Surgical hand antisepsis: the evidence

Achieving Perfect Hand Washing: an Audit Cycle with Surgical Internees

The aim of this study is to achieve 100% compliance in surgical hand antisepsis along with identification of areas of worst compliance and efficacies of various interventions best suited to deal with them. This audit was performed over 6 days in a tertiary care hospital in Calcutta, India, with 42 surgical internees. Compliance to ideal hand washing technique was recorded after each attempt with the first attempt as baseline. Video demonstration, personal demonstration by a consultant, and individual instruction were used as subsequent interventions to achieve 100% compliance. The baseline level of compliance was found to be 33.59%. A total of 6 attempts was required to achieve 100% compliance, with the increase in compliance being statistically significant (p = 0.0294). Personal instruction was found to be the most effective intervention. Hand washing technique was the criterion that needed the most number of attempts (n = 6) to rectify. This study found video-based instruction and individual guidance effective teaching tools for surgical hand disinfection and gave novel data regarding the reasons responsible for poor compliance to proper hand washing in a general surgical setting. This study demonstrated the efficiency of audit cycles in the improvement of surgical hand washing and can be the preferred mode of intervention in future studies aimed at achieving ideal hand antisepsis.

Infection prevention preparedness and practices for female sterilization services within primary care facilities in Northern India

Background

In 2014, 16 women died following female sterilization operations in Bilaspur, a district in central India. In addition to those 16 deaths, 70 women were hospitalized for critical conditions (Sharma, Lancet 384,2014). Although the government of India’s guidelines for female sterilization mandate infection prevention practices, little is known about the extent of infection prevention preparedness and practice during sterilization procedures that are part of the country’s primary health care services. This study assesses facility readiness for infection prevention and adherence to infection prevention practices during female sterilization procedures in rural northern India.

Method

The data for this study were collected in 2016–2017 as part of a family planning quality of care survey in selected public health facilities in Bihar (n = 100), and public (n = 120) and private health facilities (n = 97) in Uttar Pradesh. Descriptive analysis examined the extent of facility readiness for infection prevention (availability of handwashing facilities, new or sterilized gloves, antiseptic lotion, and equipment for sterilization). Correlation and multivariate statistical methods were used to examine the role of facility readiness and provider behaviors on infection prevention practices during female sterilization.

Result

Across the three health sectors, 62% of facilities featured all four infection prevention components. Sterilized equipment was lacking in all three health sectors. In facilities with all four components, provider adherence to infection prevention practices occurred in only 68% of female sterilization procedures. In Bihar, 76% of public health facilities evinced all four components of infection prevention, and in those facilities provider’s adherence to infection prevention practices was almost universal. In Uttar Pradesh, where only 55% of public health facilities had all four components, provider adherence to infection prevention practices occurred in only 43% of female sterilization procedures.

Conclusion

The findings suggest that facility preparedness for infection prevention does play an important role in provider adherence to infection prevention practices. This phenomenon is not universal, however. Not all doctors from facilities prepared for infection prevention adhere to the practices, highlighting the need to change provider attitudes. Unprepared facilities need to procure required equipment and supplies to ensure the universal practice of infection prevention.

Two-Layer Wound Sealing before Surgical Hand Washing for Surgeons with a Minor Cut Injury on the Hand

Background: There is a lack of evidence-based recommendations for surgical hand washing when there is a minor cut on the hand. We sought to evaluate whether two-layer wound sealing functions as a barrier to prevent the spread of micro-organisms. Methods: We randomly categorized 20 surgeons into subjects with either a right- or left-hand injury. Each subject was assumed to have a minor injury on the assigned hand and the other hand was used as a control. Subjects applied a waterproof topical dressing as a first layer, then protected the injured area with a second layer using an antimicrobial drape, and finally performed surgical hand rubbing. Subjects stamped each hand onto an agar plate. The injured hands were checked by an investigator to confirm the wounded area remained properly sealed after hand rubbing. Colonies were counted and the micro-organisms were identified after 48 hours of incubation. Results: There was no leak found from two-layer wound sealing after hand washing. Mean number of the colonies was 0.2 on the injured hand and 0.25 on the uninjured hand (p = 0.772). The micro-organisms cultured from both the injured and uninjured hands were coagulase-negative staphylococci. Conclusions: Using a model for a minor cut injury on the hand this study demonstrated that two-layer wound sealing is an effective barrier not only to prevent the spread of micro-organisms but also to protect surgeons.

