Comparison of surgical hand scrub and alcohol surgical hand rub on reducing hand microbial burden.
Abstract: This study was performed to compare the effects of two hand decontamination methods on the microbial burden of operating room staff hands. The surgical hand washing methods compared were a traditional surgical hand scrub using a povidone iodine solution, and a social wash using a liquid non-antibacterial soap followed by the application of an alcoholic hand rub.

KEYWORDS Hand microbial burden / Surgical hand rub / Surgical hand scrub
Article Type: Report
Subject: Infection control (Research)
Cross infection (Prevention)
Cross infection (Research)
Nosocomial infections (Prevention)
Nosocomial infections (Research)
Preoperative care (Research)
Surgical scrub (Research)
Authors: Ghorbani, Azam
Shahrokhi, Akram
Soltani, Zahra
Molapour, Azam
Shafikhani, Mahin
Pub Date: 02/01/2012
Publication: Name: Journal of Perioperative Practice Publisher: Association for Perioperative Practice Audience: Academic Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2012 Association for Perioperative Practice ISSN: 1750-4589
Issue: Date: Feb, 2012 Source Volume: 22 Source Issue: 2
Topic: Event Code: 310 Science & research
Geographic: Geographic Scope: Iran Geographic Code: 7IRAN Iran
Accession Number: 283274422
Full Text: One group washed their hands with non-antibacterial soap for 30 seconds then rubbed their hands for three minutes with a hand rub containing 70% ethanol. The control group staff performed a traditional surgical hand scrub by brushing hands with povidine iodine for six minutes. Findings of the microbial burden (mean log of hand's colony count) showed both methods were effective in reducing microbial burden of the hands. There was no significant statistical difference between these two methods.

Introduction

The term 'nosocomial infection' has now been changed to 'healthcare-associated infection' (HCAI) in most sources. An HCAI is an infection that occurs within a hospitalisation period because of exposure to a microorganism during medical procedures (Mayhall 2004, Lewis et al 2007). These infections are a serious problem in our hospitals because they have significant morbidity and mortality rates associated with them and treatment can be difficult because of bacterial resistance to antibiotics (Asl Soleymani 2000). The Centre for Disease Control and Prevention estimates that there are 1.8 million nosocomial infections per year and 20,000 deaths which can be directly attributable to these infections (CDC 2002). As a lot of healthcare tasks are carried out using our hands, they can be responsible for the inadvertent transmission of microorganisms to the patients. Semmel Weis in the 19th century enforced the washing of hands thoroughly as an easy way to reduce or remove microorganisms of the skin (Masoomi Asl et al 2006). One of the most simple and effective methods for the prevention of the spread of microorganisms is hand washing; the CDC (2002) suggests that 30% of HCAIs can be prevented if proper hand washing is conducted.

Wound infection or surgical site infection (SSI) is one of healthcare associated infections that can threaten all patients who undergo surgery. Hands are known as the most important source of micro-organism from the skin of healthcare staff (Hubner et al 2011). Staff in preparing for surgery must decontaminate their hands prior to donning sterile gowns and gloves in order to significantly reduce the number of transient and resident micro-organisms on the hands so that microorganisms due to skin flora are not transmitted to the patient during surgery. An effective way to reduce the numbers of micro-organisms is to undertake surgical hand scrub. This can be performed using different application methods and solutions (Razlansari 2002).

Guidelines of the National Committee on Nosocomial Infection Surveillance in Iran (Masoomi Asl et al 2006) emphasise the importance of proper hand washing before surgery and recommend hand scrubbing for two to six minutes, according to the solution and the manufacturer's guidelines. These guidelines suggest that washing for more than six minutes is not necessary. Razlansari (2002) compared the effect of hand scrub with povidine iodine with different hand washing durations namely two, four and six minutes. Razlansari concluded that two minutes washing is not enough to remove gram-negative bacillus from the hands, but that there was no significant difference between four and six minutes scrub. The author recommended at least a four minute brushed scrub with povidine iodine as an important factor for hand decontamination before surgery.

The CDC (2002) and Masoomi Asl (2006) recommended that a hand rub with a alcoholic-based solution is as an effective method for surgical hand hygiene. Alcoholic solutions are more effective than other solutions such as chlorhexidine gluconate and aqueous povidone iodine, particularly for resident micro-organisms, so it would be better to use alcohol-based solutions for surgical hand hygiene among operating room staff (Kampf & Ostermyer 2011). Totally, non-brushed surgical hand washing methods that take less time are recently becoming more acceptable (Gupta et al 2007). Alcoholic hand rub is as effective as washing with povidone iodine, meanwhile surgical hand rub has been more acceptable and durable by OR staff because it causes less skin irritation (Tavolacci et al 2006).

Gupta et al (2007) suggest that sometimes operating room personnel do not consider hand hygiene a precise and proper surgical procedure for reasons such as time limitation, high workload and skin dryness. Some staff felt that hand washing procedures do not play important role in surgical wound contamination and nosocomial infections, despite in-service education.

