should finger rings be removed prior to scrubbing for theatre?
TRANSCRIPT
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
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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
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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
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
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