Chlorhexidine is not an essential component in alcohol-based surgical hand preparation: a comparative study of two handrubs based on a modified EN 12791 test protocol

BACKGROUND

Surgical hand preparation is an essential part of modern surgery. Both alcohol-based and antiseptic detergent-based hand preparation are recommended practices, with a trend towards use of alcohol based handrubs. However, discussion has arisen whether chlorhexidine is a required ingredient in highly efficacious alcohol-based formulations, in view of providing sustained antimicrobial efficacy.

METHODS

One alcohol-only formulation (product A), containing ethanol and n-propanol, and one formulation containing a chlorhexidine-ethanol combination (product B) were directly compared with each other using a modified test protocol based on European standard EN 12791 (2016) with 25 volunteers. The alcohol-only formulation (product A) was applied for only 90 s, the chlorhexidine-alcohol formulation (product B) for 180 s. Microbial log reduction factors were determined and statistically compared immediately after application and at 6 h under surgical gloves.

RESULTS

The alcohol-only formulation (product A) achieved mean log reduction factors of 1.96 ± 1.06 immediately after application and 1.67 ± 0.71 after 6 h. The chlorhexidine-alcohol combination (product B) achieved mean log reduction factors of 1.42 ± 0.79 and 1.24 ± 0.90 immediately and after 6 h, respectively. The values for product A were significantly greater than those for product B at both measured time points (p ≤ 0.025 immediately after application and p ≤ 0.01 after 6 h).

CONCLUSIONS

An optimized alcohol-only formulation tested according to a modified EN 12791 protocol in 25 healthy volunteers outperformed a chlorhexidine-alcohol formulation both immediately after application and at 6 h under surgical gloves, despite a much shorter application time. Thus, optimized alcohol-only formulations do not require chlorhexidine to achieve potent immediate and sustained efficacy. In conclusion, chlorhexidine is not an essential component for alcohol-based surgical hand preparation.

Effect of 4% chlorhexidine gluconate predisinfection skin scrub prior to hepatectomy: a double-blinded, randomized control study

This trial was designed to compare the efficacy of 4% chlorhexidine gluconate (CHG) with normal saline (NS) as a predisinfection skin-scrub solution prior to standard presurgical skin preparation. Data was collected at a single transplantation center where patients electing resection of hepatic tumors were recruited between October 2011 and September 2012. In total, 100 patients were consecutively enrolled for random assignment to either 4% CHG or NS as a predisinfection skin-scrub solution prior to surgery. Our aim was to assess the comparative antiseptic efficacy of CHG in this setting, focusing on cutaneous microbial colonization (at baseline, preoperatively, and postoperatively) and postsurgical site infections as primary outcome measures. Positivity rates of baseline, preoperative, and postoperative cultures were similar for both groups, showing significant declines (relative to baseline) after skin preparation and no significant postsurgical rebound. Rates of surgical site infection were also similar in both groups (CHG, 6.0%; NS, 4.1%; P = 1.0). For patients with hepatic tumors undergoing hepatectomy, the effect of 4% CHG as a predisinfection scrub solution was similar to that of NS in terms of skin decontamination and surgical site infections.

Effects of peer monitoring and peer feedback on hand hygiene in surgical intensive care unit and step-down units

Attempts to increase hand hygiene compliance of health care workers solely through education have met with mixed success. A peer-monitoring and feedback intervention was evaluated to determine the effectiveness in increasing hand hygiene among health care staff at a large teaching hospital. Comparisons of pre- (n = 263) and post- (n = 253) observations revealed that the intervention had a significant effect on increasing hand hygiene compliance after nonpatient contact in a patient's room (P = .006).

The importance of hand disinfection prior to surgery

'Hand washing is a practice we perform ritualistically, but as healthcare professionals we need to appreciate its importance in clinical practice and not become complacent about it' (Kerr, 1998).