The current study was performed to compare the efficacy of two different surgical hand hygiene procedures on reducing the microbial burden of the hands of operating room staff in Qazvin teaching hospitals. The hand decontamination methods used were: washing the hands with water and a povidone iodine solution for six minutes by brush, and washing with liquid soap for 30 seconds and applying a hand rub with 70% ethanol for three minutes.

Method and materials

This study recruited 33 operating theatre staff (both surgeons and nurses) from four teaching hospitals in Qazvin who were keen to participate in the study. Staff were briefed on the study and signed an informed consent form. This research project was approved by the medical research ethical committee of Qazvin University of Medical Sciences.

The participants were randomly divided into two groups: 18 in the first group and 15 in second group (control group). Initially there were 18 participants in the control group but three were lost via attrition.

The first hand washing of the workday was observed. The main groups were taught about surgical hand hygiene using an alcoholic hand rub. They had to wash their hands and forearms with non-antibacterial soap and water for 30 seconds to remove solid and transient flora (AORN 2004, Gupta et al 2007), then rub with 70% ethanol for three minutes or until complete drying of the skin occurred. A one minute hand rub is needed to reduce 4.0--5.0 log10 of hand colony count (CDC 2002). The control group were asked to wash their hands using their routine technique (counted brush stroke method, Phippen & Wells 2000) for six minutes with only povidone iodine. Samples were taken from the hands of both groups before and after washing for microbial culture to assess the microbial burden and bacterial colony count. Following hand washing using one of the techniques agreed, the subjects were asked to rinse their hands in order to rinse any residual soap or solution on the hands. Samples were then taken from the finger tips by swabbing and cultured in blood-agar. Other simple growth environments could have been used, but at first we had no information about the kind of micro-organisms that might be present, therefore we had to use an enriched supportive environment such as blood agar. The samples were incubated at 37[degrees]C for 24-48 hours. A 24 hour incubation period is in fact sufficient, but we waited for an extra 24 hours to make sure that there was no more growth (Forbes et al 2006).

Following the above procedure all subjects (case and control groups) put their hands into sterile gloves containing 10ml of nutrient broth for 20-30 seconds. This was done to make sure that the maximum numbers of bacteria were transmitted to the nutrient broth solution.

Samples from the gloves' solution were diluted to 1:1000, to make the colony count easier. 10ml of nutrient agar was then added to 0.5ml of the diluted sample followed by incubation at 37[degrees]C for 24-48 hours. Then the colonies were counted. These diluted samples were also cultured in mac-congy agar and monnitol-salt agar for investigating Gram-negatives bacillus and Gram-positive cocci.

The data were analysed by SPSSTM software to compare the mean logarithm of the hands' colony count. Microbial colony counts are usually shown as a huge number, such as 1,000,000, so we preferred to indicate it as logarithm of 10. For calculating the difference between the two methods we chose a mean reduction of the logarithm of ten because there is a one to one correspondence between the colony counts and their logarithm. A P-value of [Less than]0.05 was considered significant.

Results

Thirty three members of the scrub team participated in the study. The results obtained from the microbial cultures showed the gram negative bacillus, entrobacter aeroginosa on the hands of the subjects prior to the commencement of the surgical hand washing in 9 subjects (50%) in the main group, and 5 (33.3%) in the control group. Following the surgical hand washing procedure the numbers of microorganisms that had been removed by both hand hygiene methods was significant. For the case group P = 0.004, and the control group P = 0.016. This showed that both the case group and the control group had gram positive cocci on their hands that had been eliminated by both hand hygiene methods. The differences were significant (P [Less than] 0.001).

The findings also showed that the bacterial colony count of the hands was reduced after both hand washing methods were used and again this difference was significant (p [Less than] 0.001, see Table 1). Also, significant statistical differences were seen in the microbial burden of the hands before and after both hand hygiene methods (P [Less than] 0.01, see Table 2). Comparison of the mean logarithm of 10 of the microbial burden and bacterial count of the hands did not show significant difference between the two groups, hand wash with soap followed by the application of an alcoholic hand rub, and normal surgical scrub using povidine iodine (P = 0.53).

Discussion

This study demonstrated that both of the hand hygiene methods: either washing with soap followed by application of an alcoholic hand rub for three minutes, or washing with povidone iodine for six minutes could remove microorganisms from the hands. Either technique decreases the microbial burden of the hands. This result supports the findings of other studies (Hinyst et al 1992, Tavolacci et al 2006, Gupta et al 2007).

Pereira et al (1997) studied five methods of hand washing and concluded that microbial reduction depends on using a proper solution and doing every hand washing procedure well. The microbial burden of the hands following two different methods of hand hygiene using different solutions demonstrated no significant difference in the colony count after washing. Each technique effectively removed the microorganisms from the hands. Some studies have shown that the duration of efficacy of rubs has been significantly more than scrubs with brushing (Tavolacci et al 2006, Furukawa et al 2004).

