FAQs clinical standards

Caveat 

The ACORN Standards for Perioperative Nursing in Australia are voluntary documents that set out specifications, procedures and guidelines that aim to ensure products, services, and systems used in perioperative nursing are safe, consistent, and reliable. Although ACORN works directly with its members to develop perioperative nursing standards, ACORN is not responsible for enforcing, regulating or certifying compliance with those standards.

We hope that the responses provided by ACORN to FAQs about specific ACORN standards/ clinical practices provide some guidance for our stakeholders' queries. The ACORN Standards are developed through rigorous review of the best available research, public policy and other evidence in Australia and abroad. Individual standards, guidelines and position statements are best-practice at the time of their revision. Although ACORN publishes the Standards ACORN cannot provide interpretation of the Standards. The application and interpretation of the ACORN Standards involve many factors that will be individual to the situation, facility and jurisdiction in which you provide perioperative nursing care.

Currently no government or other agency requires compliance with the ACORN Standards; however, compliance is the key to organisations and individuals ensuring perioperative care is consistently safe and of high quality. As such, it is ACORN’s goal that ACORN standards for perioperative nursing in Australia are accessed, interrogated and applied in every Australian health service organisation that performs surgical procedures. Perioperative staff should use the ACORN Standards in conjunction with other national and jurisdictional legislation, guidelines and requirements including, specifically, the National Safety and Quality Health Service Standards (NSQHS Standards). It is hoped that the ACORN Standards continues to represent the minimum expected, by the profession and its stakeholders, of all perioperative staff.

 

Is ACORN able to provide guidance re: surgical sount documentation (eg; what it should include as a minimum), or an example template? We are looking to review our count policy and documentation as staff feel it is inadequate and doesn't reflect the Accountable items standard.

This response refers to the Accountable items standard contained in the current edition of the ACORN Standards for Perioperative Nursing in Australia. As you would appreciate the ACORN Standards are designed to provide an overarching framework as a series of recommendations and rationales regarding various aspects of perioperative nursing. ACORN is aware that some jurisdictions have their own recommendations regarding mandatory fields within a Count Sheet. Where specific national or state legislation and guideline exist they will take precedence. For that reason and also due to the introduction of electronic medical record systems, ACORN no longer promotes its template on the ACORN website.


I need some clarification on accountable items. In the process of updating the policy. Also clarification of disposal of swabs on completion of count and end of surgery.

See above.


When conducting a first count (i.e. uterine count LUSCS) and a pack has been deliberately been retained in the patient, how is this legally documented on the count sheet? Currently, when a pack is put in-situ it is written on our whiteboard x1 pack in-situ @ time, but if there is a pack in-situ and a count is required it is still documented as the amount of packs in the sterile field even though the pack in-situ is not able to be visualised. 1) Should we be writing the packs only which can be visualised with an asterix and explanation on the count sheet where the remaining pack is? or, 2) Should we document all the packs in the sterile field even though the scrub/scout cannot see all the packs?

Please review the ACORN standard, Accountable items.

In the principle of that standard it is noted in reference to prevention of inadvertently retained items that:

“This is achieved by performing a manual and visual search of the operative/procedural field, as thoroughly as possible and in a way that is compatible with the safety and welfare of the patient".

Further, please note Standard statement 2 and specifically Criteria 2.9 which states:

"2.9 the instrument nurse has a duty to ensure that when accountable items are deliberately retained in the patient, the number of retained accountable items and their location is documented on the APD. The totals in the final count are minus the number left in the patient."

As you would appreciate the ACORN Standards are designed to provide an overarching framework as a series of recommendations and rationales regarding various aspects of perioperative nursing. ACORN is aware that some jurisdictions have their own recommendations regarding mandatory fields within a Count Sheet. Where specific national or state legislation and guideline exist, they will take precedence. For that reason and also due to the introduction of electronic medical record systems, ACORN no longer promotes a specifc template or form.

Also please note that Standard statement 1 specifically states:

“The health service organisation has a duty to develop a policy/guideline which clearly defines the management of items used during surgery and procedures within their organisation and is used in conjunction with the standard”.

This statement indicates that your organisation should develop a policy and recommendations specific for the organisation. In view of that ACORN is unable to provide you with a definitive answer.


