Water vs Alcohol hand rub – which scrubs up best?

Although Earth is the ‘blue planet’, only a very small percentage of water is drinkable for humans animals, insects, plants and all wildlife. It is a precious resource that needs to be used responsibly. Population growth, rising water use and climate change will increasingly affect future water resources in the UK. If water efficiency action is not increased, the UK could be hit by water shortages by 2050.

Water use also adds to our carbon footprint, since we use energy to clean water, pump it around the country and to heat it up. Saving water can therefore help to reduce carbon emissions and save money.

Water is of course essential in veterinary practice to clean and maintain hygiene standards. Beyond the usual water saving devices, such as washing up bowls and cistern displacement devices, it may be hard to imagine how veterinary practices can safely reduce their water use without affecting clinical standards.

One area that offers potential is to look at your surgical hand preparation, since traditional scrubbing methods can use up to 20 litres of water[1]. Reviewing this may allow veterinary team members to save large quantities of water, and even help to improve infection control.

Methods of scrubbing up

Scrubbing up is an important part of preparing for surgery, to ensure asepsis and reduce surgical site infection. Gloves can be easily perforated, so even gloved hands need to be clean before carrying out a procedure.

Traditional scrubbing up consists of a lengthy timed scrub with a brush and antiseptic soaps; all surfaces of the hands and arms are scrubbed and then rinsed with tap water and dried with a sterile towel. However, evidence from the past decade has been bringing this method into question. Scrubbing brushes irritate the skin on hands, creating small excoriations, which is counterproductive for infection control[2]. Repeated hand washing damages the barrier function of skin, making it more permeable to toxins and microorganisms[3], and the products used for scrubbing can also negatively affect its natural antimicrobial properties. Evidence has shown the skin on hands of surgical staff has higher bacterial contamination with more pathogenic organisms[4].

An alternative which has been widely adopted by human surgeons for over a decade, is to use alcohol-based hand rubs (AHRs).  The AHR is applied and rubbed over clean hands and wrists for 90 seconds contact time.  With this method, hands only need to be washed with water if visibly soiled - avoiding hand washing increases the efficacy of AHRs[5]. This reduces water use considerably – that’s up to 20 litres of water saved every time you scrub up. It also avoids needing to use a brush, which is an added benefit for the environment.

This method also has other advantages, being better for your skin, quicker to use (usually taking less than 2 minutes), and saving money. It’s been shown to be safe to use regularly, with alcohol allergies being extremely rare and no evidence of resistance or toxic effects[6]^,[7]. But perhaps most importantly, evidence shows that alcohol had rubs are not just a safe alternative for your patients – but potentially a more effective option too.

Clinical standards

From the human healthcare sector, there is increasing evidence that alcohol rubs are as effective if not more effective than the traditional scrub[8]^{,[9],[10],[11]}. Alcohol has rapid and immediate antibacterial action, with the sustained effect of alcohol hand rubs being found to be better than the chemicals used in traditional scrub[12]. Use of this method also causes less skin damage with repeated use.

Data from the veterinary sector is more limited, and there is certainly room for further study, but the evidence that is available points to alcohol-based rubs being superior. An RCVS knowledge summary paper concluded that “The current literature suggests that the use of alcohol hand rubs provide similar, if not better, reductions in bacteria colony forming units, both immediately after hand antisepsis and in the immediate postoperative period.”

The World Health Organization (WHO) guidelines on hand hygiene in health care recommend AHRs for hand asepsis, with the top reason being “evidence-based, intrinsic advantages of fast-acting and broad-spectrum microbicidal activity with a minimal risk of generating resistance to antimicrobial agents”. As with all products, AHRs must be used properly and according to the manufacturer’s instructions in order to be effective, as improper use can lead to an increase in infections[13].

What next?

As the evidence grows for the advantages and safety of alcohol-based rubs, many healthcare institutions are moving towards using these prior to surgery. For example, successful transition has been made at The Royal Veterinary College and Davies Veterinary Specialists in the past decade, where I’ve been working in referral clinical practice. 

