should finger rings be removed prior to scrubbing for theatre?

3
Should finger rings be removed prior to scrubbing for theatre? N.K.R. Kelsall a , R.K.L. Griggs b , K.E. Bowker a , G.C. Bannister a, * a Avon Orthopaedic Centre, Southmead Hospital, North Bristol NHS Trust, Westbury-On-Trym, Bristol, UK b University of Bristol, Bristol, UK Received 7 November 2003; accepted 1 September 2005 KEYWORDS Bacteria; Scrubbing; Jewellery; Finger rings Summary Finger rings increase surface bacterial counts. Although scrubbing reduces these (PZ0.05), there are more bacteria under rings than on adjacent skin or the opposite hand. If rings are removed before scrubbing, bacterial counts are reduced but remain higher than on adjacent skin or the opposite hand. Ideally, finger rings should not be worn by theatre staff. However, if they are, they should be removed prior to scrubbing for surgical operations. Q 2005 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved. Introduction The hands of operating theatre staff are one of the sources of bacteria that cause deep infection. 1–4 The Association of Operating Room Nurses suggest that all jewellery should be removed before involvement in surgical procedures. 5 This practice has no bacteriological basis, although Bartlett et al. have shown that all jewellery is associated with higher surface bacterial load. 6 The bacterial load around rings is higher than on other parts of fingers, 7–9 but there is a paucity of studies that indicate how well this load can be reduced by scrubbing 1,10 or whether it is better to remove rings altogether. The aim of this study was to measure the effect of retaining or removing finger rings on surface bacterial counts before and after scrubbing and at the end of operative procedures. Material and methods Research Ethics Committee approval was obtained to swab the finger rings of theatre staff. Thirty- two staff were recruited. Incomplete data were obtained on four, leaving a total of 28 subjects (nurses and surgeons). All but one were right handed, and all scrubbed with chlorhexidine gluconate (0.5%). Two of the rings were silver, two were platinum and the rest were gold. Subjects acted as their own control, thereby minimizing differences of individual skin bacterial loads. Eighteen samples were taken from each subject. On the first occasion, the ring remained in place. The ring itself, the skin directly beneath it, the skin Journal of Hospital Infection (2006) 62, 450–452 www.elsevierhealth.com/journals/jhin 0195-6701/$ - see front matter Q 2005 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jhin.2005.09.002 * Corresponding author. Tel.: C44 117 959 5795; fax: C44 117 959 5924. E-mail address: [email protected]

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Page 1: Should finger rings be removed prior to scrubbing for theatre?

Should finger rings be removed priorto scrubbing for theatre?

N.K.R. Kelsalla, R.K.L. Griggsb, K.E. Bowkera, G.C. Bannistera,*

aAvon Orthopaedic Centre, Southmead Hospital, North Bristol NHS Trust, Westbury-On-Trym, Bristol, UKbUniversity of Bristol, Bristol, UK

Received 7 November 2003; accepted 1 September 2005

01do

95

KEYWORDSBacteria; Scrubbing;Jewellery; Finger rings

95-6701/$ - see front matter Q 2005i:10.1016/j.jhin.2005.09.002

* Corresponding author. Tel.:C44 119 5924.E-mail address: gordon.bannister@

Summary Finger rings increase surface bacterial counts. Although scrubbingreduces these (PZ0.05), there aremore bacteria under rings than on adjacentskin or the opposite hand. If rings are removed before scrubbing, bacterialcounts are reduced but remain higher than on adjacent skin or the oppositehand. Ideally, finger rings shouldnotbewornby theatre staff.However, if theyare, they should be removed prior to scrubbing for surgical operations.Q 2005 The Hospital Infection Society. Published by Elsevier Ltd. All rightsreserved.

Introduction

The hands of operating theatre staff are one of thesources of bacteria that cause deep infection.1–4 TheAssociation of Operating Room Nurses suggest thatall jewellery should be removed before involvementin surgical procedures.5 This practice has nobacteriological basis, although Bartlett et al. haveshown that all jewellery is associated with highersurface bacterial load.6 The bacterial load aroundrings is higher than on other parts of fingers,7–9 butthere is a paucity of studies that indicate how wellthis load can be reduced by scrubbing1,10 or whetherit is better to remove rings altogether.

The aim of this study was to measure the effectof retaining or removing finger rings on surface

The Hospital Infection Societ

7 959 5795; fax:C44 117

nbt.nhs.uk

bacterial counts before and after scrubbing and atthe end of operative procedures.

Material and methods

Research Ethics Committee approval was obtainedto swab the finger rings of theatre staff. Thirty-two staff were recruited. Incomplete data wereobtained on four, leaving a total of 28 subjects(nurses and surgeons). All but one were righthanded, and all scrubbed with chlorhexidinegluconate (0.5%). Two of the rings were silver,two were platinum and the rest were gold.Subjects acted as their own control, therebyminimizing differences of individual skin bacterialloads.

Eighteen samples were taken from each subject.On the first occasion, the ring remained in place.The ring itself, the skin directly beneath it, the skin

Journal of Hospital Infection (2006) 62, 450–452

www.elsevierhealth.com/journals/jhin

y. Published by Elsevier Ltd. All rights reserved.

Page 2: Should finger rings be removed prior to scrubbing for theatre?

