Four bold questions about hand asepsisHand asepsis is one of the most critical components of surgical asepsis to lower the risk of nosocomial diseases May 24, 2019 By Phil Zeltzman, DVM, DACVS, CVJ, Fear Free CertifiedHand asepsis is one of the most critical components of surgical asepsis to lower the risk of nosocomial diseases. In this column, we answer four critical and bold questions related to hand asepsis. Could you lose your driver’s license by scrubbing in? One third of the respondents in the “camera study” by Canada’s Ontario Veterinary College did not wear a gown during abdominal surgery. With the emergence of alcohol-based hand-rub solutions (ABHRS), you may be concerned that with repeated use, you could have enough alcohol in your bloodstream to lose your driver’s license. Alcohol is indeed absorbed through the skin, and you inhale plenty of it while scrubbing (or “rubbing”). So could a breathalyzer test be positive? A 2006 Australian study1 looked at 20 health-care workers and their use of ABHRS repeatedly over a short period of time: 30 applications in an hour! Then serum and breath ethanol and isopropanol absorption were assessed. Traces of ethanol were detectable in the breath of 30 percent of subjects at one to two minutes after application and in the serum of 10 percent of them at five to seven minutes postexposure. Serum isopropanol levels were undetectable at all time points. Even though ethanol did have a positive result, whether through cutaneous absorption or inhalation of fumes, neither level would be considered positive during a police-issued alcohol test. Based on this study, poor hand hygiene cannot be blamed on a fear of losing one’s driver’s license. Should women who perform surgery wear nail polish? The next controversial topic is whether nail polish is acceptable in the operating room. Human studies are conflicting. Current recommendations include short nails, no nail polish, no artificial nails, and of course no hand jewelry (i.e. rings, watches, and bracelets). Washington State University’s veterinary school conducted a study2 to investigate this touchy topic. A group of 21 surgical team members (nine faculty and 12 students) was divided in two groups: one wore nail polish for one week and the other didn’t. Nail length was measured and cultures were taken from the surface and subungual area of both hands using sterile swabs and sterile toothpicks. The samples were collected before and after a presurgical scrub was performed with chlorhexidine. Results of the study indicated bacterial counts did not differ between personnel with or without painted nails. The length of the nails was the only variable associated with higher bacterial counts, especially when the nails were 2 mm or more past the fingertip. So ladies, in spite of the old dogma, feel free to wear nail polish, as long as your nails are short. Are you scrubbing in long enough? Do you know how long you are supposed to scrub in before surgery? How long do you actually take to scrub in? A team at Canada’s University of Guelph, Ontario Veterinary College (OVC) performed a study3 to investigate whether practitioners were meeting current presurgical hand asepsis guidelines. Video cameras were installed in 10 small-animal practices in Ontario to monitor various areas, including the scrub sink. Alcohol hand rubs were used in 20 percent of clinics, while standard scrubbing solutions were used in 80 percent. Researchers analyzed a total of 190 “preparations.” Amazingly, standard scrubs ranged from zero seconds to nine minutes, with an average of two minutes. Textbooks recommended a contact time of two to seven minutes for standard scrubs (with a usually accepted average of five minutes). Prepping with alcohol hand rubs lasted from four seconds to two minutes, with an average of 25 seconds. Manufacturers recommended a contact time of 1.5 to two minutes for alcohol hand rubs. The shortest contact times were associated with prep prior to a cat neuter (i.e. from none to 2.5 minutes). In comparison, prep time prior to dog neuters ranged from 25 seconds to seven minutes, with a mean of two minutes. The data is pretty clear: on average, practitioners did not “rub” or scrub their hands long enough. How should you handle perforated gloves? Surgical glove perforation is not a crime—it’s a simple fact of surgery. One of the biggest concerns with surgical glove perforation is it can lead to surgical site contamination. OVC performed another study,4 this time to determine the frequency and causes of glove perforation. The study was conducted over 363 surgeries where sterile surgical gloves were worn. Gloves were assessed for perforation at the end of the procedure using a water leak test. Amazingly, at least one glove had a perforation during 26 percent of surgeries. Worse: 31 percent of “weavers” did not notice the tear. Increased risk factors included: gloves made of polyisoprene (versus latex); surgical duration (gloves worn for more than one hour had an 80 percent higher risk of perforation); wear by the primary surgeon (versus assistant); orthopedic procedures (versus soft tissue); use of cerclage wires; and use of power equipment. Interestingly, the wearer’s experience did not impact perforation rates. Strategies proposed by the study’s conclusions to reduce the risk of glove perforation included: not using polyisoprene gloves; double gloving; double gloving with an indicator (earlier detection of a perforation); and reinforced orthopedic gloves (with cloth, steel mesh, or thicker latex). A human study5 found that when double-gloved surgeons had a perforation of the outer glove, the inner glove was still intact in 82 percent of the cases. Infections are probably inevitable. That said, it is our responsibility to minimize their incidence by adhering to the following simple and well-known strategies: proper patient preparation, wearing the required attire (gown, gloves, cap, and mask), a clean environment, sterile instruments, and rigorous hand asepsis. Surgical asepsis is serious business. For your patient’s sake, please don’t take it lightly. Phil Zeltzman, DVM, DACVS, CVJ, Fear Free Certified is a board-certified veterinary surgeon and author. His traveling surgery practice takes him all over Eastern Pennsylvania and Western New Jersey. You can visit his websites at www.DrPhilZeltzman.com and www.VeterinariansInParadise.com. Kat Christman, a certified veterinary technician in Effort, Pa., contributed to this article. References 1 TL Brown et al. “Can alcohol-based hand-rub solutions cause you to lose your driver’s license? Comparative cutaneous absorption of various alcohols.” Antimicrob Agents Chemother. 2007, Vol 51, N 3, p. 1107-1108. 2 JM Hardy et al. “The effect of nail characteristics on surface bacterial counts of surgical personnel before and after scrubbing.” Vet Surg. 2017, Vol 46, N 7, p. 952-961. 3 ME Anderson et al. “Observational study of patient and surgeon preoperative preparation in ten companion animal clinics in Ontario, Canada.” BMC Vet Res. 2013, Vol 9, p. 194-204. 4 GM Hayes et al. “Investigation of incidence and risk factors for surgical glove perforation in small animal surgery.” Vet Surg. 2014, Vol 43, N 4, p. 400-404. 5 S Thomasa et al. “Intraoperative glove perforation–single versus double gloving in protection against skin contamination.” Postgrad Med J. 2001, Vol. 77, p. 458-460.