IS A DROP OF WATER WORTH SAVING?? Dr. Nafees Ahmed Dayma DNB Resident Dr. Anantha Krishna M A Dr. Lakshman K

Among the countries likely to run short of water in the next 25 years are Ethiopia, India, Kenya, Nigeria. UNEP, 2008

INTRODUCTION Water a very scarce resource. World is moving towards an era of Drought Surgical practice makes abundant use of this scarce resource – hence the responsibility of the surgical fraternity to save this resource 2-5 minutes are spent on an average on scrubbing About litres of water spent on one traditional scrub About 31,000 L water spent only for scrubbing in 1 month in high volume centres. Sean McKay Wheelock, RN, Sandra Lookinland, RN(1997) Effect of Surgical Hand Scrub Time on Subsequent Bacterial Growth; AORN Journal Volume 65, Issue 6, Pages A. Ahmed(2007) Surgical Hand Scrub: Lots of Water Wasted,; Annals of African Medicine Vol. 6, No.1; 2007: 31 – 33 A Al-Qahtani, F Messahel. Water Wastage At The Scrub Sink: Critical evaluation and recommendations. The Internet Journal of Surgery Volume 20 Number 1.

Scrubbing methods Traditional scrub – povidone iodine and recently chlorhexidine – a better alternative Hand rub with alcohol based preparation can be used as alternative avoiding water & aqueous based disinfectants We used Povidone iodine based scrub (Betadine®) for water scrub and Alcohol based Antiseptic solution (Sterimax®; Ecomax ®) for dry Scrub Ecomax ® contains: 2.5% v/v Chlorhexidine gluconate solution IP, 0.5% w/v Triclosan USP, 50% v/v Isopropyl alcohol (2-Propanol) IP, 25% v/v N-Propanol (1-Propanol) BP, Skin emollients, Perfume, Brilliant Blue FCF as colour.

AIMS & OBJECTIVES To analyse the difference between chemical disinfection without water (dry scrubbing) and standard surgical scrubbing (wet scrubbing) To try to establish the difference in surface flora on the hands of the operating team as a surrogate marker of wound infection; as a function of the different methods of scrubbing

Methodology STUDY DESIGN Prospective Randomised Trial Randomization done using Computer generated Random Numbers INCLUSION CRITERIA Clean and clean contaminated surgeries Duration of surgery less than two hours Pre-operative prophylactic antibiotics administered to the patients EXCLUSION CRITERIA Evidence of needle stick injuries and glove punctures Contaminated and dirty cases which lead to a major contamination Repeat surgeries within the study period

Post Procedure Data Collection Needle Stick Injuries Glove Punctures Glove juice culture 1,2 of a representative member of the operative team Follow up the patient for one week and one month after discharge to look for wound infection based on CDC criteria 1.Mulberrry G, Snyder AT, Heilman J, Pyrek J, Stahl J(2001) Evaluation of a waterless, scrubless chlorhexidine gluconate/ethanol surgical scrub for antimicrobial efficacy. Am J Infect Control Dec;29(6): Linda K.M. Olson BS a,*, Dan J. Morse MSa, Collette Duley BS b, Brenon K. Savell BS(2012) Prospective, randomized in vivo comparison of a dual-active waterless antiseptic versus two alcohol-only waterless antiseptics for surgical hand antisepsis;; Am J Infection Control 40 (2012) Sean McKay Wheelock, RN, Sandra Lookinland, RN(1997) Effect of Surgical Hand Scrub Time on Subsequent Bacterial Growth; AORN JournalVolume 65, Issue 6, Pages , June 1997

Total Cases Wet Scrub – 28 cases, 2 cases excluded 1 for laparoscopic cholecystectomy excluded as he had reoperation for intestinal obstruction 1 case of appendicular abscess discovered intraoperatively All 26 cases reported as no growth at Culture, Waterless dry scrub – 31 cases, 1 excluded 1 excluded as she underwent reoperation for completion thyroidectomy 29 reported as no growth at culture 1 case showed growth of Group D Streptococcus

