How hard can it be to wash your hands properly when you're using brush-free scrubs? Squirt. Rub. Let dry. What could possibly go wrong? Plenty, as it turns out. Researchers have found that while waterless, alcohol-based hand rub agents are widely used in the perioperative setting, they're not always being used properly. And that, in turn, can nullify their infection-fighting efficacy.

Studies have shown that waterless, alcohol-based hand rubs are more effective than traditional antimicrobial scrubs in reducing bacterial counts and are at least as effective in preventing surgical site infections. But "Low Adherence With Waterless Surgical Hand Antisepsis," an AORN poster presentation, chronicled a long list of what can go wrong when you squirt and rub:

• You don't rub the waterless product into the skin until dry.
• You don't routinely perform a pre-wash.
• You don't apply enough product before donning surgical gloves.
• You towel-dry before donning surgical gloves.

Each of these missteps could conceivably compromise the efficacy of antimicrobial hand rubs, says Lawton Seal, PhD, senior program manager of research and development for Healthpoint in Fort Worth, Texas, who co-authored the poster with Shanta Modak, PhD, and Cenk Cayci, MD, of the Columbia University College of Physicians & Surgeons. Other factors that can lead to improper use of brush-free scrubs include lack of awareness of AORN guidelines (see "AORN Guidelines for Proper Hand Hygiene" on page 34) and manufacturers' recommendations, time constraints within the OR and your staff's dissatisfaction with the products you've purchased.

So maybe waterless scrubs aren't so simple and foolproof after all.

Splat, you're it
To raise the level of hand hygiene compliance in a non-threatening way, Janet Haas, RN, DNSc(c), CIC, the associate director of infection prevention and control for New York University Hospitals Center in New York City, helped develop a game called Splat!.

The game is simple: Players are provided with business-sized cards listing the indications for hand hygiene from the Hospital Infection Control Practices Advisory Committee's 2002 guidelines for hand hygiene in healthcare. Players also get Splat! stickers in their team color; Ms. Haas used neon green, yellow and pink that she bought at an office supply store.

The object of the game is to remember to perform hand hygiene when indicated and to Splat! opposing players by placing a sticker on them if they forget to properly perform hand hygiene. Players place stickers on their facility ID badges so others know their team identity. Team members are encouraged to remind each other to perform hand hygiene; there's no penalty for reminding a teammate. Teams are multi-disciplinary, so that all healthcare providers can play the game.

Play periodically instead of often and when patient loads allow, says Ms. Haas. Also remember that stickers are friendly reminders, not scarlet letters, so keep the atmosphere light. As one nurse commented, "the game heightens the nerves." This game helps recognize mistakes in a good-natured way if used properly and encourages a culture where correcting hand hygiene behavior is acceptable. To that end, Ms. Haas provided each player with a blank index card where multiple Splats! could be stuck and tucked away in a pocket.

Hand hygiene compliance is a complex behavior that's difficult to improve. Splat! helped increase compliance, possibly by illustrating the multiple indications for hand hygiene in everyday practice, says Ms. Haas.

Barriers to protection
Within the past year, more than 700 AORN members responded to an online survey Dr. Seal and his team created. While the survey didn't ask nurses how satisfied they were with their facility's rubs, responses suggest dissatisfaction with available products. Many admitted that they didn't use the rubs because they didn't like how the waterless products made their skin feel. Products that are gentler on the skin and leave no residual film that could interfere with the use of surgical gloves are clearly needed, the survey found. Besides monitoring for inappropriate application of surgical scrubs and reinforcing AORN and manufacturer directions, recognize that the formulation of hand rubs can affect staff compliance.

Lack of time was the main reason nurses gave for not following instructions to rub the waterless product into the skin until dry and, to a lesser extent, for not routinely performing a pre-wash. In particular, nurses indicated that they had difficulty donning gloves and re-gloving during surgical procedures. Consequently, nurses tended to apply less product or towel-dry before donning surgical gloves. Each of these actions could conceivably compromise the efficacy of the antimicrobial hand rub, say researchers.

The poster showed that it's apparent that a substantial proportion of perioperative nurses have a less-than-complete understanding of the revised guidelines and manufacturers' directions for the proper use of waterless, alcohol-based hand rubs. This is evidenced by the low level of adherence to the pre-wash and nail cleaning steps before the application of the hand rub, variations in the amount of waterless product applied and use of a towel to facilitate drying. Use of less product, either through application or removal during towel-aided drying, may compromise the efficacy of a hand rub by decreasing its ability to achieve and sustain antisepsis.

Respondents also indicated that they don't routinely perform a pre-wash, use a nail cleaner or apply the hand rub according to the manufacturer's directions because they feel that these handwashing steps aren't clinically necessary.

A lack of familiarity with hand hygiene guidelines and inadequate understanding of the risk of cross-contamination and the impact of hand hygiene on SSI rates can all negatively affect compliance, according to studies. Two recently published reports demonstrated that hospital-wide initiatives to educate and increase awareness of hand hygiene in healthcare workers were associated with an 18 percent to 26 percent increase in compliance over a three-year to four-year study period.[1,2,3] Moreover, improvements in compliance were associated with significant decreases in nosocomial infection rates, including those caused by MRSA and MDR pathogens.

"These findings suggest that education may be a powerful tool to boost compliance rates in the present population of perioperative nurses," says Dr. Seal.

