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Literature review and survey comparing surgical scrub techniques
AUGUST 2001, VOL 74, NO 2 C I, I N I C A L I N N 0 V A T I 0 N S
Literature review and survey comparing surgical scrub techniques
S
urgical scrub solutions ensure that microbial loads on hands are reduced significantly (ie, 90% to 99%). This reduction in microbial loads decreases the potential for surgical site infections. In addition, surgical scrubs should provide persistent antimicrobial action, which helps keep microbial load to a minimum as surgical staff members perform surgery. The moist environment of surgical gloves allows microorganisms to grow on the hands within, and these gloves frequently are damaged during surgical procedures, thus increasing the risk for surgical site infections.’ The two principles of surgical scrubs (ie, reduction in microbial load, persistent antimicrobial action) are dependent on the length of time and how a person scrubs. It also depends on what antimicrobial agent is used.* When changing surgical scrub policies, it is important to remember these two key principles. In March 1998, administrators in the surgical support business unit at Toronto General Hospital of the University Health Network, Toronto, requested that the infection prevention and control unit investigate changing the existing surgical scrub policy. Team members had noted the results of a study that concluded three-minute brush scrubs provide the same reduction in hand microbes as five-minute brush scrubs.’ Administrators wanted to determine if it was safe, from a patient care perspective (ie, no increase in
surgical site infections), to change from the existing hand scrub policy, which was a five-minute anatomical hand scrub without the use of a brush or sponge, to a two-minute hand scrub. Currently, a five-minute surgical scrub with 2%chlorhexidene gluconate or 7.5% povidoneiodine is performed before each procedure. Staff members need to ensure that the skin of their hands and arms is intact. If technique is broken while scrubbing, staff members repeat the procedure (Table 1). A review of existing literature on the topic and a survey of various Canadian and US hospitals allowed staff members to critically evaluate the efficacy of twominute anatomical surgical scrubs in reducing microbial SIU MEE CHENG, BAA, MHSC, is the corporate quality improvement manager of the infection prevention and control unit, University Health Network, Toronto. MARTA GARCIA, RN, BSCN, MED, CIC, is a manager and an integrated health care practitioner in the infection prevention and control unit, University Health Network, Toronto. SHERRY ESPIN, RN, BSCN, MED, is an OR clinical teacher at Toronto General Hospital, University Health Network, Toronto. J. CONLY, MD, is a hospital epidemiologist and the director of infection prevention and control in the infection prevention and control unit, University Health Network, Toronto.
218 AORN JOURNAL
loads on hands versus the fiveminute anatomical scrub. The purpose of the survey was to determine if short-duration anatomical hand scrubs were prevalent among several wellrespected Canadian and US hospitals. It should be noted that the term “anatomical scrubs’’ refers to surgical scrubs not requiring the use of brushes and the term “surgical scrubs’’ refers to surgical scrubs requiring brushes.
LITERATURE REVIEW A review of scientific literature was conducted via PubMed and EMBASE between July 1998 and December 1999. Reviewers used keywords, such as surgical scrub, hospital, infection, microorganisms. No studies specifically compared a fiveminute anatomical scrub (ie, brushless scrub) with a twominute anatomical scrub. There were numerous articles, however, on surgical scrubs using brushes for different time durations. Consequently, articles that compared surgical scrubs (ie, scrubs requiring brushes) with anatomical scrubs were reviewed to determine and establish whether surgical scrubs are as effective in reducing microbial load as anatomical scrubs. Several articles that compared microbial load reductions for different duration surgical scrubs were reviewed to try and prove the hypothesis that if surgical scrubs are as effective as anatomical scrubs, results for various different-duration surgical
AUGUST 2001, VOL 74, NO 2
Table 1 scrubs should be similar for different-duration anatomical scrubs. Additionally, existing national and international guidelines regarding recommendations on surgical scrubs were reviewed. One of the articles reviewed shows that five-minute surgical scrubs with a brush or sponge are as effective as five-minute anatomical scrubs without the use of brush or sponge with respect to microbial load reduction on hands." Studies also show that five-minute surgical scrubs are as effective as two- to fourminute surgical scrubs. For instance, in one study, when sixminute scrubs with a brush were compared to four-minute and two-minute scrubs, hand bacterial counts for each duration were not statistically significantly different from prescrub counts.' This study indicates that a two-minute scrub is as effective as four-minute and six-minute scrubs; one-hour postscrub microbial reductions were 47%, 55%, and 58%, respectively ( P = .01). It should be noted that this study had a small sample size (n = 10). Other studies show that threeminute surgical scrubs are as adequate as five-minute surgical scrubs! One study, however, indicates surgical scrubs that started with an initial five-minute scrub. followed by three-minute between-procedure scrubs, provided greater microbial reductions, compared to five-minute and three-minute initial scrubs with 30-second between-procedure scrubs.' Interestingly, another study indicates that two-minute surgical scrubs with brushes are common,' and, according to some researchers, three-minute surgical scrubs reduce microbial loads
SCRUB PROCEDURE AT TORONTO GENERAL HOSPITAL
Stem in scrubbina Drocedure 1 . Rinse hands and forearms while keeping hands elevated above elbows.
