Are Brushes Necessary for

Surgical Hand Scrubbing

in a District Hospital?
Eng-Choo Tan*, Nurasykin Salim# and Guat-Eian Ong*
*Infection Control Unit, Hospital Teluk Intan, #Pathology Department, Hospital Teluk Intan

Perak Annual Medical Research & Scientific Conference 2010

INTRODUCTION
 Q.A study conducted in March 2006 showed that
compliance to the standard traditional surgical hand
scrubbing technique (using brush) was only 40%
amongst the scrubbed personnel in Hospital Teluk
Intan.
 Factors lead to the non compliance including:-
 bristles too hard and painful to the skin
 Prolonged and repeated use of brush traumatizes the skin &
cause dryness
 The brushes are too big to reach areas between fingers &
web spaces, leaving some missed areas
OBJECTIVES
 GENERAL
 to determine whether the using of brushes (current
practice) is necessary for surgical hand scrubbing in the
operation theater of Hospital Teluk Intan, Perak.
 SPECIFIC
 To look for any significant difference in the total amount
of colony counts after scrubbing hands with standard
traditional hand scrubbing technique with brush and
without brush
METHODOLOGY-study design
50 subjects

Self-assessment
questionnaires

Scrub hands Scrub hands

with brush without brush

fingertip impression fingertip impression

on culture plate on culture plate

Culture plate incubated Culture plate incubated

& bacterial growth & bacterial growth
quantified quantified
METHODOLOGY
 Study type
 Analytical prospective study
 Conducted in the General Operation Theatre
Hospital Teluk Intan from the 6th March 2006 –
4th May 2006
METHODOLOGY
 Ethical Considerations
 After fingertip impression was taken on BA plate,
every subjects re-brushed before surgery to
ensure current practice was maintained
 2 trained observers were responsible for the
standardization of the whole protocol (sampling
of fingertips imprints and observation for
compliance in hand scrubbing)
METHODOLOGY
 Variables
 Demographics (gender, category of staff, unit
discipline & years of experience)
 Total colony counts per subject for brush
technique
 Total colony counts per subject for non-brush
technique
METHODOLOGY
 Sample size & sampling method
 A total of 52 hospital personnel from 6
multidiscipline surgical based departments were
chosen on convenience sampling and voluntary
basis
METHODOLOGY
 Data collection technique
 Self-assessment questionnaires
 Bacterial colony count on BA culture plate,
quantified by personnel in microbiology lab
RESULTS
Comparison of total colony counts (cfu) between brush and non-brush technique

Technique N Mean SD p value (T-

test)
Brush 52 40.54 76.89 0.54
(NS)
Non-brush 52 32.12 60.37

Results showed less bacterial contamination after scrubbing hands without brush
(mean 32.12, SD 60.37) as compared to with brush method (mean 40.54, SD76.89)
but the difference was not significant (p = 0.54)
RESULTS
Comparison of total colony counts (cfu) between gender

Gender N Mean SD Mean p value (T-test)

Difference
Male 44 58.11 84.65 37.76 0.01 (significant)
Female 60 20.35 49.56

Male staff showed higher bacterial contamination in comparison with the females
(p = 0.01)
RESULTS
Comparison of total colony counts (cfu) among different category of staff

Category of Category of staff Mean Standard P value

staff (I) (J) Difference (I-J) Error
Specialist 70.65 31.51 0.027
Medical (significant)
Assistant Medical Officer 62.54 27.12 0.023
(significant)
House officer 67.58 28.23 0.019
(significant)
Nurse 86.27 25.54 0.001
(significant)

Medical Assistants showed significant higher bacterial contamination in comparison

with all other category of staff involved i.e. Specialists, Medical Officers, House
Officers & Nurses (p < 0.05)
RESULTS
Comparison of total colony counts (cfu) among different groups for duration of
working experience in operation theatre

Duration of Duration of Mean Standard P value

working working Difference (I-J) Error
experience (I) experience (J)

> 6 – 12months 52.30 26.51 0.051(NS)

