Effective Hand Preparation for Surgical Procedures in Low- and Middle-Income Countries

Abstract

Background:

The burden of healthcare-associated infections (HAIs) is greatest in low- and middle-income countries (LMICs); surgical site infections (SSIs) are the most common HAI in LMICs. Hand hygiene is the single most effective strategy for reducing HAIs and the transmission of antimicrobial drug-resistant pathogens. Similarly, effective surgical hand preparation is a critical step in the prevention of SSIs in the surgical patient.

Methods:

Surgical hand preparation (SHP) is a seemingly simple activity that is easily overlooked. Performed properly, however, along with other measures, it has the potential to reduce SSIs in LMICs. The article reviews the current state of surgical hand preparation in LMICs.

Results:

Alcohol-based handrubs (ABHRs) have received wide acceptance by healthcare workers for both hand hygiene and SHP; when mixed with emollients, ABHRs retain efficacy against microorganisms and gain skin tolerability and user acceptability. Healthcare institutions in many LMICs face difficulties obtaining the products needed to ensure effective SHP using ABHRs.

Conclusion:

The ABHRs are the most efficacious surgical hand preparation products available today. They are cost-effective and can safely be prepared locally in hospitals, even in LMICs. The challenge of access to ABHRs should be addressed by national and local governments, through advocacy by healthcare workers coupled with continued lobbying and campaigns by the World Health Organization. Effective surgical hand preparation, like hand hygiene, saves lives.

Hand hygiene, a core component of infection prevention and control (IPC), is a critical process in healthcare provision in any resource setting [1]. The skin harbors two primary types of microorganisms: Resident and transient or contaminant flora [2]. Whereas resident microorganisms in general have low pathogenic potential and are difficult to remove mechanically, transient microorganisms have high pathogenic potential. Transient microorganisms usually do not multiply on the hands of healthcare workers (HCWs) but may survive for as long as 150 hours. Such microorganisms most commonly are acquired by HCW during patient care and are responsible for most healthcare-associated infections (HAIs), as well as the spread of antimicrobial drug resistance [3,4]. The hands of HCWs therefore are important vehicles in the transfer of microorganisms throughout the clinical environment, including to patients [5].

In the context of this paper, “hand hygiene” refers to the action of washing the hands with soap and water to remove dirt and loose transient flora from the “visibly contaminated hand”; it also includes the use of alcohol-based handrubs (ABHRs) for purposes other than surgical hand preparation. Hand hygiene is directed exclusively against transient hand microorganisms. It is noteworthy that the antimicrobial effect of ABHRs far exceeds that of handwashing with both non-medicated and medicated soap [6].

Hand hygiene prevents the transmission of pathogens via the hands of HCWs, thereby reducing the occurrence of preventable HAIs [4,7 –10]. These HAIs are associated with a substantial economic burden because of longer hospital stays, morbidity, additional interventions, and antibiotic costs occasioned by treatment and antimicrobial drug-resistance spread [11]. Whereas between 5% and 10% of hospitalized patients acquire HAIs in high-income countries (HICs), this risk is 2 to 20 times greater in LMICs [12]; HAIs thus are significantly more common in LMICs than in HICs. In addition, SSI is the most common HAI in LMICs and also the most expensive to treat [13].

Unfortunately, although hand hygiene performance has such great potential for the reduction of HAIs, it has very low compliance among HCWs in LMICS, where it arguably has the potential for the greatest impact [14,15]. Ataiyero et al. found compliance rates of <21% in a meta-analysis of hand hygiene studies in sub-Sahara Africa; the included studies identified heavy workloads and infrastructural deficits as important barriers to the performance of hand hygiene [14]. Weinshel et al. conducted a multicenter study and found big gaps in the IPC programs and practices in developing countries [15]. It is noteworthy, however, that even in the USA, a country with a strong patient safety culture, hand hygiene compliance is only 40%–60% [4].