2. Step on the pump once and apply foam. 3. Lather hands and arms, but do not rinse at this stage.
4. Clean nails under running water with a nail stick. 5. Rinse from fingertips to elbows.
6. Step on the pump again and apply foam. 7. Scrub nails against palm of hand for 15 seconds.
8. Scrub the four sides of each finger for 45 seconds, paying special attention to interdigital areas (ie, the web). 9. Scrub the back of the hand and palm from the base of the fingers to the wrist for 45 seconds. 10. Repeat steps 1 through 9 with the other hand. 1 1. Scrub the arm with small, overlapping circles from wrist to 2 inches above the elbow for 45 seconds.
12. Repeat the above step with the other arm. 13. Rinse hands and forearms from fingertips to elbows while keeping hands elevated above elbows and away from body. Brushes are available for heavily soiled hands.
more than two-minute surgical scrubs? The mean log difference between the two scrub durations was 0.29, with respect to growth on gloves; this was statistically significant at P = .02. The subjects sampled, however, did not participate in surgical procedures or any other routine procedures in the surgical field. In addition, the researchers did not sample microbial loads prescrub and postscrub. This would have provided results of microbial load reductions, which would have helped reveal which scrub method is more effective. A study on anatomical scrubs that compared 30-second scrubs with different povidone-iodine contact times (ie, two minutes, one and one-half minutes, one minute, no additional contact time) found that microbial count reductions 221 AORN JOURNAL
from prescrub to postscrub were statistically significant for all different contact times. Researchers concluded that there was no difference in efficacy between a 30-second scrub and a two-minute scrub, but this study was not very comprehensive and had some limitations. For example, it did not provide a clear description of its anatomical scrub procedure, so the scrub procedure could have been interpreted as a normal handwashing procedure, rather than the more rigorous anatomical scrub that is practiced at Toronto General Hospital. In addition, hands were sampled 30 minutes after the scrub, and no actual surgical procedure had been performed before sampling hands for bacterial load. Data about colony forming unit reductions also are not provided, and readers are
AUGUST 2001. VOL 74, NO 2
required to extrapolate estimates from graphs. Consequently, the results of this particular study may not provide an accurate description of actual microbial loads after a routine surgical procedure."' NATIONAL AND INTERNATIONAL GUIDELINES Existing North American guidelines on surgical scrubbing do not indicate a specific duration for surgical scrubbing or the type of scrub technique (eg, with a brush or sponge, handwash with subsequent alcohol rub). The Association for Professionals in Infection Control and Epidemiology continues to recommend a five-minute scrub with a brush, but it also recognizes the use of the European technique, which is essentially a handwash followed by an alcohol rub." AORN promotes the use of brushes for surgical scrubs, but it does not mention a specific scrub duration and advises following antiseptic manufacturers' recommendations.'*In addition, AORN mentions that European studies recommend shorter duration surgical scrubs be performed after the initial surgical scrub, provided that surgical procedures do not exceed one hour. The Centers for Disease Control and Prevention mentions a three- to five-minute surgical scrub with a brush," and the American College of Surgeons (ACS) says that a surgical scrub duration as short as two minutes is p0ssib1e.l~ Despite this, the ACS does not clearly state whether this applies to anatomical scrubs or to surgical scrubs only. SURGICAL SCRUB WITH AN ALCOHOL ANTISEPTIC Alternative surgical scrub practices are commonly practiced in Europe. The most common
