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Surgical Hand Disinfection 1

A long story before surgical gloves End of 19th century, Lister shows the impact of surgical hand disinfection and of the disinfection of surgical site on the incidence of surgical site infections. 1894: Reinicke recommand surgical hand disinfection in 3 steps Hand scrub with warm water and antimicrobial soap for 5 min Hand rub with ethanol 90% for 3 min to 5 min Rinse with antimicrobial liquid 1939, Price suggest Hand scrub with warm water and soap for 7 min followed by Hand rub with ethanol 70% for 3 min 3

And gloves? They contribute to the reduction of surgical site infections Thomas M Lancet 1974; 1: 1215-7 No Evidence based! They contribute to the reduction of risk contamination with bloodborne pathogens for the surgical team. Cfr Standard precautions 4

Are gloves a perfect protection? Gloves present microscopic holes before their use. 18% (5-82%) gloves present holes at the end of the surgical procedure Unknown holes in more than 80% of the cases Double gloving reduce the risk of holes in the first glove (4%) Principal surgeon > assistant > theater nurse 5

Objectives of the surgical hand disinfection Reduce the contamination risk of the surgical site if unknown holes in gloves by Eliminating transient flora Reducing resident flora Inhibiting bacterial growth under gloves 6

2 protocoles Surgical hand disinfection by handwashing with antimicrobial soap Surgical hand disinfection with alcoholic handrub solution SCRUB Polyvidone iodine soap Chlorhexidine soap RUB Alcoholic handrub associated with Chlorhexidine Ammonium quaternaire 7

How to choose the good product? Has to pass the european norm EN13727 Method: suspension test on 4 reference strains Objective: 5 log reduction in defined time Has to pass the european norm EN12791, wich compares the immediate and remanent efficacy of the tested solution with a reference (n-propanol 60% 3 ml to be repeated to have a contact time of 3 min) 8

European norm for surgical hand disinfection products

5 products tested according to the european norms EN13727 EN12791 Marchetti MG et al JHI 2003;54, 63-7 10

Special considerations Do not wear artificial fingernails or extenders when having contact with patients. Keep natural nails tips less than ¼ inch long Remove rings, watches, and bracelets before beginning the surgical hand rub Remove debris from underneath fingernails using a nail cleaner under running water Do wash hands before entering the operating theater if visibly soiled 11

Artificial nails and extenders! 12

Use of artificial nails by healthcare workers poses no risk to patients. 1. Strongly agree 2. Agree 3. Don t know 4. Disagree 5. Strongly disagree

Can a Fashion Statement Harm the Patient? ARTIFICIAL NATURAL POLISHED Avoid wearing artificial nails, keep natural nails <1/4 inch if caring for patients Edel et. al, Nursing Research 1998: 47;54-59

Candida Osteomyelitis and Diskitis after Spinal Surgery: An Outbreak that implicates artificial nail use Michael Parry et al,connecticut, New York Epidemic: 3 patients with deep surgical site infection (osteomyelitis and diskitis) after laminectomy with the same Candida albicans in 3 weeks. No cases during the last 10 years. Investigation: a nurse used artificial nails and was implicated as risk factor Resolution: no more artificial nails, no more cases 16

Effect of Hand Cleansing with antimicrobial Soap or Alcohol-based Gel on Microbial Colonization of Artificial Fingernails worn by HCWs, Shelly M. McNeil, Michigan 17

International guidelines CDC Guideline for Hand Hygiene in Healthcare Settings (2002 ) Do not wear artificial fingernails or extenders when providing patient care. (1A category) Keep natural nails less than 1/4 inch long. (II category) 19

The legend of the brush! Recommanded in 1894! 1978: leave it No more efficacy Less skin traumatism Less skin dermatitis Saving time More economic More ecologic Galle PC, Surgery, gynecology and obstetrics 1978, 48;215-18 Do not use a brush but if necessary it has to be sterile 21

The scrub ritual! 10 min 5 min 2 or 3 min 90 sec rubbing better than 3 minutes hand scrubbing with antimicrobial soap 22

SCRUB or RUB SCRUB? Well established ritual RUB? As effective Saving time Better compliance Reduce irritations More ecologic Lower cost 23

Microbiologically more efficient Tavolacci MP JHI 2006;63:55-59 24

Ability of Hand Hygiene Agents to Reduce Bacteria on Hands % 99.9 Time After Disinfection log 0 60 180 minutes 3.0 Bacterial Reduction 99.0 90.0 2.0 1.0 Alcohol-based handrub (70% Isopropanol) Antimicrobial soap (4% Chlorhexidine) 0.0 0.0 Plain soap Baseline Adapted from: Hosp Epidemiol Infect Control, 2 nd Edition, 1999. 25

Infection Rates: Surgical Handscrub vs. Handrub 2 Test of Class of No. SSI/No. Operations (%) Equivalence Contamination Handscrub Handrub (p-value) Clean 29/1485 (1.9) 32/1520 (2.1) 16.0 (<0.001) Clean- Contaminated 24/650 (3.7) 23/732 (3.1) 1.9 (0.09) All 53/2135 (2.5) 55/2252 (2.4) 19.5 (<0.001) Parienti et al. JAMA 2002: 288(6);722-27.

More rapid Srub each side of the fingers, between the fingers and the palm and the. of the hands for 2 min Scrub foreamrs keeping hands above during the procedure Srub each side of the forearm from wrist till elbow for 1 min Repeat it on the other site. Rince with tap water from hand tips till elbow Don t splash yourself during the procedure Dry forearms and hands with a sterile tissue before gloving Push the button of the timer Take enough products to keep hands and forearms wet during 90 seconds of the procedure Rub till hands and forearms are completely dry before hand gloving Go to the operating theater with hands above elbow 27

Better compliance Scrub Rub P value Duration of the procedure in seconds 287 (100-480) 313 (60-510).01 Compliance rate Surgeon/Assistant 20/83 (24%) 51/133 (38%) 0.04 Theater nurse 9/21 (42%) 26/41 (63%) 0.18 All 29/104 (28%) 77/174 (44%) 0.008 28 Parienti JJ JAMA 2002;288:722-7

Effect of Alcohol-Based Handrubs on Skin Condition Dry Self reported skin score Epidermal water content Healthy Healthy Dry ~ Alcohol-based handrub is less damaging to the skin ~ Boyce J, ICHE 2000;21(7):438-441. 29

Lower cost Global cost of surgical hand disinfection with different techniques 30 Tavolacci MP JHI 2006;63:55-59

Is the volume important? No, the more important is to keep the hands and the forearms wet for the time of applications Kampf G, Applied and Environmental Microbiology Dec 2004;7066 31

Does the previous handwashing reduce the efficacy of the rubbing? Hubner NO BMC Microbiology 2006, 6:57 32

The importance of let it dry before handgloving! Hubner NO BMC Microbiology 2006, 6:57 33

Practically Wash hands and forearms with nonantimicrobial soap for only 1 min before the first intervention and if they are visibly soiled. Use the brush only for nails if they are visibly soiled 34

37 Completely dry with disposable non sterile paper towels

38 Mesure the time: 90 sec

alcohol alcohol

Audit «surgical hand disinfection»

Audit Based on «the» procedure 58 observations between 22 and 30 of july 10 nuses (17%) 25 assistants (43%) 23 seniors (40%)

Observation roster

Results

Results Résultats by professionnal par catégorie category d opérateurs

Results by type of surgery

SCRUB or RUB 47

SCRUB or RUB! 48