The hand hygiene campaign championed by the World Health Organization (WHO) has nonetheless made great gains across the globe since the publication of the WHO Hand Hygiene Guidelines in 2009 [8,16 –18]; indeed, the monumental successes of the global WHO hand hygiene campaigns have convinced the WHO that to be effective, healthcare interventions must of necessity include multi-modal implementation strategies [19], a fact borne out both in the hand hygiene campaigns and SSI prevention studies in LMICs [20]. Luangasanatip et al. confidently asserted that only multi-modal interventions lead to better HAI outcomes [21]. The WHO multi-modal hand hygiene strategy applies five core steps: System change, staff education and training, evaluation and feedback, reminders in the workplace, and an institutional safety climate [16].

A number of success stories describing increased hand hygiene uptake among HCWs has been reported in LMICs, with some attesting to reductions in HAIs. All used WHO's multi-modal improvement strategy [5]. With the lessons learnt from hand hygiene and the reported successes, one would think that effective surgical hand preparation (SHP) performance would be an easy process across the globe. This unfortunately is not the truth. Although existing hand hygiene infrastructure does make the implementation of effective SHP easier, the cultural/behavioral changes needed for adoption by HCW are still a challenge that must be overcome.

Surgical Hand Preparation

In contrast to regular hand hygiene, SHP must eliminate transient flora and provide a sustained reduction in the resident flora for the duration of the surgical procedure [16,19]. The WHO Guidelines on Hand Hygiene in Healthcare published in 2009 state that agents used for SHP should reduce microorganisms on intact skin significantly, contain a non-irritating antimicrobial preparation, have broad-spectrum activity, and be fast-acting and persistent [19].

The current recommendation on SHP as contained in the 2016 WHO Surgical Site Infection Prevention Guidelines states that: “Surgical hand preparation should be performed either by scrubbing with a suitable antimicrobial soap and water or using a suitable alcohol-based handrub before donning sterile gloves” [22]. The intended outcome of this recommendation is the potential elimination of the release of bacteria from the surgical staff to the open incision throughout the duration of a surgical procedure, while recognizing that sterile gloves do not eliminate the transmission of such bacteria completely, nor block transmission of blood pathogens from the patient to the surgical team [23,24]. This fact is important when one considers that 80% of glove micro-perforations go undetected by the surgeon [25] and that such perforations may double the risk of SSI [26].

Traditional or standard SHP in many LMICs is water-based, with povidone–iodine (PI) solution or plain soap being the principal agents. Chlorhexidine gluconate (CHG) soap is available in some LMIC hospitals, especially in the more affluent urban private hospitals. It is worth noting that CHG soap is considered traditional SHP in some LMICs [27]. The ABHR, although widely available in many hospitals, with local production in some, is used largely as a hand hygiene agent; it has not been adopted widely for SHP in many LMIC operating rooms. It is likely that similar barriers (and facilitators) exist for SHP as for hand hygiene, with some similarities between LMIC and HIC settings [3,9,21]. The use of ABHR has not been emphasized in hand hygiene campaigns.

Ho et al. performed a meta-analysis comparing the antiseptic efficacies of ABHR, CHG, and PI in surgical settings. Whereas residual colony-forming unit (CFU) counts were significantly lower in the ABHR and CHG groups than in the PI group, the differences in counts between the ABHR and CHG groups were non-significant. No important differences were observed in the SSI rates between the ABHR and traditional hand scrub groups. However, ABHRs were considered most favorable and were associated with higher compliance rates than the other products [28]. Tanner et al. noted that whereas ABHRs reduced CFU counts more than aqueous SHP products, there was no firm evidence that one type of hand antisepsis was better than another in reducing SSIs. These authors noted, however, that the clinical relevance of efficacy in CFU reduction was unclear [29].

A number of studies from developing economies have demonstrated that, compared with the traditional surgical scrub, SHP with ABHRs improves the quality and reduces the duration of SHP and is at least equally effective for the prevention of SSIs [30,31]. However, the switch from traditional water-based SHP to the gold standard ABHRs in LMICs has not in general been achieved for a number of reasons:

The perceived extra expense with no obvious added financial benefit to the institution;

Cultural/ behavioral resistance to change;

Lack of access to ABHRs or the raw materials for local production;

Misconceptions about the use of alcohol in hand hygiene products, including smell, flammability, etc.;

Lack of champions, including IPC personnel;

Absence of local or regional studies informing local/regional choices, as well as the absence of local guidelines;

Complexity and multiplicity of related guidelines with minimal or no local implementation guidelines that are easy to digest and apply by the busy surgeon;

Multiple competing priorities.

