The heightened scrutiny placed on infection prevention practices in surgical facilities over the past year presents an opportunity for you to challenge your team to demonstrate their competency in surgical scrub protocols and commit to the goal of 100% hand hygiene compliance. Use the following review of the basics (based on the CDC Guideline for Hand Hygiene in Health-Care Settings and AORN's Recommended Practices for Surgical Hand Antisepsis) to assess your facility's scrub products and practices.

WHO must perform the scrub? Members of the operative team who'll be in contact with the sterile operative field or sterile instruments and supplies are required to perform a surgical scrub. Those members of the team who won't be in contact with the field or sterile supplies — the circulator, anesthesiologist and other team members — should always perform basic hand hygiene using an alcohol-based hand rub or, if hands are soiled, with water and a facility-approved agent.

WHAT products should they use for hand antisepsis? Use either an antimicrobial soap with water or an alcohol-based, waterless hand rub. The scrub should be FDA-compliant and have fast-acting, broad-spectrum, persistent activity in reducing microorganisms on intact skin, without irritating the skin. According to the CDC, "studies have demonstrated that formulations containing 60% to 95% alcohol alone or 50% to 95%, when combined with limited amounts of a quaternary ammonium compound, hexachlorophene or chlorhexidine gluconate, lower bacterial counts on the skin immediately post-scrub more effectively than do other agents. The next most active agents (in order of decreasing activity) are chlorhexidine gluconate, iodophors, triclosan and plain soap." (See "Scrub or Rub: Which Method Is Right for Your Facility?" on page 22.)

WHERE is the scrub performed? At a scrub sink located in a separate scrub room or directly outside the OR in an open corridor. Remember that alcohol-based products are flammable and therefore should be kept away from electrical or sparking devices (such as light switches), flames and high-temperature areas. Refillable soap dispensers are not recommended, as topping off dispensers can pose a contamination risk. Use soap that comes in self-contained dispensers instead.

WHY scrub in for surgery? According to the CDC, "no randomized, controlled trials have been conducted to indicate that surgical-site infection rates are substantially lower when pre-operative scrubbing is performed with an antiseptic agent rather than a non-antimicrobial soap," but "certain other factors provide a strong rationale for this practice." Those factors include studies showing bacterial growth under surgical gloves is slowed after pre-operative antisepsis, but not after washing with non-antimicrobial soap, and at least one known outbreak that occurred when surgeons switched from an antiseptic surgical scrub to a non-antimicrobial product. Therefore the CDC, AORN and other regulatory and professional bodies recommend scrubbing with an antiseptic agent before performing invasive procedures.

WHEN do you perform the scrub? Before donning sterile gloves for a surgical procedure or other invasive procedures. The World Health Organization's "5 Moments for Hand Hygiene" defines the key moments when healthcare workers should perform hand hygiene: before touching a patient; before clean or aseptic procedures; after body-fluid exposure or risk; after touching a patient; and after touching patient surroundings. You should also perform hand hygiene after removing gloves (this is a common area of non-compliance).

HOW is the scrub performed? Start by removing all rings, watches and bracelets. Wash hands and forearms with soap and running water, use a disposable nail cleaner under running water to remove debris from under the fingernails and then rinse.

• When using an antimicrobial soap with water: Dispense an appropriate amount of facility-approved soap according to the manufacturer's guidelines and apply it to wet hands and forearms. Scrub hands and forearms for as long as the manufacturer of the soap recommends, usually 2 to 6 minutes (the old standard of 10 minutes is not necessary and can harm the skin).

According to the CDC, "several studies indicate that neither a brush nor a sponge is necessary to reduce bacterial counts on the hands of surgical personnel to acceptable levels, especially when alcohol-based products are used." If you do use a soft sponge, discard it immediately before drying. For optimal results, AORN recommends you visualize each finger, hand and arm as having 4 sides and wash all 4 sides thoroughly. When finished, hold hands higher than the elbows and away from clothing. Dry arms and hands with a sterile towel before donning surgical gloves.

• When using an alcohol-based, waterless hand rub: Dry hands and forearms thoroughly with a paper towel. Dispense an appropriate amount of surgical hand rub according to the manufacturer's directions. Apply the product to hands and forearms as recommended by the manufacturer and rub thoroughly, letting hands and forearms dry completely before donning gloves. After the first scrub-in of the day, the waterless rub can be reapplied to clean hands between cases without rewashing, as long as hands are not visibly soiled. Consult with the manufacturer's and FDA's recommendations for the product you use.

Standardizing the surgical scrub products and procedures at your facility is the best way to engineer out potential application errors and enable staff to perform the scrub the same way each time. When I first started in the OR, there were up to 10 products next to the scrub sink. Those days are gone. Too many choices at the scrub sink facilitate inconsistencies from day to day and shift to shift. Do your due diligence, research the evidence-based, FDA-approved products, choose the 1 or 2 your facility supports and stock only those products. Have the product representative come in to give a demonstration annually on the use and efficacy of the scrub you use. This annual refresher helps staff remember your facility's commitment to infection prevention through meticulous, standardized hand hygiene practices.

A shared responsibility
While it's important to designate an infection preventionist to routinely assess surgical scrub practices and ensure they're being performed correctly every time, you should also make hand hygiene a facility-wide priority and involve all staff members and surgeons in helping to achieve the goal of 100% compliance, 100% of the time. Have your surgeons and staff make a commitment to remind each other if they notice hand hygiene not being performed when recommended.