Are Brushes Necessary for Surgical Hand Scrubbing

in a District Hospital?

Eng-Choo Tan*, Nurasykin Salim# and Guat-Eian Ong**Infection Control Unit, Hospital Teluk Intan, #Pathology Department, Hospital Teluk Intan

Perak Annual Medical Research & Scientific Conference 2010

INTRODUCTION Q.A study conducted in March 2006 showed that

compliance to the standard traditional surgical hand scrubbing technique (using brush) was only 40% amongst the scrubbed personnel in Hospital Teluk Intan.

Factors lead to the non compliance including:- bristles too hard and painful to the skin Prolonged and repeated use of brush traumatizes the skin &

cause dryness The brushes are too big to reach areas between fingers &

web spaces, leaving some missed areas

OBJECTIVES GENERAL

to determine whether the using of brushes (current practice) is necessary for surgical hand scrubbing in the operation theater of Hospital Teluk Intan, Perak.

SPECIFIC To look for any significant difference in the total amount

of colony counts after scrubbing hands with standard traditional hand scrubbing technique with brush and without brush

METHODOLOGY-study design

50 subjects

Self-assessment questionnaires

Scrub hands with brush

fingertip impressionon culture plate

Culture plate incubated & bacterial growth

quantified

Scrub hands without brush

fingertip impressionon culture plate

Culture plate incubated & bacterial growth

quantified

Study type Analytical prospective study Conducted in the General Operation Theatre

Hospital Teluk Intan from the 6th March 2006 – 4th May 2006

METHODOLOGY

Ethical Considerations After fingertip impression was taken on BA plate,

every subjects re-brushed before surgery to ensure current practice was maintained

2 trained observers were responsible for the standardization of the whole protocol (sampling of fingertips imprints and observation for compliance in hand scrubbing)

METHODOLOGY

Variables Demographics (gender, category of staff, unit

discipline & years of experience) Total colony counts per subject for brush

technique Total colony counts per subject for non-brush

technique

METHODOLOGY

Sample size & sampling method A total of 52 hospital personnel from 6

multidiscipline surgical based departments were chosen on convenience sampling and voluntary basis

METHODOLOGY

Data collection technique Self-assessment questionnaires Bacterial colony count on BA culture plate,

quantified by personnel in microbiology lab

METHODOLOGY

RESULTS

Technique N Mean SD p value (T-test)

Brush 52 40.54 76.89 0.54(NS)

Non-brush 52 32.12 60.37

Comparison of total colony counts (cfu) between brush and non-brush technique

Results showed less bacterial contamination after scrubbing hands without brush (mean 32.12, SD 60.37) as compared to with brush method (mean 40.54, SD76.89) but the difference was not significant (p = 0.54)

RESULTS

Gender N Mean SD Mean Difference

p value (T-test)

Male 44 58.11 84.65 37.76 0.01 (significant)

Female 60 20.35 49.56

Comparison of total colony counts (cfu) between gender

Male staff showed higher bacterial contamination in comparison with the females

(p = 0.01)

RESULTS

Category of staff (I)

Category of staff (J)

Mean Difference (I-J)

Standard Error

P value

Medical Assistant

Specialist 70.65 31.51 0.027 (significant)

Medical Officer 62.54 27.12 0.023 (significant)

House officer 67.58 28.23 0.019 (significant)

Nurse 86.27 25.54 0.001 (significant)

Comparison of total colony counts (cfu) among different category of staff

Medical Assistants showed significant higher bacterial contamination in comparison with all other category of staff involved i.e. Specialists, Medical Officers, House Officers & Nurses (p < 0.05)

RESULTS

Duration of working

experience (I)

Duration of working

experience (J)

Mean Difference (I-J)

Standard Error

P value

< 6 months

> 6 – 12months 52.30 26.51 0.051(NS)

> 1 -5 years 17.20 19.51 0.38 (NS)

