ABSTRACT: Hand hygiene is an important part of peri-operative veterinary practice; the aim of surgical hand disinfection is the elimination of transient – and the reduction of resident – micro-organisms. If completed correctly, it reduces the transmission of micro-organisms, thus decreasing cross-contamination and surgical site infections (SSI) in patients With the widened concern and incidences of methicillin-resistant Staphylococcus aureus (MRSA) infections in recent years, this has never been more important. Between 10 per cent and 20 per cent of companion animals are found to carry MRSA each year, and these numbers are thought to be increasing.1 MRSA will never be eradicated, so all veterinary personnel must follow best practice to minimise the spread of infection

Recently, surgical hand antisepsis has undergone three main changes: the decline in scrub brushes; the introduction of the new alcohol rubs; and a reduction in the time needed to scrub prior to surgery.2

Decline in scrub brushes

Recent studies have demonstrated that the scrubbing method actually increases the amount of skin damage as a result of the abrasive action of the brush, resulting in excessive shedding of bacterial flakes of skin and removal of the superficial layers of epithelium.3-4 The damaged skin increases the risk of infection owing to the increased bacterial growth on the hands, especially under gloves, which provide a warm environment.5

The scrubbing-brush method is still an accepted tradition in many operating theatres where it has become more of a ritual because of personal habits, familiarity and beliefs.

Scrubbing the hands and arms with a brush has been discontinued in human surgery; however, brushes are still recommended for use on the nails.6

Reduction in hand scrubbing times

In the late twentieth century, the recommended length of hand scrubbing declined from ten to five minutes, as it was thought that increased scrubbing times actually increased the microbial count on the skin.5

Five-minute surgical scrubs are still common practice today, although shorter durations are now being recommended by the Hospital Infection Society (HIS), Association for Peri operative Practice (AfPP), Association of Peri-operative Registered Nurses (AORN), Centers for Disease Control (CDC) and the Australian College of Operating Room Nurses (ACORN). They recommend durations ranging from two to three minutes with an aqueous scrub.7

Many veterinary surgeons (VS) and veterinary nurses (VN) were – and still are – trained that a five-minute scrub duration is the correct procedure to follow.8 Perseverance with this may be a consequence of habit and lack of understanding regarding why a shorter duration could possibly be beneficial, or perhaps professionals are unfamiliar with the manufacturers’ guidelines. However, a number of studies all agreed that two to five minutes scrubbing is as effective as a ten-minute scrub.9-10-11-12-13-14

Alcohol rubs versus aqueous scrubs

Alcohol-based rubs are being used as an alternative to scrubbing with a brush and an aqueous solution.5 Many studies have compared the efficacy of surgical hand scrubbing and surgical hand rubbing, concluding that the immediate efficacy of rubs were similar to that of scrubs, but rubs had a more lasting effect.3-15-16-17-18-19

Alcohol rubs are considered to be less irritating to the skin, with better skin tolerance and a general acceptance that they are a kinder disinfectant to use,20 even on pre-irritated skin.21 Emollients in the alcohol rubs are available if a drying effect is observed.

Another consideration whilst scrubbing is the increased risk of contamination to clothes and the environment, which is higher compared to a hand rub. The scrubbing of hands can pose more of a risk whilst carrying out the ‘wetting then drying’ procedure prior to gloving, whereas the alcohol rub is applied and then left to dry without the need of a sterile hand towel.20

A study which compared costs of surgical hand rubbing and surgical hand scrubbing, concluded that rubbing reduced the cost by 67 per cent and saved time by one to two minutes compared to hand scrubbing.15

The other consideration is the ecological saving with hand rubbing because of the reduction in the volume of water needed on a daily basis.22 It has also been found that the taps in hospitals are a common source of Pseudomonas species, including P. aeruginosa and Gram-negative bacteria which have been associated with infections – even automated sensor-operated taps have been linked to contamination.'1

Importance of surgical gloves

Surgical gloves are an aseptic barrier in theatre and help to prevent surgical site contamination,8 but should never be used as an alternative to good hand hygiene.

