Infection Control Today - 02/2004: Clinical Update

AORN Reviewing Hand Hygiene Guidelines for Perioperative Nurses

By Kathy Dix

The practices review committee at the Association of periOperative Registered Nurses (AORN) has been busy reviewing updated guidelines for hand hygiene from the Centers for Disease Control and Prevention (CDC). What will their new recommendations for perioperative nurses include?

The committee set itself the task of reviewing the CDC guidelines to establish a new surgical prep/handrub policy based on those recommendations. The Proposed Recommended Practices For Surgical Hand Antisepsis/Hand Scrubs were posted on AORN’s Web site (www.aorn.org) for public comment through Nov. 21, 2003.

“The AORN recommended practices are posted on the Web site as ‘proposed’ to elicit comment and input from members and others,” says Dorothy M. Fogg, RN, BSN, MA, senior perioperative nursing specialist at the AORN Center for Nursing Practice. “When the deadline for comment is reached, the document is removed from the Web and the comments collected and reviewed. Comments appropriate to the document are included in the document as it is revised. After revision, the document is forwarded to the AORN board of directors for final approval. Following that approval, the document is published in the AORN Standards, Recommended Practices, and Guidelines, an AORN publication that is updated each year.”

The proposed recommended practices have not been approved by the board of directors at this time. However, Fogg says, “We anticipate that happening in the near future. The document is expected to appear in the 2004 recommended practices book unless the board voices a concern or requests changes.”

The document addresses both general hand hygiene in the operating room and the surgical scrub. The CDC guideline is a comprehensive document, addressing far more than hand hygiene in the operating room, Fogg points out.

“As an association of perioperative nurses, we try to limit our document to addressing issues of interest to perioperative nurses and to providing our members with recommendations for safe practice,” she says.

Fogg notes that the board of directors’ approval was expected by Jan. 1, 2004. “The actual book will be released upon publication and will be available at the AORN annual Congress in San Diego in March,” she says.

When asked how long it takes to review and integrate the public’s comments into a recommended practice document, Fogg explains that the time to review varies based on the document itself and the comments received in relation to it. “The turnaround could be as little as a couple of weeks or as long as several months,” she adds.

Accepted components commonly used as antimicrobial agents include the following:

• Alcohols
• Chlorhexidine, both 2 percent and 4 percent aqueous
• Iodine compounds
• Iodophors
• Phenol derivatives
• Troclosan 
• Quaternary ammonium compounds

However, each product has its bonuses and negatives. Alcohol, for example, is very effective, but has no residual activity. Other components are too irritating to use for hand hygiene.

The proposed recommended practices for surgical hand antisepsis and hand scrubs are relatively straightforward. Available at www.aorn.org/proposed/handscrub.htm, the draft of the recommended practices was posted online for comment until Nov. 21, 2003.

“These recommended practices are intended as achievable recommendations representing what is believed to be an optimal level of practice,” the Web site states. “Policies and procedures will reflect variations in practice settings and/or clinical situations that determine the degree to which the recommended practices can be implemented.”

The settings in which these guidelines might be appropriate include:

• Operating rooms
• Ambulatory surgery units
• Physicians’ offices
• Cardiac catheterization suites
• Endoscopy suites
• Radiology departments

Settings also include other areas where operative and other invasive procedures may be performed.

AORN observes that from the time of Semmelweis’ research, hand hygiene has been recognized as a crucial means of preventing the spread of infection from healthcare workers to their patients, and that hand hygiene in relation to patient care — both before and after care — “remains the most effective and least expensive measure to prevent and control the transmission of microorganisms and prevent healthcare- associated infection. Hand hygiene is the single most important step in the prevention of infections.”

Therefore, “It is of critical importance that the entire healthcare team routinely practice the basic tenets of hand hygiene. Basic hand hygiene/antisepsis refers to handwashing, antiseptic handwash, or use of an antiseptic hand rub,” the proposed guidelines read.