anatomical scrubbing practice requires less scrubbing time and use of an antiseptic, usually alcohol-based. For example, the German Federal Institute of Health's guidelines recommend that preoperative surgical hand disinfection include at least two minutes of hand washing, along with a nonantiseptic washing substance and disinfection with an alcohol-based disinfectant rubbed into the hands for at least two minutes.I5 Some researchers believe that alcohol is an effective scrub agent and that long scrub times are not necessary to reduce microbial load to acceptable levels.'' Another researcher studied five protocols for surgical hand washing practices and discovered that a two-minute surgical scrub with a brush followed by a 30-second application of alcohol provided better microbial colony forming unit log reductions compared to a five-minute surgical scrub with a brush (P = .003)." In another study, the difference in microbial load reduction between a five-minute scrub with a brush and a one-minute scrub with a brush followed by alcohol foam rubbed into hands was studied.IXStatistically, neither method was significantly different at reducing microbial loads after one- and two-hour surgical procedures (P = .59, P = .33, respectively). Researchers do not recommend a one-minute surgical scrub with povidone-iodine without an antiseptic, and they warn that scrubbing techniques may become sloppy as a result. THE SURVEY Eight Canadian hospitals participated in the survey. These hospitals were chosen because of 222 AORN JOURNAL
their proximity to the University Health Network. These hospitals provide a baseline for best practice that the University Health Network can gauge itself against comfortably. Three US hospitals were chosen from a survey of the top five US hospitals." These hospitals were chosen to provide a best practice model baseline. Surveys, which took place from July to September 1998, were conducted via telephone. Interviewees often were infection control practitioners, although those interviewed in the United States were surgical staff members. Figure 1 is a graphical representation of the data collected from the Canadian and US hospitals. Of the 11 hospitals surveyed, only three practiced anatomical scrubbing, and eight scrubbed with brushes. Two of the 1 1 hospitals had scrub times of three minutes, six had scrub times of five minutes, and the remainder had varying times. Five of the hospitals used brushes for five minutes, one used a brush for three minutes, one performed an anatomical scrub for five minutes, another performed an anatomical scrub for three minutes, and three performed other types of scrubbing techniques. DISCUSSION The survey led to the conclusion that there is a lot of inconsistency among the Canadian and US hospitals surveyed. The majority of these hospitals still perform surgical scrubs, rather than anatomical scrubs. Only one downtown Toronto hospital practices an anatomical scrub for three minutes. At the time of the survey, the hospital in question indicated that the practice had been in place for one and one-half years and
AUGUST 2001. VOL 74, NO 2
that it had been well received by surgical staff members, although the hospital does provide nail picks and scrub brushes for staff members who prefer to use them. The lack of popularity of anatomical scrubbing among the surveyed hospitals may suggest that there is a lack of confidence in its capability to reduce microbial load on hands to acceptable levels. Based on the existing literature and the small survey, it is very difficult to support replacing the practice of five-minute anatomical scrubs with two-minute anatomical scrubs. A lot of literature on surgical scrubs addresses different scrub time durations. Unfortunately, no studies specifically address comparing a five-minute anatomical scrub with a two-minute anatomical scrub. One study does say that 30-second anatomical scrubs are as effective as two-minute anatomical scrubs, but this still does not reveal if a five-minute anatomical scrub is as effective as a two-minute anatomical scrub.’”
THE DECISION Infection prevention and control unit staff members were not able to recommend the implementation of a two-minute anatomical scrub policy to replace the current practice of a five-minute anatomical scrub. This was due to the lack of literature on the effectiveness of two-minute anatomical scrubs compared to five-minute anatomical scrubs. In addition, the survey indicated that only one hospital had established a shorter duration, anatomical scrub system: the
I
61
Brush and 5 minute
Figure 1
Brush and 3 minute
Anatomical Anatomical and 5 minute and 3 minute Type of scrub technique
Other
Surgical scrub technique among 12 hospitals.