The cost of the product used in SHP is an important variable for the institutional administration in deciding whether to switch to ABHRs. Nthumba et al. used the WHO ABHR formulation II (isopropyl alcohol) prepared locally in the hospital pharmacy and found that the cost of the plain soap and water and that of the ABHR were roughly equal [30]. Use of ABHR for SHP (and hand hygiene) saves clean water (a precious resource in many LMICs), improves the quality of SHP, eliminates the need for towels for drying hands after SHP, and saves time [16,30]. A single surgical hand scrub uses 20.2 liters of water. Only 5.8 liters actually comes into contact with the hands—the rest is wasted [32].

The ABHRs have wide-spectrum antimicrobial activity that is more rapid than other disinfectants, are less irritating to the skin, and avoid re-contamination by contaminated water while rinsing the hands [16,33]. Furthermore, ABHR activity is not affected by substances such as an ion-rich environment, protein or blood, and detergents [6]. Consequently, surgeons have indicated a preference for ABHRs, primarily because of the reduced procedure time and better tolerability and therefore acceptability [6,27,31,34,35]. Table 1 provides basic information on the SHP products most readily available in an LMIC market: Kenya's market. Povidone–iodine solution is the cheapest and most commonly available SHP product, as indicated. Consideration of the risks of re-contamination by contaminated water, the amount of water wasted, and the need for clean hand towels for re-use is relevant.

Table 1.

Most Common Surgical Hand Preparation Solutions [32,47 –51]

	Cost/5 L^a	Water [32]	Advantages	Disadvantages [6, 50]	Antimicrobial activity [48]
Plain soap (bar/cake or liquid)	1 bar = 1 USD 1 cake = 50 US cents 5 L = 5 USD	20 L per wash	Cheap, affordable, universally available	Drying of skin Irritant contact dermatitis	None—only mechanical detergent cleansing removes loosely adherent microorganisms from hands
Povidone–iodine [49, 51]	2.60 USD	20 L per wash	Bactericidal against GMP and GMN organisms No known resistance Universally available in LMICs	Slow onset of action, activity ends when it dries Inactivated by blood and other organic matter Sensitization and allergy may occur Irritant contact dermatitis	GMP bacteria, GMN bacteria, environmental viruses, mycobacteria, fungi Activity against spores doubtful
CHG soap	56.85 USD	20 L per wash	Prolonged antimicrobial activity	Allergy may develop May cause ototoxicity, injury to mucous membranes. Should not be used in neonatal infants [52] Activity reduced by soaps	GMP bacteria, GMN bacteria, environmental viruses, Mycobacteria, fungi No activity against spores
ABHR: WHO formulations [53] ethanol, isopropyl alcohol	30 USD	X	ABHRs: Reduce costs for hand hygiene. Cost represents 1% of the cost of managing an HAI	Flammable Should not be used with visibly dirty hands Frequent use without emollients causes skin drying and may result in irritant contact dermatitis	GMP bacteria, GMN bacteria, environmental viruses, Mycobacteria, fungi No activity against spores

Cost conversion: 100 Ksh = 1 USD.

ABHR = alcohol-based hand rub; CHG = chlorhexidine gluconate; GMN = gram negative; GMP = gram positive; HAI = healthcare-associated infection Ksh = Kenya shillings; LMIC = low-and-middle income countries; USD = United States dollar; US = United States of America; WHO = World Health Organization.

High-quality SHP is a core element in the prevention of SSI that must be performed by all members of the surgical team prior to donning sterile gowns and gloves for any procedure. Frequent hand washing exposes the HCW to potential drying, cracking, and fissuring of their hands: The efficacy of a SHP agent must be matched with HCW tolerability and acceptability, for which ABHRs are most favored [31].

