ACORN Standards Applied to Practice (ASAP)

Why shouldn't hand scrub and alcohol-based surgical hand rub be used sequentially?

The 2020 ACORN Standards stipulate that surgical hand scrub and alcohol-based surgical hand rub should not be used sequentially. Of all the recommendations included in the ACORN Clinical Standards this issue is one of the most commonly questioned. It's time we made it simpler to implement so please read on to learn more about this recommendation, where it comes from, what it means and how you can follow it clinically. 

ACORN does not make recommendations regarding specific products as we appreciate that different jurisdictions and organisations have various procurement procedures in place including tenders with specific manufacturers and distributors. Important issues such as staff tolerance to the active ingredients in a solution used for surgical hand antisepsis should also influence what's used. Organisations should take care in selecting hand hygiene solutions as sensitivities may develop. Clinicians should also follow all manufacturer instructions for use (IFU) and only use the solution how and for what it was intended.

Both iodine and Chlorhexidine (CHG) are excellent antiseptics, the main benefit for CHG is its persistence. CHG should be in combination with alcohol so that both immediate kill is achieved (by the alcohol) and persistence is attained (by the CHG). 

Members of the surgical team should perform a surgical hand scrub using an antiseptic surgical solution (surgical hand scrub) before the first and every subsequent surgical procedure of the day1.

Traditionally, surgical team members have performed a presurgical hand preparation (‘scrub’) using a surgical hand preparation and water. Recent formulations of waterless, alcohol-based antiseptic hand rub, when used according to IFUs, no longer require the preliminary scrub using a surgical hand preparation and water. The waterless, alcohol-based antiseptic hand rub alone should be sufficient to eliminate transient flora and reduce resident skin flora on the user's hands.

The 2020 ACORN Standards stipulate that surgical hand scrub and alcohol-based surgical hand rub should not be used sequentially as using surgical hand scrub and washing may result in moist hands and moisture may dilute the antimicrobial properties of the surgical hand rub. Surgical hand scrub may also enhance skin irritation and dryness. This recommendation is based on World Health Organization guidelines2 which cite a seminal paper by Kampf3.

Applying this recommendation requires a necessary change in long-held practice. Perioperative nursing often involves following highly ritualised behaviours and so ACORN appreciates this change may be difficult. ACORN also recognises that differences in  recommendations, procurement and supply may exist and these need to be considered by perioperative staff at a local decision-making level. Also staff sensitivities; compatibility of hand hygiene solutions with other protections, such as surgical gloves; pricing; safety and IFUs also rightly influence purchasing decisions and practice.

ACORN encourages perioperative staff to engage with hand hygiene suppliers regarding IFUs, benefits, limitations and educational materials associated with their specific hand hygiene formulations. Also please refer to ACORN standard ‘Surgical hand antisepsis’, including its glossary of important terms.


  1. National Health and Medical Research Council (NHMRC). Australian guidelines for the prevention and control of infection in healthcare [Internet]. Canberra: NHMRC; 2019 [cited 2020 March 24]. Available from:
  2. World Health Organization. Guidelines on hand hygiene in health care. First global patient safety challenge: Clean care is safe care. Geneva: WHO; 2009.
  3. G Kampf, H Löffler. Dermatological aspects of a successful introduction and continuation of alcohol-based hand rubs for hygienic hand disinfection. J Hosp Infect 2003;55(1):1–7. DOI: 10.1016/S0195-6701(03)00223-8.