majority of hospitals surveyed still were using brushes. Based on the above information, it may be inferred that a two-minute anatomical scrub can be as effective as a five-minute anatomical scrub, but this assumption would be based on the premise that a two-minute surgical scrub is as effective as a five-minute surgical scrub, which, in turn, is as effective as a fiveminute anatomical scrub. Based on the available evidence, it is difficult to make such an inference. Before a well-informed decision can be made, more studies are needed to compare fiveminute and two-minute surgical scrubs with brushes to brushless anatomical scrubs of the same duration. Future studies will need to ensure large sample sizes; conduct studies in a clinical setting under less controlled environments (ie, sampling hands after a surgical procedure); use high efficiency sampling methods to
NOTES I . E L Larson, “APIC guideline for handwashing and hand antisepsis in health care settings,” American Journal oflnfiction control 23 (August 1995) 25 1-269. 2. Ihid; A J Mangram et al, “Guidelines for prevention
obtain results from hands (ie, glove juice technique); and indicate the statistical significance and confidence limits in the results obtained. Data that currently exist do not provide enough evidence about microbial load reduction to support a two-minute anatomical scrub versus a five-minute anatomical scrub. Additionally, it may be interesting to study anatomical and surgical scrubs followed by alcohol rubs, as is being more commonly practiced in Europe, to determine if these practices can be adopted effectively and feasibly in North America. A The authors would like to acknowledge Betty Watt, OR manager, Toronto General Hospital, University Health Network, Toronto;Joyce Flemming, OR manager; Toronto General Hospital, University Health Network. Toronto; and the surgical support senices department staff members at Toronto General Hospital, University Health Network. Toronto.
of surgical site infection. 1999. Centers for Disease
Contrgl and Prevention (CDC) Hospital Infection Control Practices Advisory Committee,” American Journal of Infection Control 27 (April 1999) 97-132. 3. L J Pereira. G M Lee, K J Wade, “An evaluation of
223 AORN JOURNAL
AUGUST 2001, VOL 74,NO 2
five protocols for surgical handwashing in relation to skin condition and microbial counts,” Journal of Hospital Infection 36 (May 1997) 49-65. 4. M B Loeb et al, “A randomized trial of surgical scrubbing with a brush compared to antiseptic soap alone,” American Journal of Infection Control 25 (February 1997) 11-15. 5. M O’Shaughnessy et al, “Optimum duration of surgical scrub-time,” British Journal of Surgery 78 (June 1991) 685-686. 6. Pereira, Lee, Wade, “An evaluation of five protocols for surgical handwashing in relation to skin condition and microbial counts,” 49-65; L J Pereira G M Lee, K J Wade, “The effect of surgical handwashing routines on the microbial counts of operating room nurses,’’ American Journal of Infection Control 18 (December 1990) 354-364. 7. O’Shaughnessy et al, “Optimum duration of surgical scrub-time,’’685-686. 8. D S Paulson, “Comparative evaluation of five surgical hand scrub preparations,” AORN Journal 60 (August 1994) 246,249-256. 9. S M Wheelock, S Lookinland, “Effect of surgical hand scrub time on subsequent bacterial growth,” (Comments)AORN Journal 65 (June 1997) 1087-1092; 1094-1098. 10. C Poon et al, “Studies of the surgical scrub,” Australian and New Zealand Journal of Surgery 68 (January 1998) 65-67. 11. Principles and Practice (Toronto: Association for Professionals in Infection Control and Epidemiology,
Inc, 1996). 12. “Recommended practices for surgical hand scrubs,” in Standards, Recommended Practices, and Guidelines (Denver: AORN, Inc, 2001) 237-242. 13. Mangram et al, “Guidelines for prevention of surgical site infection, 1999. Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advisory Committee,” 97-132. 14. Committee on Operating Room Environment, “Infection in the OR: Best practices for the next millennium,” American College of Surgeons, http://www.facs .org/about/committees/core/coreprop.html (accessed 6 April 2001). 15. B Rehork, H Ruden, “Investigations into the eficacy of different procedures for surgical hand disinfection between consecutive operations,” Journal of Hospital Infection 19 (October 1991) 115-127. 16. Larson, “APIC guideline for handwashing and hand antisepsis in health care settings,” 25 1-269. 17. Pereira, Lee, Wade, “An evaluation of five protocols for surgical handwashing in relation to skin condition and microbial counts,” 49-65. 18. N Deshmukh, J W Kramer, S I Kjellberg, “A comparison of 5-minute povidone-iodine scrub and 1-minute povidone-iodine scrub followed by alcohol foam,” Military Medicine 163 (March 1998) 145-147. 19. “Best hospitals,” US News Online (July 27, 1998) http://www.usnews.com/usnews/nycu/health/hosptl /hospalph.htm (accessed 14 Sept 1998) 20. Poon et al, “Studies of the surgical scrub,” 65-67.