> 5 – 10 years 37.20 20.72 0.08 (NS)

> 10 years 17.14 20.23 0.44 (NS)

Comparison of total colony counts (cfu) among different groups for duration of working experience in operation theatre

There was no significant difference noted in bacterial counts among different groups for duration of working experience in operation theatre

RESULTSComparison of total colony counts (cfu) among different unit discipline

Unit discipline

(I)

Unit discipline (J)

Mean Difference (I-J)

Standard Error

P value

Operation Theatre

Surgical -21.32 19.08 0.27 (NS)

O&G -5.06 19.75 0.80 (NS)

Orthopedic -11.10 20.55 0.59 (NS)

ENT -60.72 26.74 0.025 (significant)

Eye -38.06 30.17 0.21 (NS)

Operation theatre staff showed lower bacterial counts in comparison with all other departments involved but significant mean difference was only observed in comparison with ENT department (mean difference -60.72, p<0.05).

DISCUSSION Study limitations

Study was carried out on different occasions for the brush and non-brush technique which could have led to differences in environment & resulting in different bacterial counts

Simple fingertips impression on agar plate method was used instead of ‘glove juice test’ method which is more accurate to assess bacterial contamination on hands. Simple fingertips impression was chosen since this method is cheaper & easier to conduct

This study reported that there was no significant difference between brush and non brush technique therefore using brush might not be necessary for preoperative surgical hand scrubbing in operation theatre

Emphasize should be given to male staff particularly Medical Assistants during training and refresher course on surgical scrubbing as they showed significant higher bacterial contamination as compared to the females staff and other categories respectively.

DISCUSSION

Higher bacterial counts in brush technique could be due to:- scrubbing procedures were not followed properly

by personnel (cause discomfort, shortage of OT time etc.)

Poor attitude of personnel (lack understanding on the importance of proper hand scrubbing)

DISCUSSION

Study carried out by Kiyonori Furukawa et al from Japan in 2005 shows that brushes and sterile water are not necessary for preoperative scrubbing up

Studies in western countries have concluded that the use of brush for surgical hand scrubbing is not necessary for adequate reduction of bacterial counts. Skin damage from scrubbing with brush can lead to an increase in the number of gram negative bacteria and Candida and is associated with an increase in skin shedding (Guidelines for Hand Hygiene)

DISCUSSION

CONCLUSIONS & RECOMMENDATIONS

It was noted that there was no significant benefit in using brush for pre-operative surgical hand scrub as both technique yielded almost similar results in culture growth therefore hospital management may: review the requirements of using brush for preoperative

hand scrubbing in operation theatre Consider the alternative hand scrubbing technique

without brush that has been well accepted in some other developed countries

REFERENCES Improving Compliance in Surgical Hand Scrubbing Amongst Scrubbed

Personnel in General Operation Theatre, Hospital Teluk Intan; Tan Eng Choo, Norlela Baharom, Zarina Ismail, Ong Guat Eian; Q.A Study 2006 Report

Are Sterile Water and Brushes Necessary for Hand Washing before Surgery in Japan?; Kiyonori Furukawa, Takashi Tajiri and Yoshihiro Norose, Journal of Nippon Medical School 2005; 72(3)

Scrubbing to rubbing, J Nippon Med Sch. 2004: Guidelines for Hand Washing

ACKNOWLEDGEMENTS

Dr. Krishna Kumar, former Director Hospital Teluk IntanDr. Nor Azian A. Zainuddin, Head Anestesiology Department, HTIEn. Sabab bin Hashim, former Head of Pathology Department, HTI

Operation Theatre staff of Hospital Teluk IntanMicrobiology staff of Hospital Teluk Intan

Dato’ Dr. Amar Singh Ms. Tan Pui San

All CRC members

And everyone who has directly and indirectly contributed to make this study a success

“JAZAKUMULLAHU KHAIRAN KATHIRAA..”