When performing bilateral cataract removal and intraoccular lens implantation, is it advisable to have a seperate instrument set-up for each eye? During this most recent case, we utilised the same instruments, however changed the sterile drapes. We are unsure of best practice guidelines during bilateral implant procedures.

In responding to your question ACORN found it necessary to review recommendations from AORN which are reproduced below:


"Can the same sterile field setup be used for two different areas on the same patient?

Two procedures on the same patient that involve two different wound classifications (ie, clean, clean-contaminated, contaminated, dirty) should have separate sterile fields and instrumentation. Instruments should not be used interchangeably. Having separate sterile fields and instruments for sites of different wound classes on the same patient reduces the risk of infection of the cleaner wound.

Resource:

•           Guideline for sterile technique. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2018:e133-e172. Updated October 24, 2018

https://www.aorn.org/guidelines/clinical-resources/clinical-faqs/sterile-technique Accessed 5/8/2020

It would seem that it is common practice in Australia to use one set-up for sequential procedures where the wound classifications are consistent across both operative sites.

Please also be aware of the recommendations contained in the Accountable items standard as reproduced below from the current edition of the ACORN Standards for Perioperative Nursing n Australia:

"2.6 where sequential procedures are undertaken on the same patient, or when a two-stage procedure is performed, which requires two ‘set-ups’, e.g. laparoscopic assisted vaginal hysterectomy

2.6.1 when the operating room is being cleared between the surgery/procedures and different ‘set-ups’ are being used, then a separate APD is used for each procedure

2.6.2 when the operating room is not being cleared between the surgery/procedures and the same ‘set-up’ is being used, then the instruments and other accountable items from the first surgery/ procedure are isolated and a separate APD is used. The final count of the first procedure is carried over to be the first count of the second procedure and so on. Accountable items should not be removed from the operating room until all procedures have been completed."

Our theatre complex of 9 theatres has only one corridor shared to transport sterile set-ups, used instruments from the cases, patients and staff. I would like advice on how to contain used instruments being transported from individual theatres to CSSD using this shared corridor. Currently we fold the back table cover over the instruments and trays to contain them but we have been advised that this is insufficient to meet accreditation.

Please review the following ACORN Standards:

•           Asepsis

•           Infection Prevention and

•           Planning and design of the perioperative environment

The Planning and design of the perioperative environment standard does in fact refer to a single corridor model and ACORN encourages you to re-read that standard.

In the Asepsis standard statement 4 and its associated rationale and criteria, specifically 4.6-4.8 indicate that covered containers or vehicles must be used to move soiled instruments to the reprocessing area. Please liaise with your infection control team to establish a system for this in your operating suite. Please also refer to Standards Australia. AS/NZS 4187:2014 Reprocessing of reusable medical devices in health service organisations. Canberra: Standards Australia; 2014 which is the cited reference to that requirement at Criteria 4.7.


How long can I leave a sterile surgical tray open before surgery? We open our trays up in a small area with walk through, so this isn't a big theatre, it is day surgery. Just wondering if there is an ACORN standard for this?

With regard to asepsis this issue is well described in detail in the ACORN Standards; specifically the standards on Asepsis, Infection Prevention, Instrument nurse and Reprocessing re-usable medical devices. Please access and read each of those specific standards. Please note that ACORN’s clinical responses are not a substitute for the ACORN Standards and ACORN does not provide in depth responses for questions relating to content covered in the ACORN Standards.


The organisation I work for currently does not allow staff to count in the set up room, however staff are allowed to set up for cases there. As they are not allowed to count there, staff take instruments out of the trays, remove the inner packaging of consumables and have everything ready before the trolleys are pushed into theatre after the patient has been positioned on operating table where the initial count is performed. The staff do this as they find that by the time they get into the operating room, they have very little time to count.I am not comfortable with this practice, as I believe no instrument should be taken out the trays or inner packaging removed until one is ready to count. I have worked in other facilities where staff set up and count in set up room before trolleys are pushed in operating room. What will be an acceptable practice in this instance? I have been taught that one should count where one is setting up regardless of where, whether it is in set up or operating room. Can the initial count be done in set up room before case commences?

Under criteria 2.5 within ACORN's Asepsis standard it states: “

Perioperative personnel have a duty to:

2.5           prepare an aseptic field for one patient at a time and within the confines of the operating/procedure room where the procedure is intended to occur

By its nature the implication of this standard is that the first and all subsequent counts must be undertaken in the the confines of the operating/procedure room where the procedure is intended to occur or has occurred.

