The authors concluded that an alcohol rub is more effective in reducing microbial counts than a traditional surgical hand scrub with chlorhexidine gluconate (CHG), and that there is no evidence that a 2-minute CHG hand scrub is more effective than a 3-minute scrub. The use of inappropriate statistical methods means that the authors' conclusions are not reliable.
To evaluate the effectiveness of surgical hand scrubs in reducing bacterial growth on the hands of operating room staff.
PubMed, EMBASE, CINAHL, Current Contents, Clinical Evidence, the Cochrane Library and Dissertation Abstracts were searched from 1990 to December 2004; the search terms were reported. The reference lists of retrieved articles and relevant journals were also searched. The search was restricted to English language articles.
Studies of surgical hand scrubs were eligible if they compared different durations of scrubbing, different antiseptic agents and/or the use or non-use of brushes. The interventions in the included studies comprised alcohol hand rub compared with 6-minute surgical scrub using a brush and 4% chlorhexidine gluconate (CHG); and a 2-minute versus a 3-minute surgical scrub using a brush and 4% CHG. The participants in eligible studies were operating theatre staff who scrub for invasive procedures (e.g. surgeons, anaesthetists, scrub nurses and operating department practitioners). The primary outcome in eligible studies was the microbial count found on participants' hands, measured using the 'glove juice' technique. Studies using other techniques were excluded. The outcomes in the included studies were measured at various time points: immediately after scrubbing (all studies), at 2 and 3 hours (one study), and on two further occasions over the following 2 weeks (one study). Study designs eligible for inclusion were randomised controlled trials (RCTs) and quasi-experimental trials.
The three authors independently selected studies for inclusion, with any disagreements resolved by discussion.
Assessment of study quality
The authors used the following list of criteria (which they apparently compiled themselves) to evaluate study validity: random assignment, allocation concealment, clearly described inclusion and exclusion criteria, sample size calculation, description of outcome measures, and baseline comparability.
Two authors jointly applied the quality criteria, with any disagreements resolved by discussion with the third author and an independent person.
Methods of synthesis
The data were meta-analysed to obtain weighted mean differences (WMDs) with 95% CIs using a fixed-effect model (in the absence of significant statistical heterogeneity). Statistical heterogeneity was evaluated using a χ2 test (level of significance p<0.10).
Results of the review
Three studies (n=82) were included: one parallel design RCT (n=27), one crossover RCT (n=25) and one quasi-randomised parallel study (n=30).
The methodological quality of the studies was rated as adequate, although none clearly described allocation concealment or utilised blinding. The drop-out rate was low and baseline values were similar in the parallel-group studies, but not measured in the crossover study.
Alcohol hand-rub versus 6 minute CHG scrub (two parallel-group RCTs, n=57): there was a statistically significant difference between the groups in microbial count (measured in log10 colony forming units), favouring the alcohol rub group (WMD -0.83, 95% CI: 0.99, 0.27, p=0.0006). No statistically significant heterogeneity was found.
Two-minute versus 3-minute CHG scrub (one crossover RCT, n=25): there was no statistically significant difference between the groups in microbial count (WMD 0.29, 95% CI: -0.13, 0.71, p=0.18).
An alcohol rub is more effective in reducing microbial counts than traditional surgical hand scrub using 4% CHG. There is no evidence that a 2-minute CHG hand scrub is more effective than a 3-minute scrub.
Implications of the review for practice and research
Practice: The authors stated that their results validate brushless scrubbing with an alcohol-based agent for surgical hand antisepsis.
Research: The authors stated that well-designed RCTs are needed to evaluate the optimum duration of surgical scrubbing methods, the best antiseptic product to use, and whether a brush is beneficial. Baseline, immediate, persistent and residual microbial counts should be measured.
Hsieh H F, Chiu H H, Lee F P. Surgical hand scrubs in relation to microbial counts: systematic literature review. Journal of Advanced Nursing 2006; 55(1): 68-78. [PubMed: 16768741]
Subject indexing assigned by NLM
Database entry date
This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.
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