Comparison Wet Scrub Glove Juice Culture All Negative Wound infection Wound abscess – 1 for a case of Lap cholecystectomy at umbilical port Purulent discharge – 1 for a case of Appendicectomy Both infections cleared after a course of antibiotics Dry Scrub Glove Juice Culture 1 positive with Group D Streptococcus for a case of open hernioplasty. Patient did not show any signs of wound infection Wound Infection Purulent discharge – 1 for a case of laparoscopic hernia repair. Mild Wound gap still present at umbilical port, no discharge at last follow-up

Statistical Significance – Chi Square Test Glove Juice Culture Category/Woun d Infection PresentAbsent Wet Scrub2 ( Both Culture Negative) 26 Dry Scrub1 ( Culture Negative) 29 Wound Infection Category/GrowthPositiveNegative Wet Scrub026 Dry Scrub1 ( No Wound Infection) 29 P= , Statistically Insignificant P= , Statistically Insignificant

Historically Hand washing as a method of preventing infection – Joseph Lister Ritualistic practice among surgeons Many practice multiple methods increasing costs & time Tend to waste plenty of water and time over it Many studies have shown similar results that no significant difference in rates of SSI noted between these two scrub protocols Sean McKay Wheelock, RN, Sandra Lookinland, RN(1997) Effect of Surgical Hand Scrub Time on Subsequent Bacterial Growth; AORN Journal Volume 65, Issue 6, Pages

Attempts at water Conservation Conserve water Regular soap vs Antiseptic soap Antiseptic soap vs. Antiseptic scrub Taps on vs. Taps off method – 15.4 L vs. 4.5L water used Wet vs Dry Scrubbing – Conserves water better All methods have been shown to be effective in controlling bacterial growth 1. Ahmed(2007) Surgical Hand Scrub: Lots of Water Wasted,; Annals of African Medicine Vol. 6, No.1; 2007: 31 – Petterwood J, Shridhar V (2009), Water conservation in surgery: a comparison of two surgical scrub techniques demonstrating the amount of water saved using a 'taps on/taps off' technique, Aust J Rural Health Aug;17(4): doi: /j x.

Advantages of non aqueous rub Saves water Reliable disinfection Prevents dryness of skin Cost cutting* Tavolacci MP, Surgical hand rubbing compared with surgical hand scrubbing: comparison of efficacy and costs. J Hosp Infect May 2006

What other Papers say.. Hand rubbing with alcohol based solution before any procedure is as good as traditional hand scrubbing in preventing surgical site infections – JAMA Aug 14, 2002, Vol 288, No.6 In addition, the initial reduction of the resident skin flora is so rapid and effective that bacterial regrowth to baseline on the gloved hand takes more than six hours. This makes the demand for a sustained effect of a product superfluous. For this reason, preference should be given to alcohol-based products – WHO Guidelines on Hand Hygiene in HealthCare, First Global Patient Safety Challenge, Clean Care is Safer Care, May 5, 2009

Conclusion No statistically significant difference among dry and wet scrub arms were noted with regard to rates of bacterial growth over the surgeons’ hands Rates of wound infection upto 30 days Hand rub with alcohol based solution can be recommended as a safe alternative to traditional water wash

ACKNOWLEDGEMENTS Dr. M. Munireddy Dr. M.S. Sridhar Dr. H R Ravishankar Dr. R. C. Subhash Dr. Sachin D Nale Dr. Vasanth Kumar Dr. Ajitha

COSTS Povidone Iodine Scrub Betadine ® 1 Bottle 500ml Scrub – Rs ml = Rs Water = Rs per scrub 1 Scrub = 10 ml = = Rs = Rs Alcohol based disinfectant Sterilium ® 1 Bottle 500ml = Rs ml = Rs Rub = 8ml = Rs. 6.72