The provision of hand hygiene products requires accompanying behavioral modification strategies in what the WHO has popularized as the multi-modal strategy, one that has proved successful for both hand hygiene campaigns and SSI prevention [17,20,36]. Understandably, therefore, in order to succeed in changing SHP practices, the provision of the agents should be accompanied by a behavioral modification strategy [37]. Schwarz et al. found that adherence to correct SHP technique was sub-optimal in their institution, citing a lack of organizational oversight, monitoring, and direct hands-on training as important barriers to adherence [35].

The WHO five core hand hygiene strategies may thus be adapted for SHP to be sold successfully to institutions and users. The author has modified these to suit SHP [16]:

System change: Healthcare facilities should have the infrastructure needed to allow HCWs in the operating room (OR) to perform effective SHP. This includes reliable and uninterrupted antimicrobial detergent, a continuous supply of potable water and ABHR at the point of care/scrub sinks, as well as re-usable linen gowns or disposable gowns, hand towels, and disposable nonpowdered gloves (including non-latex). The institutional system and procurement process should protect the OR from ABHR or antimicrobial detergent stock-outs. As with hand hygiene products, SHP product tolerability and acceptability by HCWs is critical for optimal adherence. Some water needs to be available for washing the “visibly dirty” hands but is not necessary for SHP where ABHR is available.

Staff education and training: The HCWs in the OR should be educated about the impact of HAIs and the role of an effective SHP in patient care. Staff should be trained in correct SHP technique, gowning, and gloving. Programed repetition will ensure that new staff get educated, while older staff are updated on knowledge and technique.

Evaluation and feedback: Regular evaluation of SHP technique and performance feedback is required to ensure that progress is monitored over time. The SHP observations can be used to demonstrate improvements after interventions and therefore help sustain motivation for good practice or, alternatively, highlight areas or professional categories with poor compliance.

Reminders in the workplace: Posters make great reminders. These continually prompt HCWs regarding the importance of effective SHP.

Institutional safety climate: This involves creating an environment that prioritizes patient safety and high compliance with hand hygiene and SHP. Patient safety champions should lead institutional campaigns on hand hygiene and SHP. Institutionalizing patient safety activities within hospital organizational structures will ensure that changes and improvements outlive individuals.

These strategies, along with any other culturally sensitive local measures, will keep staff engaged at all times and energize a sustained culture change.

Local Production of Alcohol-Based Handrub [38]

Local production of ABHR remains a challenge in LMICs for a number of reasons: The raw materials needed may not be available, and when they are imported, red tape in procurement, both at the institutional and national (customs) level may create bottle-necks that lead to frequent, unpredictable stock-outs. Such interruptions negate attempts at sustained institutional patient safety culture change. In general, the most reliable suppliers in LMICs stock commercial products whose cost may not be sustainable. Additionally, donated ABHRs and dispensers make sustainability difficult by creating donor dependency. Jacquerioz-Bausch et al. demonstrated the feasibility of building local capacity in ABHR production in limited-resource settings when materials and training are provided [39]. Ndegwa et al. confirmed modest hand hygiene uptake after local ABHR production was started in three Kenyan hospitals [40]. Ditai et al. reported the use of a commercially produced ABHR using local raw materials. As in other studies, the cost of the ABHR production was not borne by the institutions involved but were funded externally [41].

Sustainable Local ABHR Production: A Brief Case Study

There is nevertheless evidence that where institutional buy-in exists, and sustainable systems are set up, local ABHR production can be sustainable. A good example of sustainable systems is the author's hospital, the AIC Kijabe Hospital, which first got into ABHR production in 2006 during a study that was funded externally [30,42]. This experience led to the appointment of a designated IPC nurse and later to an IPC department. Initial responsibilities included overseeing local ABHR production. In 2013, the hospital was recruited into the WHO SUSP-Africa project, which required local ABHR production, enhancing the quality of such production [20].

Thus, the hospital has had nearly 14 years of continuous ABHR production. Factors that have supported sustainability include:

A champion;

An IPC team;

An informed and supportive hospital administration (or the country Ministry of Health);

A resourceful supply-chain manager;

Affordable, locally sourced raw materials;

A pharmacy team;

ABHR dispensers (durable and affordable);

ABHR audit process.