Surprisingly, gloves can be perforated even before the packet has been opened; the accepted industry standard for perforated surgical gloves before use is 1.5 per cent.23 On average, 18 per cent (range 5-82 per cent) of gloves have tiny punctures after surgery, and after two hours of surgery, 35 per cent are punctured.5 Punctured gloves double the risk of SSIs,24 double-gloving reduces potential contamination through punctures, but they are still observed in 4 per cent of cases after a procedure.25

Evaluation of hand hygiene for VNs in practice

The results of a web-based questionnaire, distributed by the author in 2011, showed 92.9 per cent of VNs scrubbed with a brush and aqueous solution prior to applying sterile gloves and the remaining 7.1 per cent used an alcohol hand rub (Figure 1).

Figure 1: Aqueous solution v. alcohol hand rub

Almost 55 per cent of VNs scrubbed their hands for three to five minutes, followed by 34.5 per cent for more than five minutes and 10.9 per cent for one to two minutes (Figure 2).

Figure 2: Time spent scrubbing

Just over a half of the VNs questioned already followed a standard operating procedure when scrubbing or rubbing their hands, whilst 48.2 per cent did not (Figure 3).

Figure 3: Use of SOP

Figure 4 shows that 77.3 per cent of VNs stated that the practice did not have a particular staff member responsible for hand hygiene protocols and training of staff, and only 22.7 per cent did.

Figure 4: Dedicated hygiene staff

Recommendations and the VN’s role

As already stated, research is available to support the change from scrubbing to rubbing with the newer alcohol-based solutions available as an alternative to the traditional scrub. Less skin reaction from rubbing is beneficial to personnel and helps to reduce SSIs in patients.

Reducing the scrubbing duration from five to three minutes has been found to be beneficial – reducing precious time, water and aqueous products, if the brusfi cannot be disregarded.

VNs play a crucial role in influencing evidence-based improvements in surgical hand techniques. A competent VN should have the responsibility for instigating these hand hygiene methods within every practice. This role should include the setting of standards of best practice, as well as undertaking regular clinical audits to make sure every member of staff is adhering to practice policy. New members of staff should receive initial training followed by assessment.

Regular reassessment of the protocol with regard to current literature and practice outcomes should also be undertaken, as well as a clinical audit to monitor postoperative surgical cases and their progress. If evidence of SSIs is found, liaison with the clinical director or practice principal – following discussion of the relevant cases with staff members – will enable appropriate steps to be taken to improve future standards.

A written protocol should be placed in the theatre suite for all staff to see and which should be based in the use of posters/charts demonstrating correct hand technique. Visual resources enable clarity with respect to practice expectations as well as manufacturers’ recommendations regarding their product.

It is also useful to consider requesting a visit from the representative of the manufacturer of the rub/aqueous solution used in the practice to discuss the correct way of using their product, including application and duration.

Conclusion

Veterinary nurses are in a prime position to manage hand hygiene within the practice and to implement best practice. The requirement that RVNs ensure that they keep their knowledge and skills up to date by engaging with current research and literature should be embraced, and should include challenging the status quo within their place of work, instead of accepting the mind-set of‘well this is how it has always been done’.

Change is not necessarily a negative thing and progressing with the times is crucial and enables review of current practice. With the formal regulation of the veterinary nursing profession, it is important that nurses are proactive in setting and ensuring adherence to standards. 

Author

Nina Tudor

BSc (Hons) CVN Dip AVN (Small Animal) Dip HE CVN RVN MBVNA 

Nina qualified as a Veterinary Nurse in 1998 and in 2012 she graduated with an Honours Degree in Clinical Veterinary Nursing from Myerscough College After spending 16 years in several small animal practices – general, charity and referral – Nina is now working as a veterinary nurse teaching assistant at Harper Adams University College.

To cite this article use either

DOI: 10.1111/j.2045.0648.2012.00215.x or Veterinary Nursing Journal Vol 27 pp 341-343

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Veterinary Nursing Journal • VOL 27 • September 2012 •