Bryce et al (2001) indicated that, although there is no significant difference between bacterial colony count of the hands immediately after using alcoholic and other solutions like povidone iodine, after two hours this changes significantly. These authors found that staff who had used an alcoholic rub solution showed less bacterial colony count on their hands.

Gupta et al (2007) found that immediately after povidone iodine hand washing, the colony count reduction was more significant in comparison to an alcoholic hand rub, but after two and five days the alcohol hand rub was more efficient. Gupta et al (2007) compared the effect of povidone iodine and two different alcoholic solutions in microbial burden reduction of the hands of OR staff. Each solution was used for hand hygiene for one week and then the researchers took samples from hands on the beginning of the first day and the end of the first, second and fifth day of the week. They found that, after hand hygiene using povidone iodine on the first day of hand washing, the colony count reduction was significant in comparison to the alcoholic hand rub. However, at the end of the second and fifth days, the effect of alcoholic hand rub was greater.

Some researchers have recommended using an alcoholic hand rub solution because it has the same effect as other methods and is easier and quicker and so saves time (Hubner et al 2006, Gupta et al 2007). The findings of this study showed that there was no significant difference in the reduction of microbial burden on the hands when using either an antimicrobial solution such as povidone iodine, or soap followed by an alcohol rub, as part of the surgical hand washing procedure.

The effects on colony counts over time were not explored in this study. However, indications from the literature (Bryce et al 2001, Kampf et al 2008) suggest that the use of an alcohol rub based solution used as part of the surgical hand washing procedure significantly reduces the colony count of micro-organisms over a longer period of time. Gupta et al (2007) showed that alcohol-based waterless solutions (ABWL) have greater efficacy on microbial reduction even after five days. Alcohol hand rubs are an important method to prevent surgical site nosocomial infection but the exact method and formulation need more precise and proper research (Kampf & Ostermyer 2011).

References

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Association of periOperative Registered Nurses 2004 Recommended practices for surgical hand antisepsis/hand scrubs AORN Journal 79 (2) 416-31

Bryce EA, Spence D, Roberts FJ 2001 An in-use evaluation of an alcohol-based pre-surgical hand disinfectant Infection Control & Hospital Epidemiology 22 (10) 635-9

Centers for Disease Control and Prevention 2002 Guideline for hand hygiene in healthcare setting Morbidity and Mortality Weekly Report 51 (PR-16) 1-44

Forbes BA, Sahm DF, Weissfeld AS 2007 Bailey & Scott's diagnostic microbiology 12th ed, St Louis, Mosby

Furukawa K, Ogawa R, Norose Y, Tajiri T 2004 A new surgical handwashing and hand antisepsis from scrubbing to rubbing Journal of Nippon Medical School 71 (3) 190-7

Gupta C, Czubatyj AM, Briski LE, Malani AK 2007 Comparison of two alcohol-based surgical scrub solutions with an iodine-based scrub brush for presurgical antiseptic effectiveness in a community hospital Journal of Hospital Infection 65 65-71

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Ministry of Health, Treatment and Medical Education. Centre of Diseases Control, Tehran

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Acknowledgement

We want to thank surgeons and OR nurses for their participation in this study and deputy of research in Qazvin University of Medical Sciences for financial support. The authors would also like to thank Farzan Institute for Research and Technology for their guidance.

by Azam Ghorbani, Akram Shahrokhi, Zahra Soltani, Azam Molapour and Mahin Shafikhani

Correspondence address: Akram Shahrokhi, Room 236, Nursing & Midwifery School, Qazvin University of Medical Sciences, Bahonar Blvd, Qazvin, Iran. Email: ashahrokhi@qums.ac.ir

Provenance and Peer review: Commissioned; Peer reviewed; Accepted for publication November 2011.

About the authors

Azam Ghorbani MSc

Faculty Member of Nursing & Midwifery School, Qazvin University of Medical Sciences, Iran

Akram Shahrokhi MSc

Faculty Member of Nursing & Midwifery School, Qazvin University of Medical Sciences, Iran

Zahra Soltani BSN

OR Nurse Educator, Health & Paramedic Faculty, Qazvin University of Medical Sciences, Iran

Azam Molapour BSc

Shahid Rajaei Teaching Hospital, Qazvin, Iran

Mahin Shafikhani BSN

Health & Paramedic Faculty, Qazvin University of Medical Sciences, Iran

No competing interests declared
Group    Test    Mean   SD    P-value

Case     Before  2.77  1.16  < 0.001
         After    1.3  0.85

Control  Before  3.26   0.7  < 0.001
         After    1.7  1.09

Table 1 Colony count of finger tips of the hands before
and after two hand hygiene methods

Group       Test    Mean   SD      Mean     SD     P-value
                                Reduction
                                  log 10

Case       Before   1.32  0.46       0.47  0.27    < 0.001

           After    0.85  0.44

Control    Before   1.47  0.26        0.5  0.48    < 0.001

           After    1.41  0.96

Table 2 Microbial burden of the hands before and after two
hand hygiene methods
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