CDC draft recommends alcohol agents as alternatives for surgical scrubs
CDC draft recommends alcohol agents as alternatives for surgical scrubs
In the meantime, however, you risk citation in Medicare survey
The draft hand hygiene guideline developed by the Atlanta-based Centers for Disease Control and Prevention (CDC) recommends that waterless, alcohol-based agents be used as surgical scrubs except when the hands are visibly soiled, says Bill Jarvis, MD, associate director for program development at the CDC’s Division of Healthcare Quality Promotion. The draft guideline, which includes no requirement for brushes, allows alcohol-based foams and gels to be used for the initial scrub as well as between cases. The guideline says that when dirt or organic matter are on the hands, an antimicrobial-containing soap and water should be used, Jarvis says.
The draft guideline had not been released at Same-Day Surgery press time. The guideline should be published in the Federal Register and available for public comment within the next six months, he says. Before you throw out the soap and destroy your scrub sinks, however, keep in mind that the Health Care Financing Administration (HCFA) currently does not accept the practice.
"I was on a survey last year in which an [ambulatory surgery center] was using regular antibacterial gels from the nurses’ medication cart before surgery and between patients," says a HCFA official who cannot be named because of agency policy. The center received a citation, the official says. "One issue is that when sink facilities are available, they should be using an anti-microbial scrub as opposed to using gels or foams."
One surgery center in Arizona was cited by HCFA for having an "immediate jeopardy" deficiency that put patients’ lives at risk after state examiners noticed a surgeon using an alcohol-based product between cases in place of a surgical scrub, says Eric Zimmerman, JD, attorney with McDermott, Will, and Emery in Washington, DC. Before the surgery center had the opportunity to appropriately respond, HCFA posted a notice in the local paper that said the center had been cited and its Medicare certification was at risk, Zimmerman says. The center has since stopped using the alcohol product between cases, he adds. "My advice is: Don’t make a stink over it," Zimmerman says. "Your certification is important. We think HCFA is overstepping its bounds, but you have to operate within its system."
The HCFA official says that in a recent discussion she had with a manufacturer of an alcohol-based product, she was told that the hand gels and foams were not meant to be used as surgical scrubs. "There are some concerns, and I do believe surveyors would cite until they are educated [on the upcoming guidelines from the CDC] and new products are out there and proven to be effective," the official says.
Although the practice of using alcohol-based foams and gels as surgical scrubs is fairly new, proponents maintain that research supports the fact that they kill more bacteria than traditional scrub agents do.
"The alcohol products are fast-acting and kill the most microorganisms of any product on the market," says Elaine Larson, RN, PhD, professor at Columbia University School of Nursing and professor at the School of Public Health at Columbia University, both in New York City. Larson has conducted extensive research on alcohol-based products. (See selected references.) Larson has researched the published studies in a paper that will appear in the proceedings of a conference, Disinfection, Sterilization, and Antisepsis in Health Care, of the Association for Professionals in Infection Control and Epidemiology in Washington, DC. (See "Sources and resources," at the end of this article.)
Larson looked at six studies published in the 1990s that compared the antimicrobial efficacy of scrub products [containing], 4% chlorhexidine gluconate, 7.5 or 10% povidone-iodine, and/or an alcohol preparation.1-6 Several of those studies showed that the products containing alcohol were at least the equivalent, and in some cases, were superior to, other products, Larson says.
Jarvis agrees that the alcohol-based products are effective. "The cell wall of micro-organisms is pretty well destroyed," he says.
There are several benefits to using the alcohol-based products as compared to the surgical scrubs, with the advantage of it being easier on the hands at the top of the list, according to experts. "Skin integrity, with scrubbing all the time, seems to be the No. 1 concern," says Carol Petersen, RN, BSN, MAOM, CNOR, perioperative nursing specialist at the Association of periOperative Registered Nurses (AORN) in Denver.
The ideal pre-surgery preparation has microbiologic activity plus an emollient and other materials or agents that may condition hands, Jarvis says. Skin damage from scrubbing with brushes can lead to an increased number of gram-negative bacteria and Candida spp, Larson maintains.7
Another advantage of the alcohol-based products is that they save time, Jarvis and others say. Because they have a quick effect, the duration of time to wash hands may be shortened, he says. A shortened time span for application is true not only of the alcohol-based foams and gels, but also of a new brushless scrub, Triseptin, marketed by Healthpoint in Fort Worth, TX, users say. Triseptin is water-aided and contains alcohol, as well as emollients and a preservative. It costs $19 per bottle, which contains approximately 64 applications. The cost per application is 30 cents, which compares to 35-55 cents for scrub brushes, according to Shawn Gentry, Healthpoint’s marketing director at the infection prevention division. (For ordering information, see "Sources and resources.")
"It cuts down the scrub time to three minutes," says Gene Bowers, materials manager at HealthSouth Surgery Center of Atlanta. "Most everything else is 10 minutes, so you’re in the room and doing the procedure quicker."
It isn’t necessary to use a brush with the alcohol-based products either, Larson maintains. "In fact, in general, a brush increases shedding of skin and potential for transmission of bacteria from hand to the patient," she maintains.
You may find that switching to Triseptin or another alcohol-based product improves compliance with your hand-washing policy. That was the case at Christus St. Joseph Hospital in Houston, says Etta Hodge, RN, MBA, director of surgical services. The hospital had a policy of doing timed scrubs before the first case and between cases, but quality improvement studies indicated that no one was complying with scrubbing for the amount of time set in the policy, which was five minutes, Hodge says. In addition, the product allowed cost savings, although users weren’t able to provide specific amounts. Now her entire hospital system is looking at converting to the product, Hodge says.