Data on direct and indirect costs of SSI to the patient, family, community, and hospital make a compelling reason for a search for affordable interventions that, when adopted, result in SSI reduction and therefore cost savings for everyone. Once administrators have understood this, they have been willing to support the implementation of such measures. When initiating the SUSP-Africa project [20], the SUSP core team members at the Kijabe Hospital were required to make a business case for the change from plain bathing soap to an antimicrobial one, as part of the six process measures of the study. The finance office went through catalogues of antimicrobial soaps sold locally and identified one whose unit cost (per gram) was equivalent to that of the plain soap used at the time, but that also was acceptable to patients. The hospital then shifted to antimicrobial soap for patient bathing [20].

There are few studies on SHP in LMICs. Two notable papers report on successful use of high-quality SHP as part of a multimodal strategy to improve patient safety, with SSI as the primary outcome [20,43]. Allegranzi et al. used a multi-modal strategy (SUSP) on SSI prevention to reduce SSIs in five centers in four African countries. The SHP was one of the six process measures used [20]. Forrester et al. introduced the “Clean Cut,” a multi-modal infection control strategy to improve patient safety and patient outcomes after surgery, with the following process measures: Handwashing/skin preparation; surgical gown/drape integrity; antibiotic administration; instrument sterility; gauze counts; and WHO Surgical Safety Checklist use [43,44]. The authors also mapped out the process measures to identify challenges and obstacles to patient safety and used the results to guide organizational changes to align tasks with specific process goals. For their project, because of an inconsistent water supply, the authors defined SHP as surgical hand antisepsis with ABHR [43].

SHP Technique

In the OR

Wash visibly soiled hands with soap and water; hand wash also should be performed when staff first come into the OR and after visits to the toilet. This hand wash should take 40 to 60 seconds to perform [19]:

a. Hand drying following hand hygiene or SHP with aqueous solutions is an important part of the process.

b. One should use either a clean towel (preferably a paper towel) for hand hygiene or a sterile cloth or paper towels for SHP using an appropriate technique to avoid recontamination [19].

c. Hand dryers, a common feature in many LMIC health institutions, should not be used.

Thereafter, handrubs, with ABHRs should be performed. In many LMIC ORs, the sterile gloves have talc powder. It is important to wash the talc off with soap and water before performing a handrub. When powder-free gloves are used, there is no need for handwashing between handrubs.

The following technique, taught and practiced at the AIC Kijabe Hospital since 2007, is consistent with the WHO SHP technique [30]. Plain soap was replaced with CHG soap in 2013 [20].

CHG Soap and water Procedure

Hands and forearms are washed for four–five minutes using clean running tap water and CHG soap before each surgical procedure. A sterile cotton hand towel is used to dry the hands and forearms.

Alcohol-based handrub procedure

Before the first operation of the day and subsequently if the hands are visibly soiled, hands are washed with soap and water and dried with clean towels. Hands and forearms are then rubbed with alcohol for three minutes and kept wet throughout the procedure using 7–10 mL per SHP.

Duration of SHP

The use of ABHR for SHP is considered effective when the handrub takes three–five minutes. A multi-center African study used a multi-modal infection control and patient safety intervention that included the measurement of the quality of SHP, with good quality being three or more minutes of medium to high quality handrub (scored using a clock and a WHO surgical handrub poster). The SHP quality improved from a baseline of 78.7% to 97.4% at the end of the study [20]. A previous study at the author's institution observed SHP performance but did not report on the quality [30].

Conclusion

Surgery is now firmly entrenched in healthcare systems as a part of the Universal Health Coverage goals [45]. A simple way for national governments to improve patient safety and save money is by investing in local public production of ABHRs, including centralized quality control laboratories, for their healthcare infrastructure. Governments would thus ensure sustained availability of locally produced high-quality ABHR.

In general, studies on SHP are few; studies from LMICs are even fewer. There is, therefore, an urgent need for studies on effective SHP in LMICs to help drive policy on this important but neglected patient safety issue.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

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