So whilst this rationale is infection control based it has ramifications for management of accountable items. Again, please understand that the ACORN Standards are not mandatory however they are considered best practice and have been used previously as representation of the reasonable standard of care expected by perioperative patients and staff.

ACORN encourages you to change your local practice so that it complies with this recommendation unless you have a state-specific directive or mandate that tolerates a different approach.

I was after information on the excessive use of personal perfume in the perioperative environment. My facility is struggling to find some common ground with this. I cannot find any information in the standards. Any information would be appreciated to help develop a policy that can be implemented.

ACORN's standards are silent on this issue probably because the decision should be organisation-wide rather than perioperative-specific. There are multiple confined areas within health service organisations where staff and patient are in close proximity. Any policy should address aftershave as well as perfume. ACORN keeps a watching brief on emerging evidence or research but in this case for now ACORN advises you take it up with your organisation’s OH&S management as it is a governance issue. If you or any others in your workforce are truly sensitive then I suspect there could be good grounds from an occupational health perspective to discourage and/or ban staff from wearing perfume while at work.


I am trying get a clear direction on best practice at this time. While extubating patients in the operating theatre. Is it necessary to mop the floor between each patient when there is no visible signs of blood or body fluids evident? All equipment that has been touching the patient is wiped down in between patients and the staff are practising standard precautions. We are a private day surgery facility so therefore our patients are screened and high risk procedures are not being undertaken

ACORN’s recommendations regarding routine cleaning of the operating room are well described in the current edition of the ACORN Standards for Perioperative Nursing in Australia. I would strongly suggest that you review that document in particular the standards on Cleaning and maintaining the perioperative environment and Infection prevention

The national Infection Control Guidelines are freely available at https://www.nhmrc.gov.au/about-us/publications/australian-guidelines-prevention-and-control-infection-healthcare-2019 Please note the recommendations included in Appendix 2 on Recommended routine cleaning frequencies.

If your question relates to specific COVID-19 precautions ACORN continues to refer all members to the ACORN recommends members follow the Australian government's advice and regular updates available at www.health.gov.au

As you would appreciate members’ needs vary greatly and it is therefore difficult for ACORN to provide specific advice. I would also recommend in this case that you seek advice from your infection control staff or Chair of the infection control committee.

Can you provide advice on scenarios for when a level 2 surgical fluid resistant mask is suitable for use in an operating environment as a contingency or business as usual requirement when managing limited stock levels of surgical masks.

According to the current ACORN Perioperative Attire standard

Personnel have a duty to:

6.1 wear disposable, high filtration masks

6.1.1 whenever a sterile/aseptic field is being prepared or maintained

6.1.2 in the restricted areas during surgical procedures

6.1.3 whenever there is risk of blood or body fluid splash

Obviously, the current global demands on PPE require all health service organisations to re-consider how they manage their PPE stock and how they untake the required risk assessment that informs their choice of PPE. ACORN is currently referring all members to the national COVID 19 advice for healthcare workers and to their jurisdiction-specific advice. In this case ACORN would also recommend you seek advice from your local infection control team as they would most likely have a better understanding of the current guidelines specific to your hospital.


I am reviewing our district's procedure on perioperative attire. Would you please advise governance surrounding disposable attire (i.e. Australian Standard)?

ACORN strongly encourages you to read the current Perioperative attire standard as it details ACORN’s recommendations including a health service organisation’s obligations to supply disposable head-covers and masks.

A comprehensive table from pages 11-13 of Volume 1 - Clinical standards  lists the seven relevant Australian Standards cited in the Perioperative attire standard. It would help you get a clearer understanding of ACORN’s recommendations and from where they arise.


I am a third year nursing student and have been lucky enough to receive a placement in theatre I have facial hair and was wondering if I need to shave it off or if there are ways to protect the operating room from errant facial hairs?

With regards to strategies and processes to limit the shedding of microorganisms or hair from face of perioperative staff there are a number of recommendations. ACORN would also draw your attention to the possible limitations in protection for the wearer of a face mask and particularly an N95 ask or respirator when facial hair impedes the seal of the mask.

Please refer to the current Australian Guidelines for the Prevention and Control of Infection in Healthcare https://www.nhmrc.gov.au/about-us/publications/australian-guidelines-prevention-and-control-infection-healthcare-2019 see pages 114-116.305.

