To scrub or to rub? That's the question raised but never fully answered in the Centers for Disease Control and Prevention's (CDC) new hand hygiene guideline. So don't expect to read the 50-page document with 423 references and know whether you should change your practice in the OR from performing a surgical hand scrub before procedures to using a waterless, alcohol-based hand rub product.

I know because I've tried. "Guideline for Hand Hygiene in Healthcare Settings" extols the efficacy, fast action, convenience and skin-friendly gentleness of alcohol-based hand rubs, but in the end says it's up to you to decide what's best for your OR. A CDC Fact Sheet suggests in so doing that you use a mixture of scientific and subjective measures: "When evaluating hand hygiene products, administrators should consider the relative efficacy of antiseptic agents against various pathogens and the acceptability of hand hygiene products by personnel. Characteristics of a product that can affect acceptance and usage include its smell, consistency, color and the effect of dryness on hands."

Do, can do, must do
The guideline bases its recommendations on a five-point rating scale: Category IA (do this), Category IB (can do this), Category IC (must do), Category II (suggested) and no recommendation, no consensus reached. Here's a review.

• Wear gloves for bodily fluid contact.
• Store alcohol hand rubs in flammable-materials cabinets.

• Wash visibly dirty hands with soap and water.
• Use alcohol hand rubs to clean hands.
• Decontaminate hands after body fluid contact, even if hands are not visibly soiled.
• Wait until soap dispenser is empty to put more soap in.
• Provide staff with hand lotions/creams for dermatitis.
• Ban artificial fingernails or extenders in ICUs and ORs.
• Monitor staff compliance and give feedback on hand-hygiene practices.
• Provide staff with alcohol hand rubs.
• Provide alcohol hand rubs at the entrance to a patient's room, at a patient's bedside and for the HCW pocket.

• Wash hands with antimicrobial soap and water, if not using alcohol hand rubs.
• Decontaminate hands before patient contact.
• Decontaminate hands before donning sterile gloves for central IV catheter insertions.
• Decontaminate hands before urinary, IV and other non-surgical catheter insertions.

• A Seven-Step Guide to Surgical Hand Prepping Here are the basic chronological steps for surgical hand preparation with an alcohol-based agent. 1. Wash hands with soap and water. 2. Using a disposable nail cleaner, clean nail beds under running water, and discard nail cleaner after use. 3. Rinse. 4. Moisten hands and forearms. 5. Wash hands and forearms using antimicrobial soap or a detergent that is compatible with the agents in the alcohol-based product. 6. Rinse and thoroughly dry hands and arms. 7. Apply alcohol-based surgical hand scrub product according to manufacturer's instructions.

  Decontaminate hands after patient contact.
• Decontaminate hands after glove removal.
• Wash hands with soap and water before eating and after using restroom.
• Use antimicrobial towelettes as a substitute for soap-and-water cleansing only.
• Apply alcohol hand rubs to palm, rubbing over entire hand surface until dry.
• Wet hands with water, apply recommended product dose, rub vigorously 15 seconds over surface, rinse with water, dry thoroughly with paper towel and turn off faucet with towel. Avoid hot water, which increases dermatitis risk.
• Use antimicrobial soap or alcohol hand rub for surgical scrub before donning sterile gloves.
• Perform surgical scrub with antiseptic and water for manufacturer's stated two to six minutes only.
• Use alcohol surgical hand scrubs per manufacturer's instruction. Pre-wash with soap and water and dry thoroughly before applying alcohol surgical scrub; dry thoroughly before donning sterile gloves.
• Provide staff with effective, low irritancy hand-hygiene products.
• Obtain staff input on products regarding feel, fragrance and skin tolerance; cost is not a primary factor in product selection.
• Solicit manufacturer information on interactions among hand lotions, creams, alcohol rubs and antimicrobial soaps used in the facility.
• Remove gloves after each patient; do not reuse or wash gloves.
• Make hand hygiene adherence a priority in the facility, providing administrative support and finances.
• Implement multidisciplinary program for staff compliance to hand-hygiene practices.

• Decontaminate hands if moving from contaminated to clean body site.
• Decontaminate hands after contact with inanimate objects near patients.
• Wash hands with plain or antimicrobial soap and water for Bacillus anthracis (anthrax) spore exposure.

• AORN Recommends Scrubs over Rubs Before you abandon your antimicrobial surgical hand scrub agents, consider that the guideline indicates that surgical scrubs should contain ingredients that contribute to a persistent effect, which is not alcohol's strong point. And while it's clear that alcohol is an excellent skin disinfectant and can have a persistent effect for up to three hours when combined with other agents (chlorhexidine, for example), very few studies have compared the effects of traditional surgical hand scrubs to brushless, alcohol-based hand rub agents. It's interesting to note that AORN continues to recommend the traditional surgical hand scrub with an antimicrobial surgical hand scrub agent. AORN warns that you should only use alcohol-based hand rub agents as part of the surgical hand preparation procedure if the surgical procedure is expected to last less than three hours.

  Liquid, bar, leaflet or powdered plain soap are acceptable non-antimicrobial forms for washing hands. Use soap racks for bar soap; use small bars.
• Eliminate multiple-use hanging or roll-cloth towels in healthcare.
• Remove rings, watches and bracelets before doing surgical hand scrub.
• Remove debris under fingernails with a nail cleaner under running water.
• Solicit manufacturer information regarding interactions among hand-cleansing products, skin-care products and glove types used in the facility.
• Evaluate dispenser systems for function and dosing beforepurchase.
• Keep natural nail tips less than one-quarter-inch long.
• Change gloves if moving from contaminated to clean body site during patient care.
• Educate staff about hand-contamination activities and pros and cons of cleansing methods.
• Encourage patients and families to remind staff about decontaminating their hands.

• Routine use of non-alcohol hand rubs for hand hygiene in healthcare.
• Wearing rings in healthcare.

Evolution of surgical hand antisepsis
While "Guideline for Hand Hygiene in Healthcare Settings" is effusive in its praise of hand rubs, it does not signal a new era in hand antisepsis. CDC's stated objective in releasing the guidelines is to improve adherence to hand-hygiene in healthcare settings - not to compare and contrast rubbing your hands with alcohol-based products to washing them with soap and water.

Waterless, alcohol-based products are not new. The novelty is in the manufacturers' new gel media and emollient additive that the guideline touts as the answer to hand hygiene. If you decide to use an alcohol-based hand rub agent, you must still clean your fingernails and visibly contaminated skin surfaces with antimicrobial soap and water. Hand cleansing and disinfecting with skin care and antiseptic products require multiple steps (see "A Seven-Step Guide to Surgical Hand Prepping") - mechanical friction being the most important to rid the surface of microbes.

Surgical hand antisepsis has evolved over time based on science, common sense and routine practice. Patient safety, surgical site infection incidence, skin integrity changes, regulatory boundaries and objective product evaluations - all are integral to making an informed decision.

References
1. John M. Boyce and Didier Pittet. Guideline for Hand Hygiene in Health-Care Settings. MMWR. Supplement, October 25, 2002, Vol. 51, No. RR-16.