Gene Therapy Protocol for Alzheimer’s Disease Tested Physicians have implanted genetically modified tissue into the brain of a patient with Alzheimer’s disease, according to an April 10,2001, news release from the University of California, San Diego, School of Medicine. This is the first phase of an experimental gene therapy protocol to treat Alzheimer’s disease. The procedure lasted 11 hours and was performed on a 60-year-old Caucasian woman who was in the early states of the disease. This study marks the first attempt to use human gene therapy to treat a nervous system disease. Researchers will try to prevent Alzheimer’s cell loss by using gene therapy to deliver a natural brain-survival molecule to the dying brain cells. The purpose of this phase one clinical trial is to determine whether the procedure is safe, according to the release. Researchers do not expect gene therapy to cure
Alzheimer’s disease, but they are hopeful that it may protect and possibly restore brain cells and relieve some of its symptoms. The procedure targets a class of cells located in the cholinergic system, which is important for supporting memory and cognitive function and degenerates during the course of Alzheimer’s disease. If the protocol is successful, implanted cells could begin to affect brain function in one to two months. Researchers caution, however, that it may take several years to determine, through testing the protocol on a large enough number of patients, wether the therapy will be useful. UCSD Team Performs First Surgery in Gene Therapy Protocol for Alzheimer’s Disease (news release, Sun Diego: University of California, Sun Diego, April 1 0, 200 I ) hftp:// www.ucsdnews.ucsd.edu/newsrel/healWprotocol.htm (accessed 19April 00 I). 224
AORN JOURNAL
Literature review and survey comparing surgical scrub techniques
S
urgical scrub solutions ensure that microbial loads on hands are reduced significantly (ie, 90% to 99%). This reduction in microbial loads decreases the potential for surgical site infections. In addition, surgical scrubs should provide persistent antimicrobial action, which helps keep microbial load to a minimum as surgical staff members perform surgery. The moist environment of surgical gloves allows microorganisms to grow on the hands within, and these gloves frequently are damaged during surgical procedures, thus increasing the risk for surgical site infections.’ The two principles of surgical scrubs (ie, reduction in microbial load, persistent antimicrobial action) are dependent on the length of time and how a person scrubs. It also depends on what antimicrobial agent is used.* When changing surgical scrub policies, it is important to remember these two key principles. In March 1998, administrators in the surgical support business unit at Toronto General Hospital of the University Health Network, Toronto, requested that the infection prevention and control unit investigate changing the existing surgical scrub policy. Team members had noted the results of a study that concluded three-minute brush scrubs provide the same reduction in hand microbes as five-minute brush scrubs.’ Administrators wanted to determine if it was safe, from a patient care perspective (ie, no increase in
surgical site infections), to change from the existing hand scrub policy, which was a five-minute anatomical hand scrub without the use of a brush or sponge, to a two-minute hand scrub. Currently, a five-minute surgical scrub with 2%chlorhexidene gluconate or 7.5% povidoneiodine is performed before each procedure. Staff members need to ensure that the skin of their hands and arms is intact. If technique is broken while scrubbing, staff members repeat the procedure (Table 1). A review of existing literature on the topic and a survey of various Canadian and US hospitals allowed staff members to critically evaluate the efficacy of twominute anatomical surgical scrubs in reducing microbial SIU MEE CHENG, BAA, MHSC, is the corporate quality improvement manager of the infection prevention and control unit, University Health Network, Toronto. MARTA GARCIA, RN, BSCN, MED, CIC, is a manager and an integrated health care practitioner in the infection prevention and control unit, University Health Network, Toronto. SHERRY ESPIN, RN, BSCN, MED, is an OR clinical teacher at Toronto General Hospital, University Health Network, Toronto. J. CONLY, MD, is a hospital epidemiologist and the director of infection prevention and control in the infection prevention and control unit, University Health Network, Toronto.
218 AORN JOURNAL
loads on hands versus the fiveminute anatomical scrub. The purpose of the survey was to determine if short-duration anatomical hand scrubs were prevalent among several wellrespected Canadian and US hospitals. It should be noted that the term “anatomical scrubs’’ refers to surgical scrubs not requiring the use of brushes and the term “surgical scrubs’’ refers to surgical scrubs requiring brushes.
