ORIGINAL RESEARCH COMPLIANCE OF SURGICAL HAND SCRUB IN OPERATION THEATRE OF TEACHING HOSPITAL, CHITWAN

Background : Surgical hand scrub is an important practice that forms the base in the prevention and control of surgical site infection. The objective of the study was to evaluate the compliance of surgical hand scrub among surgical team in Operation Theatre of Teaching Hospital, Chitwan. Methods : Descriptive cross-sectional design was used. Data collection instrument (a checklist) was developed based on national and international standards of surgical hand scrub. Data was collected by observation of surgical team who were scrubbing in the Operation Theatre, Chitwan Medical College before proceeding to surgical procedures. Results : A compliance with the standards for surgical scrub prerequisites (70%), scrub process (81.53%), time of scrub (27%) and overall compliance (75.95%) observed. The total score of compliance with the standard was only 13%. The main issues found in the study were not correctly wore surgical cap and mask (44.9%), using of timer/wall clock before starting scrubbing (91.3%), improper follow the continue rotational action down opposing arms working to the elbow for one minute (53.6%) and repeat-ed blotted dry of skin area once it done (30.4%) Conclusions : The results showed there was gap in the surgical hand scrub of the studied hospital and the compliance with the standard can be im-proved by simple surgical hand scrub intervention, periodical observation audit and feedback.


INTRODUCTION
Hand Hygiene is the least expensive and most effective factors in preventing and controlling the transmission of pathogens within health care settings. 1 The hands of health workers play an important role in transmission of the health care associated pathogens from one patient to another. 2 Health care associated infection due to poor hand hygiene is a major cause of increasing morbidity, mortality and health care costs among hospitalized patient worldwide. 3 Globally, surgical site infection (SSI) rates have been reported range of 2.5% to 41.9% with significantly higher rates in developing countries. 4 SSI is the results from multiple factors related to patient, surgeon and health care environment. European Centre for Disease Prevention and Control 2015 reported 1.88% SS. In Nepal, SSI was reported about 3.99% among 92,41,979 cases. 5 SSI's leads to prolong hospitalization, financial burden, reoperation, readmission and increase mortality rates. 6 Surgical hand scrubbing is essential in order to eliminate the transient flora and reduce the resident flora. 7 Surgical hand scrubbing is an extension of hand washing with antimicrobial soap and water before donning surgical attire pre-operatively. 1,8 Jewellery and nails can be the source of microbial transmission so it is mandatory to remove jewellery, artificial nails or nail polish and to keep nails short before surgical hand preparation. 1 Before each operation, entire surgical team should scrub their hands and arms to the elbow. The first scrub of the day is longer i.e. minimum 5 minutes than any subsequent scrubs between consecutive clean operations i.e. minimum 3 minutes. 9 The most commonly use products for surgical hand antisepsis is chlorhexidine or povidine-iodine containing soaps.1 Abdollahi et al. 10 found that compliance with scrub prerequisites 58%, scrub process 68%, 2 minutes scrub time 22% and scrub equipments 55% in pre-test. Dhakal, Angadi & Lopchan 11 claimed that nurses (4.29%) on operation theatre did not scrub hands well to two inch above the elbow and completed the procedure less than 3 to 5 minutes.
Despite the considerable advancement in surgery, post-surgery infection still is one of the causes of mortality and surgical team hands are one of the most important causes of these infections and studies shown that the compliance of surgical hand scrub is not adequate even after the intervention. So, it significant to identify the level of compliance of surgical hand scrubs among the surgical team in Operation Theatre of Teaching Hospital, Chitwan.
Observational study found surgical scrubbing practices was 75.1% adequate among nurses which concluded that nurse's still need more training to achieve excellence in this area 12 so that surgical hand preparation is use to prevent surgical site infection. 7 Hence the objective of the study was to evaluate the compliance of surgical hand scrub among surgical team in Operation Theatre of Teaching Hospital, Chitwan.

METHODS
A descriptive cross-sectional study was conducted at Operation Theatre, Chitwan Medical College, Chitwan, Nepal from 20th June to 4th July, 2018 AD after getting ethical clearance from CMC-IRC. The total of sixty-nine respondents from surgical team included surgeons (n=27), residents surgery (n= 9), interns (n= 10) and registered Nurses (n=23) who were selected by non-probability consecutive sampling technique.
The study instrument was an observational checklist with Yes-No questions. The checklist developed based on the standard tool. 1,8 The observation check list of compliance of surgical hand scrub (scrub pre requisites, scrub process and scrub time) consisted 22 items. Each item in checklist rated Yes for scored '1' and No for scored '0'. Level of compliance was measured by calculating the total score in terms of percentage.
Data collection was done through observation method. One participant was observed once a time; they were excluded if they scrub next time. To describe the results, the descriptive and inferential statistics were used by the IBM SPSS version 20. Table 1 shows that among the 69 respondents, majority of males (53.6%), surgeons (39.1%) and they (47.8%) had job experience of 1-5 years. Most of the surgical hand scrub was observed in morning shift (69.6%).      Table 5 shows that most of the respondents (87%) did not compliance surgical hand scrub before proceeding to surgical procedure based on criteria.

DISCUSSION
Surgical hand scrub is an essential component of everyone who involved in operative procedures. Improper hand scrubs facilitate to carry microbes so that surgical hand scrub is significant to prevent surgical site infection. Results of the present study showed considerable lacking in the surgical scrub of the studied hospital. Compliance with the scrub time standards had the lowest score (27%).
Several studies of similar type have shown that significance dissimilarities of level of surgical hand scrub compliance. 4, 6,10,[12][13][14] This study found that only 13% of respondents had compliance the surgical hand scrub according to the standard checklist criteria of (more than 90% score without missing critical steps).
Hospital has policy to wear mask, cap, remove artificial jewelleries, nail police, certain of scrub materials and start sink timer before scrub process. Lack of awareness about hospital policy results variations in scrub practice. It is important to provide documented policy to improve compliance and to prevent post-surgery infections.
There were several lacking in the process of the observed scrubs in this study. Alaa-Eldeen, Saad & Elreface 15 mentioned that only 46.7% nurses performed the principles of aseptic technique in wearing mask, gowning, gloving and scrubbing correctly. It might be due to lack of in-service training for the surgical team. A study in King Khalid hospital, Najran found that 84.9% of surgical team scrubbed hands and forehand and dried them correctly. 14 Jeyakumar, Sabu & Segeran 12 revealed that the adequacy of scrubbing was very good (75.1%). The strict implementation of protocol and continuous inhouse skill training, providing feedback enhance the higher compliance of surgical hand scrub. 1,17 According to hospital policy, the standard time for the first scrub was 5 minutes and for the second scrub was 3 minutes. However, observations of this study found that only 17.5% respondents could follow the duration of scrub in the first and second as per determined criteria. Utilization of time in terms of both over-scrubbing and under scrubbing can increase the risk of transmitting infection so it is better for the scrubbers to follow the rules. 13 the Operation Theatre of teaching hospital in the real situation. The results showed considerable noncompliance in the scrub of studied hospital. Yet, the gap between compliance scores, still there is potentiality for improvement in all dimensions. Based on the study findings, periodical audit of the surgical hand scrub in the operation theatre to see whether it complies with the standards or not and to find out the problems to be solved through hands on skill education.