< 6 months > 1 -5 years 17.20 19.51 0.38 (NS)

> 5 – 10 years 37.20 20.72 0.08 (NS)
> 10 years 17.14 20.23 0.44 (NS)

There was no significant difference noted in bacterial counts among different groups for
duration of working experience in operation theatre
RESULTS
Comparison of total colony counts (cfu) among different unit discipline

Unit Unit Mean Difference Standard P value

discipline discipline (J) (I-J) Error
(I)
Surgical -21.32 19.08 0.27 (NS)
O&G -5.06 19.75 0.80 (NS)
Operation
Theatre Orthopedic -11.10 20.55 0.59 (NS)
ENT -60.72 26.74 0.025 (significant)
Eye -38.06 30.17 0.21 (NS)

Operation theatre staff showed lower bacterial counts in comparison with all other
departments involved but significant mean difference was only observed in
comparison with ENT department (mean difference -60.72, p<0.05).
DISCUSSION
 Study limitations
 Study was carried out on different occasions for the brush
and non-brush technique which could have led to
differences in environment & resulting in different
bacterial counts
 Simple fingertips impression on agar plate method was
used instead of ‘glove juice test’ method which is more
accurate to assess bacterial contamination on hands.
Simple fingertips impression was chosen since this
method is cheaper & easier to conduct
DISCUSSION
 This study reported that there was no significant difference
between brush and non brush technique therefore using brush
might not be necessary for preoperative surgical hand
scrubbing in operation theatre

 Emphasize should be given to male staff particularly Medical

Assistants during training and refresher course on surgical
scrubbing as they showed significant higher bacterial
contamination as compared to the females staff and other
categories respectively.
DISCUSSION
 Higher bacterial counts in brush technique
could be due to:-
 scrubbing procedures were not followed properly
by personnel (cause discomfort, shortage of OT
time etc.)
 Poor attitude of personnel (lack understanding on
the importance of proper hand scrubbing)
DISCUSSION
 Study carried out by Kiyonori Furukawa et al from
Japan in 2005 shows that brushes and sterile water
are not necessary for preoperative scrubbing up
 Studies in western countries have concluded that the
use of brush for surgical hand scrubbing is not
necessary for adequate reduction of bacterial counts.
Skin damage from scrubbing with brush can lead to
an increase in the number of gram negative bacteria
and Candida and is associated with an increase in
skin shedding (Guidelines for Hand Hygiene)
CONCLUSIONS & RECOMMENDATIONS

 It was noted that there was no significant benefit in

using brush for pre-operative surgical hand scrub as
both technique yielded almost similar results in
culture growth therefore hospital management may:
 review the requirements of using brush for preoperative
hand scrubbing in operation theatre
 Consider the alternative hand scrubbing technique
without brush that has been well accepted in some other
developed countries
REFERENCES
 Improving Compliance in Surgical Hand Scrubbing Amongst Scrubbed
Personnel in General Operation Theatre, Hospital Teluk Intan; Tan Eng
Choo, Norlela Baharom, Zarina Ismail, Ong Guat Eian; Q.A Study 2006
Report
 Are Sterile Water and Brushes Necessary for Hand Washing before
Surgery in Japan?; Kiyonori Furukawa, Takashi Tajiri and Yoshihiro
Norose, Journal of Nippon Medical School 2005; 72(3)
 Scrubbing to rubbing, J Nippon Med Sch. 2004: Guidelines for Hand
Washing
 ACKNOWLEDGEMENTS
Dr. Krishna Kumar, former Director Hospital Teluk Intan
Dr. Nor Azian A. Zainuddin, Head Anestesiology Department, HTI
En. Sabab bin Hashim, former Head of Pathology Department, HTI
Operation Theatre staff of Hospital Teluk Intan
Microbiology staff of Hospital Teluk Intan
Dato’ Dr. Amar Singh
Ms. Tan Pui San
All CRC members

And everyone who has directly and indirectly contributed

to make this study a success

“JAZAKUMULLAHU KHAIRAN KATHIRAA..”