0–101
0 0–10
0 0–15
0 0–23
0 0–54
0 0–2
1 0–500
0 0–14
0 0–18
0 0
0 0–4
0 0–1001
452 on the skin over which the ring had been worn before removal than in the control finger (PZ0.05).
After the operative procedure Colony counts on the skin under the retained rings were significantly higher than on the control finger (PZ0.01), but there was no difference when the ring had been removed before scrubbing.
Ring type There was only one positive culture from the 28 samples taken from and adjacent to the two silver rings (3.6%), compared with 31% of the gold and platinum rings (PZ0.01) and 17% of the control fingers (not significant).
Discussion This study indicates that it is preferable for operating theatre personnel to remove their finger rings before surgical procedures. Rings reduce the effectiveness of scrubbing and increase glove microtears around the base of the finger.11,12 If silver rings are worn, there are measurably fewer bacteria than under gold or platinum rings. Indeed, the antiseptic properties of silver showed a trend to lower colony counts than on control fingers. If gold and platinum rings are worn, they should be removed before scrubbing as this reduces colony counts on a digit that is more likely to tear gloves and expose patients to bacterial contamination.
N.K.R. Kelsall et al.
Acknowledgements The authors wish to thank Gavin Bartlett for advice on methodology.
References 1. Arrowsmith VA, Maunder JA, Sargent RJ, et al. Removal of nail polish and finger rings to prevent surgical infection. The Cochrane Library. Oxford: Update Software; 2002 [Issue 1]. 2. Gould D. Nurses hands as vectors of hospital acquired infection: a review. J Adv Nurs 1991;16:1216—1225. 3. Lidwell OM, Lowbury EJI, Whyte W, et al. The effect of ultraclean air in operating rooms in deep sepsis in the joint after hip or knee replacement: a randomised study. BMJ 1982;285:10—14. 4. Whyte W, Hodgson R, Tinkler J. The importance of airborne bacterial contamination in wounds. J Hosp Infect 1982;3: 123—135. 5. Association of Operating Room Nurses. Recommended practices for surgical hand scrub. AORN J 1988;69:842 [see also p. 845, 846, 848—850]. 6. Bartlett GE, Pollard TCB, Bowker KE, et al. Effect of jewellery on surface bacterial counts of operating theatres. J Hosp Infect 2002;52:68—70. 7. Salisbury DM, Hutfilz P, Treen LM, et al. The effect of rings on microbial load of health workers hands. Am J Infect Control 1997;25:24—27. 8. Hoffman PN, Cooke EM, McCarville MR, et al. Microorganisms isolated from skin under wedding rings worn by staff. BMJ 1985;290:206—207. 9. Jacobson G, Thiele JE, McCune JH, et al. Handwashing: ring wearing and number of micro-organisms. Nurs Res 1985;34: 186—188. 10. Bernthal E. Wedding rings and hospital acquired infection. Nurs Stand 1997;11:44—46. 11. Nicolai P, Aldam CH, Allen PW. Increased awareness of glove perforation in major joint replacement. J Bone Joint Surg 1997;79:371—373. 12. Larson E. Handwashing: it is essential even when you use gloves. Am J Nurs 1989;89:934—939.