LITERATURE REVIEW A review of scientific literature was conducted via PubMed and EMBASE between July 1998 and December 1999. Reviewers used keywords, such as surgical scrub, hospital, infection, microorganisms. No studies specifically compared a fiveminute anatomical scrub (ie, brushless scrub) with a twominute anatomical scrub. There were numerous articles, however, on surgical scrubs using brushes for different time durations. Consequently, articles that compared surgical scrubs (ie, scrubs requiring brushes) with anatomical scrubs were reviewed to determine and establish whether surgical scrubs are as effective in reducing microbial load as anatomical scrubs. Several articles that compared microbial load reductions for different duration surgical scrubs were reviewed to try and prove the hypothesis that if surgical scrubs are as effective as anatomical scrubs, results for various different-duration surgical
AUGUST 2001, VOL 74, NO 2
Table 1 scrubs should be similar for different-duration anatomical scrubs. Additionally, existing national and international guidelines regarding recommendations on surgical scrubs were reviewed. One of the articles reviewed shows that five-minute surgical scrubs with a brush or sponge are as effective as five-minute anatomical scrubs without the use of brush or sponge with respect to microbial load reduction on hands." Studies also show that five-minute surgical scrubs are as effective as two- to fourminute surgical scrubs. For instance, in one study, when sixminute scrubs with a brush were compared to four-minute and two-minute scrubs, hand bacterial counts for each duration were not statistically significantly different from prescrub counts.' This study indicates that a two-minute scrub is as effective as four-minute and six-minute scrubs; one-hour postscrub microbial reductions were 47%, 55%, and 58%, respectively ( P = .01). It should be noted that this study had a small sample size (n = 10). Other studies show that threeminute surgical scrubs are as adequate as five-minute surgical scrubs! One study, however, indicates surgical scrubs that started with an initial five-minute scrub. followed by three-minute between-procedure scrubs, provided greater microbial reductions, compared to five-minute and three-minute initial scrubs with 30-second between-procedure scrubs.' Interestingly, another study indicates that two-minute surgical scrubs with brushes are common,' and, according to some researchers, three-minute surgical scrubs reduce microbial loads
SCRUB PROCEDURE AT TORONTO GENERAL HOSPITAL
Stem in scrubbina Drocedure 1 . Rinse hands and forearms while keeping hands elevated above elbows.
2. Step on the pump once and apply foam. 3. Lather hands and arms, but do not rinse at this stage.
4. Clean nails under running water with a nail stick. 5. Rinse from fingertips to elbows.
6. Step on the pump again and apply foam. 7. Scrub nails against palm of hand for 15 seconds.
8. Scrub the four sides of each finger for 45 seconds, paying special attention to interdigital areas (ie, the web). 9. Scrub the back of the hand and palm from the base of the fingers to the wrist for 45 seconds. 10. Repeat steps 1 through 9 with the other hand. 1 1. Scrub the arm with small, overlapping circles from wrist to 2 inches above the elbow for 45 seconds.
12. Repeat the above step with the other arm. 13. Rinse hands and forearms from fingertips to elbows while keeping hands elevated above elbows and away from body. Brushes are available for heavily soiled hands.