There are definite benefits to making the switch, especially if you are looking for ways to save water. If you’re considering using AHRs, firstly make sure everyone knows how to use them correctly for maximal effect. Once you are using them, make sure you monitor the impact on patient care and make changes if necessary, as you would for any change in protocol.

Further research specifically in the veterinary sector would also be useful. With even more evidence, we could encourage more practices to establish new protocols, improving patient care and reducing the environmental impact. 

More information

Take a look at some of the research referenced in this blog, including the RCVS knowledge summary paper and WHO guidelines. It’s also worth reading these articles from The Veterinary Nurse and the Nursing Times, and the WHO FAQ on the hazards of AHRs.

Finally, make sure you catch up on the Greener veterinary practice webinar: Using energy and water responsibly which discusses this topic, and other ways to save water. 

[1] Jehle, K, Jarrett, N, Matthews, S: Clean and green: saving water in the operating theatre. Ann R Coll Surg Engl 2008; 90:22-24.  https://publishing.rcseng.ac.uk/doi/pdf/10.1308/003588408X242277

[2] Widmer, A, Rotter, M, Voss, A et al. Surgical hand preparation: state-of-the-art.  J Hosp Infect 2010;74(2):112-122 https://www.sciencedirect.com/science/article/abs/pii/S0195670109002576

[3] Larson, E, Hughes, C, et al. Changes in bacterial flora associated with skin damage on hands of health care personnel. Am J Infect Control 198; 26:513-521. https://www.sciencedirect.com/science/article/pii/S0196655398700252

[4] Coelho, J, Lerner, H et al. The influence of the surgical scrub on hand bacterial flora. Int Surg 1984; 69:305-307 https://europepmc.org/article/med/6526620

[5] Hubner, N, Kampf, G, Kamp, P et al. Does a preceding hand wash and drying time after surgical hand disinfection influence the efficacy of a propanol-based hand rub?  BMC Microbiol 2006; 6:57-60. https://link.springer.com/article/10.1186/1471-2180-6-57

[6]Kampf, G, and Kramer, A. Epidemiologic backgrounds of hand hygiene and evaluation of most important agents for scrubs and rubs.  Clin Microb Rev 2004; 863-893. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC523567/

[7] Verwilghen, D, Grulke, S et al Presurgical hand antisepsis: concepts and current habits of veterinary surgeons.  Vet Surg 2011; 40: 515-521. https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1532-950X.2011.00846.x

[8] Parienti, J, Thibon, P et al. Hand-rubbing with an aqueous alcoholic solution vs traditional surgical hand-scrubbing and 30-day surgical site infection rates. JAMA 2002; 288(6):722-727. https://jamanetwork.com/journals/jama/articlepdf/195187/joc20200.pdf

[9] Lai, K, Foo, T et al. Surgical hand antisepsis – a pilot study comparing povidone iodine hand scrub and alcohol-based chlorhexidine gluconate hand rub.  Ann Acad Med Sinagapore 2012; 41:12-16. https://annals.edu.sg/pdf/41VolNo1Jan2012/V41n1p12.pdf

[10] Tavolacci, M, Pitrou, I, et al. Surgical hand rubbing compared with surgical hand scrubbing: comparison of efficacy and costs.  J Hosp Infect 2006; 63:55-59. http://mamro.lk/publications_Details/Rub%20Vs%20Scrub.pdf

[11] Kampf, G, and Kramer, A. Epidemiologic backgrounds of hand hygiene and evaluation of most important agents for scrubs and rubs.  Clin Microb Rev 2004; 863-893. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC523567/

[12] Tavolacci, M, Pitrou, I, et al. Surgical hand rubbing compared with surgical hand scrubbing: comparison of efficacy and costs.  J Hosp Infect 2006; 63:55-59. http://mamro.lk/publications_Details/Rub%20Vs%20Scrub.pdf

[13] Widmer, A, Rotter, M, Voss, A et al. Surgical hand preparation: state-of-the-art.  J Hosp Infect 2010;74(2):112-122 https://www.sciencedirect.com/science/article/abs/pii/S0195670109002576