The guidelines make several recommendations that are hardly new, but certainly worth repeating:

• “Although scrubbed members of the surgical team wear sterile gloves, the skin of their hands and forearms should be cleaned preoperatively to significantly reduce the number of microorganisms. The moist environment underneath surgical gloves can promote microorganism proliferation on the hands of the wearer. Both surgical and examination gloves can fail during a procedure.”
• Surgical hand antisepsis is used to remove debris and microorganisms, to lower the microbial count as much as possible, and to prevent regrowth of said microbes for as long as possible.

The main points of the recommendations include the following:

Recommended Practice I

• Decontaminate hands before and after patient contact, after removing gloves, before and after eating, after using the restroom and after contact with potential infectious organisms.
• Avoid contact with potentially contaminated surfaces.
• Keep fingernails short, clean and healthy. Nail polish should not be chipped.
• Do not wear artificial nails.
• Keep skin free from open lesions and breaks.
• Remove all jewelry from hands and forearms before performing hand hygiene.
• Use only lotions that are approved by infection control staff; lotions must be compatible with the hand antiseptic and gloves, and be stored in disposable, hands-free dispensers.
• Wash visibly soiled hands with plain or antimicrobial soap and water, rubbing vigorously for at least 15 seconds and covering all surfaces, especially backs of hands, fingertips, and thumb and inner web. Use a disposable towel, and avoid touching the faucet by turning it off with the towel.
• Routine hand decontamination — if there is no visible soiling — can include an alcohol-based hand rub instead of soap and water.
• Alcohol hand rubs should be made available to healthcare staff, and may include individual, pocket-sized containers.

General Hand Hygiene and Surgical Hand Antisepsis Directives

Recommended Practice II

• Use an FDA-cleared, surgical hand antiseptic agent approved by infection control personnel for all surgical hand antisepsis or surgical hand scrubs. The agent should meet the following criteria: significantly reduce microorganisms on intact skin, be nonirritating, be broad-spectrum, fast-acting and have a residual effect.
• When choosing an agent, follow the AORN “Recommended practice for product selection in perioperative settings.” Use input from infection control practitioners and end users, and include alternatives for healthcare workers with product sensitivities.
• Re-scrub and re-glove if the operative procedure lasts longer than the documented persistence time of the antiseptic agent.
• Store agents in clean, closed containers; focus on single-use containers that are discarded when empty.
• Store alcohol-based products away from high temperatures, sparking devices or flames. Ensure that containers are designed to minimize spilling, leaking and evaporation.

Recommended Practice III

• Perform surgical hand antisepsis before donning sterile gloves. Use an FDA-cleared, antimicrobial surgical scrub agent or an FDAcleared, alcohol-based hand antiseptic agent approved for this role.
• Develop a standardized protocol for hand antisepsis and scrubs.

Recommended Practice IV

• Use a standardized hand scrub procedure that follows manufacturer’s written guidelines and approved by the healthcare facility. Detailed instructions on how to perform the scrub can be found at www.aorn.org/proposed/handscrub.htm.
• Use either a timed scrub or a counted stroke method for the surgical hand scrub.
• Perform the scrub with no implements and using only a soft sponge.
• Perform hand hygiene immediately after removing surgical gloves.

Recommended Practice V

• “Combination products of alcohol and another FDA-cleared active ingredient that provides persistence offer the most desirable attributes in the surgical setting.” Alcohol kills more organisms, but combination agents provide a persistent effect as well, maintain the proposed guidelines.

Recommended Practice VI

• “Policies and procedures for surgical hand antisepsis should be developed, reviewed periodically, and be readily available in the practice setting,” the proposed guidelines state.
• Provide education about surgical hand antisepsis products and protocols to all perioperative personnel, on an ongoing and systematic basis.
• Use the recommended practices as guidelines; include a review of policies and procedures in both orientation and in ongoing education of personnel.