more than two-minute surgical scrubs? The mean log difference between the two scrub durations was 0.29, with respect to growth on gloves; this was statistically significant at P = .02. The subjects sampled, however, did not participate in surgical procedures or any other routine procedures in the surgical field. In addition, the researchers did not sample microbial loads prescrub and postscrub. This would have provided results of microbial load reductions, which would have helped reveal which scrub method is more effective. A study on anatomical scrubs that compared 30-second scrubs with different povidone-iodine contact times (ie, two minutes, one and one-half minutes, one minute, no additional contact time) found that microbial count reductions 221 AORN JOURNAL
from prescrub to postscrub were statistically significant for all different contact times. Researchers concluded that there was no difference in efficacy between a 30-second scrub and a two-minute scrub, but this study was not very comprehensive and had some limitations. For example, it did not provide a clear description of its anatomical scrub procedure, so the scrub procedure could have been interpreted as a normal handwashing procedure, rather than the more rigorous anatomical scrub that is practiced at Toronto General Hospital. In addition, hands were sampled 30 minutes after the scrub, and no actual surgical procedure had been performed before sampling hands for bacterial load. Data about colony forming unit reductions also are not provided, and readers are
AUGUST 2001. VOL 74, NO 2
required to extrapolate estimates from graphs. Consequently, the results of this particular study may not provide an accurate description of actual microbial loads after a routine surgical procedure."' NATIONAL AND INTERNATIONAL GUIDELINES Existing North American guidelines on surgical scrubbing do not indicate a specific duration for surgical scrubbing or the type of scrub technique (eg, with a brush or sponge, handwash with subsequent alcohol rub). The Association for Professionals in Infection Control and Epidemiology continues to recommend a five-minute scrub with a brush, but it also recognizes the use of the European technique, which is essentially a handwash followed by an alcohol rub." AORN promotes the use of brushes for surgical scrubs, but it does not mention a specific scrub duration and advises following antiseptic manufacturers' recommendations.'*In addition, AORN mentions that European studies recommend shorter duration surgical scrubs be performed after the initial surgical scrub, provided that surgical procedures do not exceed one hour. The Centers for Disease Control and Prevention mentions a three- to five-minute surgical scrub with a brush," and the American College of Surgeons (ACS) says that a surgical scrub duration as short as two minutes is p0ssib1e.l~ Despite this, the ACS does not clearly state whether this applies to anatomical scrubs or to surgical scrubs only. SURGICAL SCRUB WITH AN ALCOHOL ANTISEPTIC Alternative surgical scrub practices are commonly practiced in Europe. The most common
anatomical scrubbing practice requires less scrubbing time and use of an antiseptic, usually alcohol-based. For example, the German Federal Institute of Health's guidelines recommend that preoperative surgical hand disinfection include at least two minutes of hand washing, along with a nonantiseptic washing substance and disinfection with an alcohol-based disinfectant rubbed into the hands for at least two minutes.I5 Some researchers believe that alcohol is an effective scrub agent and that long scrub times are not necessary to reduce microbial load to acceptable levels.'' Another researcher studied five protocols for surgical hand washing practices and discovered that a two-minute surgical scrub with a brush followed by a 30-second application of alcohol provided better microbial colony forming unit log reductions compared to a five-minute surgical scrub with a brush (P = .003)." In another study, the difference in microbial load reduction between a five-minute scrub with a brush and a one-minute scrub with a brush followed by alcohol foam rubbed into hands was studied.IXStatistically, neither method was significantly different at reducing microbial loads after one- and two-hour surgical procedures (P = .59, P = .33, respectively). Researchers do not recommend a one-minute surgical scrub with povidone-iodine without an antiseptic, and they warn that scrubbing techniques may become sloppy as a result. THE SURVEY Eight Canadian hospitals participated in the survey. These hospitals were chosen because of 222 AORN JOURNAL
their proximity to the University Health Network. These hospitals provide a baseline for best practice that the University Health Network can gauge itself against comfortably. Three US hospitals were chosen from a survey of the top five US hospitals." These hospitals were chosen to provide a best practice model baseline. Surveys, which took place from July to September 1998, were conducted via telephone. Interviewees often were infection control practitioners, although those interviewed in the United States were surgical staff members. Figure 1 is a graphical representation of the data collected from the Canadian and US hospitals. Of the 11 hospitals surveyed, only three practiced anatomical scrubbing, and eight scrubbed with brushes. Two of the 1 1 hospitals had scrub times of three minutes, six had scrub times of five minutes, and the remainder had varying times. Five of the hospitals used brushes for five minutes, one used a brush for three minutes, one performed an anatomical scrub for five minutes, another performed an anatomical scrub for three minutes, and three performed other types of scrubbing techniques. DISCUSSION The survey led to the conclusion that there is a lot of inconsistency among the Canadian and US hospitals surveyed. The majority of these hospitals still perform surgical scrubs, rather than anatomical scrubs. Only one downtown Toronto hospital practices an anatomical scrub for three minutes. At the time of the survey, the hospital in question indicated that the practice had been in place for one and one-half years and
AUGUST 2001. VOL 74, NO 2
that it had been well received by surgical staff members, although the hospital does provide nail picks and scrub brushes for staff members who prefer to use them. The lack of popularity of anatomical scrubbing among the surveyed hospitals may suggest that there is a lack of confidence in its capability to reduce microbial load on hands to acceptable levels. Based on the existing literature and the small survey, it is very difficult to support replacing the practice of five-minute anatomical scrubs with two-minute anatomical scrubs. A lot of literature on surgical scrubs addresses different scrub time durations. Unfortunately, no studies specifically address comparing a five-minute anatomical scrub with a two-minute anatomical scrub. One study does say that 30-second anatomical scrubs are as effective as two-minute anatomical scrubs, but this still does not reveal if a five-minute anatomical scrub is as effective as a two-minute anatomical scrub.’”
