Hand-rub agents; patient skin prep; smallpox vaccine; instrument tape; cardiac catheterization laboratory - Clinical Issues - question and answer

AORN Journal,  April, 2003  by Dorothy Fogg

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Question: We would like to begin using alcohol-based hand-rub agents for general hand hygiene in our holding room, surgical suite, and postanesthesia care unit. After reviewing the recently released guidelines from the Centers for Disease Control and Prevention (CDC) regarding hand hygiene, we cannot determine whether they are consistent with the Occupational Safety and Health Administration's (OSHA) bloodborne pathogen final rule. The OSHA rule stresses hand washing with soap and water. It does not mention alcohol-based products. If we switch to alcohol-based products, could we be cited for noncompliance with the OSHA rule?

Answer: Alcohol-based hand-rub agents are acceptable to both the CDC and OSHA. (1) If you follow the CDC guideline for hand hygiene, you will not be cited by OSHA on that particular practice. The primary difference in the directives stems from the difference in goals of the respective agencies. The CDC focuses on reducing the risk of infection for all patients by stressing the need for hand washing with soap and water for any visible soiling of the hands, regardless of the type of soil or body substance (eg, urine, feces, blood). The focus of OSHA is to protect the health care worker from bloodborne pathogen infection by stressing the need for hand washing with soap and water after exposure to or gross contamination by blood or other potentially infectious materials that can lead to transmission of bloodborne pathogens. Both the CDC guideline and the OSHA rule call for

* provision of accessible hand washing facilities,

* alternatives to hand washing (ie, antiseptic hand cleaners) when hand washing facilities are not available or convenient to the area,

* hand washing after removal of gloves or other personal protective equipment,

* hand washing after contact with blood or other potentially infectious materials, and

* hand washing when hands are visibly dirty or soiled with contaminated material.

When the OSHA final rule was issued in 1991, alcohol-based hand hygiene products were not well recognized or widely used in this country as an alternative to hand washing with soap and water. Since the release of the CDC guideline in 2002, these products have gained favor and are becoming more widely used. One advertised advantage of alcohol-based hand hygiene products is the reduction of dermatitis that contributes to poor hand washing compliance and increased risk of infection to the health care worker resulting from abrasion and breakdown of the natural skin barrier. (2)

Question: I work in an OR suite in which the long-standing practice for patient skin preps Is to use plastic spray bottles filled with an iodine-based product, which is sprayed on the patient's skin after an iodine-based skin scrub. The system consists of a plastic bottle and a pump-spray apparatus that is attached to the bottle after it is filled with the iodine solution. The spray bottle Is used from patient to patient and occasionally from room to room. What is the potential for cross-contamination? Is this a safe and acceptable practice in the perioperative practice setting?

Answer: AORN does not recommend the use of spray bottles in the OR as a matter of routine practice. Experience demonstrates that whenever a spray system is used, a certain amount of the sprayed product is aerosolized into the environment where it is inhaled by people in the immediate vicinity. This aerosol may be composed of an iodine product, a chemical disinfectant that is sprayed as part of the cleaning process, or any other product that is placed into the spray system. Inhaling this pollution is not in the best interest of either patients or health care workers. In addition to the inhalation potential, there is the possibility of splash back and possible eye injury if the solution is sprayed with force.

No controlled studies have been performed to investigate cross contamination from use of spray bottles of prep solution. It is known, however, that bottles of skin prep products can and have become contaminated with Pseudomonas aeruginosa and Burkholderia (ie, previously known as Pseudomonas cepacia) even when they contain an antiseptic solution. (3)

If the bottle can become contaminated, the spray attachment is equally suspect for containing organisms. With repeated use of the plastic spraying system, you have no assurance that the system itself is not contaminated. By spraying solution from the bottle, you may be adding to, rather than decreasing, the number of organisms on a patient's skin.

With or without a contaminated system, the process of spraying is problematic. If the individual performing the skin prep procedure picks up the bottle with a gloved hand that has just washed a patient, the exterior of the bottle may become contaminated with organisms from the patient's skin. Unless the bottle is cleaned with a disinfectant after the prep is completed, organisms can remain on the exterior surface of the bottle where they may be picked up and transferred to the next person who uses the system.