Keep in mind, however, that you still might have physicians and staff who require other products due to skin sensitivity to alcohol, says Bowers, who reports that sensitivity to alcohol-based products is a common problem. "I wanted to find one scrub that everyone would use, but that was impossible," she says.
AORN: Wash your hands first
The major caveat to using alcohol-based products is that they don’t remove dirt or organic material, experts point out. AORN’s recommended practice is that, even with alcohol-based products, the process should begin with washing the hands and forearms thoroughly with an approved scrub agent and running water.
When selecting a surgical scrub, Peterson suggests you use these criteria:
- It should be broad spectrum (killing multiple types of skin bacteria).
- It should be fast-acting.
- It should have a residual effect.
"The persistent chemical activity is desirable because gloves over the hand provide a moist, warm environment in which bacteria can proliferate," Peterson says. "You want something that has persistent, residual activity." At least some of the alcohol-based products have no persistent chemical effect, she points out.
If you’re going to consider purchasing an alcohol-based product, follow the manufacturer’s instructions and check studies that the manufacturer has conducted to ensure the product meets the criteria she listed above, Peterson says. "And involve an infection control professional," she adds.
References
1. Pereira LJ, Lee GM, Wade KJ. The effect of surgical hand washing routines on the microbial counts of operating room nurses. AJIC 1990; 18:354-364.
2. Pereira LJ, Lee GM, Wade KJ. An evaluation of five protocols for surgical hand washing in relation to skin condition and microbial counts. J Hosp Infect 1997; 36:49-65.
3. Loeb MB, Wilcox L, Smaill F, et al. A randomized trial of surgical scrubbing with a brush compared to antiseptic soap alone. AJIC 1997; 25:11-15.
4. Deshmukh N, Kramer JW. A comparison of 5-minute povidone-iodine scrub and one-minute povidone-iodine scrub followed by alcohol foam. Milit Med 1998; 163:145-147.
5. Hobson DW, Woller W, Anderson L, et al. Development and evaluation of a new alcohol-based surgical hand scrub formulation with persistent antimicrobial characteristics and brushless application. AJIC 1998; 26:507-512.
6. Moolenaar RL, Crutcher M, San Joaquin VH, et al. A prolonged outbreak of Pseudomonas aeruginosa in a neonatal intensive care unit: Did staff fingernails play a role in disease transmission? Infec Contr Hosp Epidemiol 2000; 21:80-85.
7. Larson EL, Hughes CAN, Pyrek JD, et al. Changes in bacterial flora associated with skin damage on hands of health care personnel. AJIC 1998; 26:513-522.
Selected references
• Boyce JM, Kelliher S, Vallande RN. Skin irritation and dryness associated with two hand hygiene regimens: Soap and water hand washing vs. hand antisepsis with an alcoholic hand gel. Inf J Hosp Epidemiol 2000; 21:442-448.
• Larson EL, Aiello A, Heilman J, et al. Comparison of different regimens for surgical hand preparation. AORN J 2001; 73:412-432.
• Larson E, Butz AM, Gullette DL, et al. Alcohol for surgical scrubbing? Inf Control Hosp Epidemiol 1990; 11:139-143.
• Larson E, Norton Hughes CA, Pyrek JD, et al. Changes in bacterial flora associated with skin damage on hands of healthcare personnel. Am J Inf Control 2000; 26:513-521.
Sources and resource
• Gene Bowers, Materials Manager, HealthSouth Surgery Center of Atlanta, 1140 Hammond Drive, Building F, Suite 6100, Atlanta, GA 30328. Telephone: (770) 551-9944. Fax: (770) 551-8826.
• Etta Hodge, RN, MBA, Director of Surgical Services, Christus St. Joseph Hospital, 1919 LaBranch, Houston, TX 77002. Telephone: (713) 757-1000. Fax: (713) 657-7153.
• Bill Jarvis, MD, Associate Director for Program Development, Division of Healthcare Quality Promotion, Mail Stop E69, Centers for Disease Control and Prevention, Atlanta, GA 30333. Telephone: (404) 639-1486. Fax: (404) 639-6459. E-mail: [email protected].
• Elaine Larson, RN, PhD, Professor, Columbia University School of Nursing, 630 W. 168th St., New York, NY 10032.
• Carol Petersen, RN, BSN, MAOM, CNOR, Perioperative Nursing Specialist, Association of periOperative Registered Nurses, 2170 S. Parker Road, Suite 300, Denver, CO 80231-5711. Telephone: (800) 755-2676, Ext. 392. Fax: (303) 338-5165. E-mail: [email protected].
For more information on Triseptin, contact: Healthpoint, Attention: Customer Care, 3909 Hulen St., Fort Worth, TX 76107. Telephone: (800) 441- 8227 or (817) 900-4036. E-mail: [email protected]. Web: www.healthpoint.com.
Disinfection, Sterilization, and Antisepsis: Principles and Practices in Healthcare Facilities, Proceeding of 2000 Postconference costs $34 for members of the Association for Professionals in Infection Control and Epidemiology (APIC) and $45 for nonmembers. To order, contact: APIC, 1275 K St. N.W., Suite 1000, Washington, DC 20005-4006. Telephone: (202) 789-1890. An order form can be downloaded from the web site (www.apic.org) and faxed to (202) 789-1899. E-mail: [email protected].
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.