THE DECISION Infection prevention and control unit staff members were not able to recommend the implementation of a two-minute anatomical scrub policy to replace the current practice of a five-minute anatomical scrub. This was due to the lack of literature on the effectiveness of two-minute anatomical scrubs compared to five-minute anatomical scrubs. In addition, the survey indicated that only one hospital had established a shorter duration, anatomical scrub system: the
I
61
Brush and 5 minute
Figure 1
Brush and 3 minute
Anatomical Anatomical and 5 minute and 3 minute Type of scrub technique
Other
Surgical scrub technique among 12 hospitals.
majority of hospitals surveyed still were using brushes. Based on the above information, it may be inferred that a two-minute anatomical scrub can be as effective as a five-minute anatomical scrub, but this assumption would be based on the premise that a two-minute surgical scrub is as effective as a five-minute surgical scrub, which, in turn, is as effective as a fiveminute anatomical scrub. Based on the available evidence, it is difficult to make such an inference. Before a well-informed decision can be made, more studies are needed to compare fiveminute and two-minute surgical scrubs with brushes to brushless anatomical scrubs of the same duration. Future studies will need to ensure large sample sizes; conduct studies in a clinical setting under less controlled environments (ie, sampling hands after a surgical procedure); use high efficiency sampling methods to
NOTES I . E L Larson, “APIC guideline for handwashing and hand antisepsis in health care settings,” American Journal oflnfiction control 23 (August 1995) 25 1-269. 2. Ihid; A J Mangram et al, “Guidelines for prevention
obtain results from hands (ie, glove juice technique); and indicate the statistical significance and confidence limits in the results obtained. Data that currently exist do not provide enough evidence about microbial load reduction to support a two-minute anatomical scrub versus a five-minute anatomical scrub. Additionally, it may be interesting to study anatomical and surgical scrubs followed by alcohol rubs, as is being more commonly practiced in Europe, to determine if these practices can be adopted effectively and feasibly in North America. A The authors would like to acknowledge Betty Watt, OR manager, Toronto General Hospital, University Health Network, Toronto;Joyce Flemming, OR manager; Toronto General Hospital, University Health Network. Toronto; and the surgical support senices department staff members at Toronto General Hospital, University Health Network. Toronto.
of surgical site infection. 1999. Centers for Disease
Contrgl and Prevention (CDC) Hospital Infection Control Practices Advisory Committee,” American Journal of Infection Control 27 (April 1999) 97-132. 3. L J Pereira. G M Lee, K J Wade, “An evaluation of
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Gene Therapy Protocol for Alzheimer’s Disease Tested Physicians have implanted genetically modified tissue into the brain of a patient with Alzheimer’s disease, according to an April 10,2001, news release from the University of California, San Diego, School of Medicine. This is the first phase of an experimental gene therapy protocol to treat Alzheimer’s disease. The procedure lasted 11 hours and was performed on a 60-year-old Caucasian woman who was in the early states of the disease. This study marks the first attempt to use human gene therapy to treat a nervous system disease. Researchers will try to prevent Alzheimer’s cell loss by using gene therapy to deliver a natural brain-survival molecule to the dying brain cells. The purpose of this phase one clinical trial is to determine whether the procedure is safe, according to the release. Researchers do not expect gene therapy to cure
Alzheimer’s disease, but they are hopeful that it may protect and possibly restore brain cells and relieve some of its symptoms. The procedure targets a class of cells located in the cholinergic system, which is important for supporting memory and cognitive function and degenerates during the course of Alzheimer’s disease. If the protocol is successful, implanted cells could begin to affect brain function in one to two months. Researchers caution, however, that it may take several years to determine, through testing the protocol on a large enough number of patients, wether the therapy will be useful. UCSD Team Performs First Surgery in Gene Therapy Protocol for Alzheimer’s Disease (news release, Sun Diego: University of California, Sun Diego, April 1 0, 200 I ) hftp:// www.ucsdnews.ucsd.edu/newsrel/healWprotocol.htm (accessed 19April 00 I). 224
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