Dr. Seal notes that it's well documented that time constraints have a negative impact on adherence to hand hygiene guidelines in the OR, as demonstrated by nurses' naming time their top reason for not using waterless products.[4] Nurses also cited a dislike for the impact of the waterless product on the skin as a reason for noncompliance, because it makes donning gloves more difficult. Slipping of the hands and fingers within gloves was also problematic, they said, and they usually compensated by applying less product or towel drying.

Skin dryness, irritation and dermatitis due to frequent handwashing are common complaints of healthcare personnel and a major reason for non-adherence to hand hygiene practices.4 Although not specifically queried in the present study, these complaints fall under the category of disliking the impact of the hand rub on the skin. Dr. Seal notes that soaps used for pre-wash can cause the skin to dry and crack over time, thus increasing susceptibility to colonization by staphylococci and gram-negative bacilli and heightening the risk of infection in both the worker and patient.[4,5]

Although waterless, alcohol-based hand rubs have added emollients and humectants to help maintain a healthy skin barrier, they still reportedly cause adverse skin reactions in up to 15 percent of users.[6-9] Skin reactions following the use of these products may be due, in part, to the residual activity of ingredients, such as chlorhexidine gluconate (1% CHG), that are added to alcohol formulations to potentiate their antimicrobial effects.

What's a manager to do?
So, how do you improve adherence and maintain optimal antisepsis in the OR? Based on the poster's findings, here are some ideas that could work for you.

• Look beyond antisepsis. Assess and select waterless, alcohol-based hand rub products as to their impact on skin as well as antiseptic properties. Keep in mind that a formula's characteristics contribute to drying, ingredient residue and glove slippage - which, in turn, can affect adherence. The first generation of rubs, released in the early part of this decade, was developed from rubs used on inpatient hospital floors. They were a lotion-like substance designed for numerous applications and created a thick tactile buildup. In a surgical setting, the buildup can create discomfort on the gloved and sweaty hands of OR staffs. The second generation of surgical rubs, which were introduced earlier this year, dry quickly and leave a minimal amount of residue under gloves worn during surgery.
• Trial the product. Accumulate data from manufacturers that support the product's efficacy, and then trial the product to get direct user feedback on how the rub works in a clinical setting. User preference is a big part of hand hygiene compliance; test the rubs you're thinking of using for a week or two and see which product your staff will be most likely to use. Are they easy to apply? Do they feel comfortable on sweaty hands and under surgical gloves? You need to know the answers.
• Know your rub. This includes the recommended volume for use, duration of the application and drying time.
• Post manufacturers' guidelines for rub application next to each dispenser. Most rub producers make small signage available for this purpose, displays that include bulleted directions for use. Ask the manufacturer to clarify the application steps if the verbiage is unclear. Your staff should have a precise understanding of how the rub works when reading the key components of the guidelines.
• Casually monitor the practices of your staff. Rely on a familiar face to ensure compliance with hand hygiene guidelines, someone who is a regular in your facility's ORs. The use of an infection control specialist may seem like the appropriate way to manage behavior, but the watchful eye of an outsider may do more harm than good to staff morale. Improving hand hygiene protocol can and should be viewed as an educational opportunity instead of a police activity, says Dr. Seal.

Simple and effective
Surgical site infections are the most common nosocomial infection encountered in surgical patients. Experts agree that hand hygiene is the simplest and most effective way to reduce those infections. But the simple effectiveness of an alcohol-based hand rub is dependent upon its proper use. Understand the way rubs work, educate your staff and listen to their product preferences to improve the hand hygiene protocol in your facility.

References:
1. Pittet D. Improving adherence to hand hygiene practice: A multidisciplinary approach. Emerg Infect Dis. 2001;7:234-240.
2. Barnes S, Barron D, Becker L, Canola T, Salemi C. Kaiser Permanente National Hand Hygiene Program. The Permanente Journal. 2004;8:45-50.
3. Pittet D, Hugonnet S, Harbarth S, et al. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Lancet. 2000;356:1307-1312
4. Boyce JM, Pittel D. CDC Guidelines: Guideline for hand hygiene in health-care settings. Available at: www.cdc.gov/mmwr/preview/mmwrhtml/rr5116a1.htm. Accessed May 22, 2006.
5. Larson EL, Norton Hughes CA, Pyrak JD, Sparks SM, Cagatay EU, Bartkus JM. Changes in bacterial flora associated with skin damage on hands of health care personnel. Am J Infect Control. 1998;26:513'521.
6. Boyce JM, Kelliher S, Vallande N. Skin irritation and dryness associated with two hand hygiene regimens: soap-and-water handwashing versus hand antisepsis with an alcoholic hand gel. Infect Control Hosp Epidemiol. 2000;21:442-448.
7. Center for Drug Evaluation and Research (FDA). Avagard CHG antiseptic hand preparation (1% chlorhexidine gluconate, 61% ethyl alcohol). NDA: Application Number 21 074 Medical Review;1999.
8. Cimiotti JP, Marmur ES, Nesin M, Hamlin-Cook P, Larson EL. Adverse reactions associated with an alcohol-based hand antiseptic among nurses in a neonatal intensive care unit. Am J Infect Control. 2003;31:43-48.
9. Gaonkar TA, Geraldo I, Shintre M, Modak SM. In vivo efficacy of an alcohol-based surgical hand disinfectant containing a synergistic combination of ethylhexylglycerin and preservatives. J Hosp Infect. June 5, 2006; [Epub ahead of print].