Table I Isolated bacteria

Bacteria isolated Number of positiveswabs

Coagulase-negative staphylo-cocci

150

Other skin flora 50Gram-negative cocci 9Pseudomonas spp. 1Staphylococcus aureus 4

Should finger rings be removed prior to scrubbing for theatre? 451

adjacent to the ring and a similar area of skin on thering finger of the opposite hand were all swabbedprior to the first scrub of the day, immediatelyfollowing the scrub and at the end of the operativeprocedure. The length of scrub ranged from 3 to6 min and the procedures ranged from 15 min to 4 h30 min (amputation of shoulder).

On the second occasion (one to 16 days later,mean eight days), the ring was removed after thefirst set of swabs was taken. After scrubbing, theskin beneath the (now removed) ring and that of theopposite ring finger were swabbed and this wasrepeated at the end of the operation. Thus a totalof 18 samples was taken from each subject.

Sterile dry cotton skin swabs were used toharvest bacterial samples from test areas. Theswab tips were rolled along the line of the test area.Samples were stored at 2 8C prior to plating out onhorse blood agar plates, pre-incubated at 37 8C for24 h to prove sterility. The plate was inoculated andthe inoculum was spread over half the plate with asterile loop, allowing two different samples to be

Table II Comparative colony counts

Ring

Colony counts

Before scrubbing, wearing ringMedian 0Range 0–100

After scrubbing, wearing ringMedian 0Range 0

After operative procedure, wearing ringMedian 0Range 0–1001

Before scrubbing, not wearing ringMedianRange

After scrubbing, not wearing ringMedianRange

After operative procedure, not wearing ringMedianRange

cultured per plate. The plates were then incubatedfor a further 18 h at 37 8C. The number of colonieswas counted and classified.

Statistical analysis

Data were non-parametric in distribution, and weretherefore analysed by theWilcoxon Signed Rank test.Ordinal data comparing silver rings with gold andplatinum rings were analysed by Fisher’s Exact test.

Results

The majority of bacteria isolated were coagulase-negative staphylococci (Table I).

Before scrubbing

There were significantly higher colony counts onthe skin under the ring than on the control ringfinger, the ring itself or the skin adjacent to the ring(PZ0.05) (Table II).

After scrubbing

Colony counts at all sites were significantly reducedby scrubbing (PZ0.05). There were significantlymore bacteria on the skin under the ring than thecontrol finger (PZ0.025) and the skin over whichthe ring had been worn before being removed(PZ0.05). There were significantly more bacteria

Beneath ring Skin next to ring Opposite hand

4 1 00–1001 0–510 0–1004

0 0 00–101 0–10 0–15

0 0 00–23 0–54 0–2

1 00–500 0–14

0 00–18 0

0 00–4 0–1001

Page 3: Should finger rings be removed prior to scrubbing for theatre?

N.K.R. Kelsall et al.452

on the skin over which the ring had been wornbefore removal than in the control finger (PZ0.05).

After the operative procedure

Colony counts on the skin under the retained ringswere significantly higher than on the control finger(PZ0.01), but there was no difference when thering had been removed before scrubbing.

Ring type

There was only one positive culture from the 28samples taken from and adjacent to the two silverrings (3.6%), compared with 31% of the gold andplatinum rings (PZ0.01) and 17% of the controlfingers (not significant).

Discussion

This study indicates that it is preferable foroperating theatre personnel to remove their fingerrings before surgical procedures. Rings reduce theeffectiveness of scrubbing and increase glovemicrotears around the base of the finger.11,12 Ifsilver rings are worn, there are measurably fewerbacteria than under gold or platinum rings. Indeed,the antiseptic properties of silver showed a trend tolower colony counts than on control fingers. If goldand platinum rings are worn, they should beremoved before scrubbing as this reduces colonycounts on a digit that is more likely to tear glovesand expose patients to bacterial contamination.

Acknowledgements

The authors wish to thank Gavin Bartlett for adviceon methodology.

References

1. Arrowsmith VA, Maunder JA, Sargent RJ, et al. Removal ofnail polish and finger rings to prevent surgical infection. TheCochrane Library. Oxford: Update Software; 2002 [Issue 1].

2. Gould D. Nurses hands as vectors of hospital acquiredinfection: a review. J Adv Nurs 1991;16:1216—1225.

3. Lidwell OM, Lowbury EJI, Whyte W, et al. The effect ofultraclean air in operating rooms in deep sepsis in the jointafter hip or knee replacement: a randomised study. BMJ1982;285:10—14.

4. Whyte W, Hodgson R, Tinkler J. The importance of airbornebacterial contamination in wounds. J Hosp Infect 1982;3:123—135.

5. Association of Operating Room Nurses. Recommendedpractices for surgical hand scrub. AORN J 1988;69:842 [seealso p. 845, 846, 848—850].

6. Bartlett GE, Pollard TCB, Bowker KE, et al. Effect ofjewellery on surface bacterial counts of operating theatres.J Hosp Infect 2002;52:68—70.

7. Salisbury DM, Hutfilz P, Treen LM, et al. The effect of ringson microbial load of health workers hands. Am J InfectControl 1997;25:24—27.

8. Hoffman PN, Cooke EM, McCarville MR, et al. Micro-organisms isolated from skin under wedding rings worn bystaff. BMJ 1985;290:206—207.

9. Jacobson G, Thiele JE, McCune JH, et al. Handwashing: ringwearing and number of micro-organisms. Nurs Res 1985;34:186—188.

10. Bernthal E. Wedding rings and hospital acquired infection.Nurs Stand 1997;11:44—46.

11. Nicolai P, Aldam CH, Allen PW. Increased awareness of gloveperforation in major joint replacement. J Bone Joint Surg1997;79:371—373.

12. Larson E. Handwashing: it is essential even when you usegloves. Am J Nurs 1989;89:934—939.