The Perioperative attire standard in the ACORN Standards for Perioperative Nursing in Australia also make the following recommendations:

"Standard statement 2

The scalp, sideburns, facial hair, ears and nape of the neck are completely covered by a surgical head cover to minimise microbial dispersal when staff are the restricted, and semi-restricted areas of the perioperative environment should be clearly defined within each health service organisation. This also applies to any perioperative staff member performing surgical hand antisepsis."


I have changed health services and recall previously reading an email regarding cloth hats within the preoperative environment. I recall this letter stating that there hadn't been specific trials or research conducted and that ACCORN was happy to support research. And that it welcomed evidence based practices. Can you point me in the right direction, as there are currently policies being reviewed and I would like to have good evidence based referencing, where possible?

ACORN’s Perioperative Attire standard which is at pages 223-234 of the current Volume 1 of the 16th edition of the ACORN Standards for Perioperative Nursing in Australia makes several statements regarding perioperative headwear.

In 2018 ACORN published a Statement regarding cloth headwear in the perioperative environment. ACORN has not changed its position since this statement was published.

From time-to-time ACORN receives requests from individuals to review its position however we are not aware of any significant valid and reliable new pieces of peer-reviewed research that invalidate ACORN’s position. We continue to scan the public policy and research fields in the event that new credible, peer-review, high-quality research from well-designed studies is published.

In the previous edition of the ACORN Standards for Perioperative Nursing in Australia I read that sharps must only be discarded by the original user and its not advised they are counted away, I cant find this in the current  edition, can you assist?

ACORN recommends that you review the general intent and over-arching principles of each Standard in the current 16th edition as they discuss ACORN’s recommendations and the need  to  always consider specific local policies and risk management. Specifically I draw your attention to Standard statement 7 of the current 16th edition Accounatble items standard and Criteria 3.4 of the current 16th edition of the Sharps and preventing sharps-related injury standard. Both standards indicate that a health care worker is indeed responsible for the management and safe disposal of any sharp they use. 

The literature suggests that screw caddies should be replaced by sterile implants packaged singularly. We have about 50 trays with caddies containing implants (screws and plates) being continually reprocessed. I would be grateful for any advice on how Operating Theatres transitioned to sterile single use. 

Unfortunately ACORN has no unique insights into this issue and has not seen “the literature” to which you refer. Perhaps you could seek the views of the authors of those pieces of literature. You may also wish to connect with the state local associations to seek advice from their orthopaedic experts.

We are updating our policy on jewellery in the perioperative area and the ACORN standards state no rings are allowed. Is it permissible for any staff in the area to wear wedding rings as some staff (mainly recovery) are physically unable to remove their rings?
 

Please refer to the Perioperative attire standard. Within this standard Standards statement 8 recommends “Jewellery worn within the perioperative environment is limited to items that can be contained within the perioperative attire.”ACORN’s  rationale for this includes evidence proving that microorganisms are harboured under and within rings and it also refers to the risk of accidental traction on the ring causing avulsion of the soft tissues. This can result in injury ranging from a simple contusion injury to traumatic amputation”

In 2019 the National Health and Medical Research Council published revised Australian Guidelines for the Prevention and Control of Infection in Healthcare. The NHMRC’s recommendation see below  are built into the National Safety and Quality Health Service (NSQHS) Standards compliance with which is mandatory for Australian health service organisations. Please note that page 40 of the NHMRC Australian Guidelines for the Prevention and Control of Infection in Healthcare states “if jewellery must be worn in clinical areas it should be limited to a plain band (e.g. wedding ring) and this should be moved about on the finger during hand hygiene practices. In high-risk settings such as operating suites/rooms, any jewellery, even a plain band, should not be worn.”  In relation to your question ACORN’s recommendation is that no jewellery, including wedding rings, should be worn.

Although there is less evidence concerning the impact of jewellery on the effectiveness of hand hygiene, rings can interfere with the technique used to perform hand hygiene resulting in higher total bacterial counts. Hand contamination with infectious agents is increased with ring wearing], although no studies have related this practice to healthcare worker-to-patient transmission. The consensus recommendation is to strongly discourage the wearing of watches, rings or other jewellery during health care; however if jewellery must be worn in clinical areas it should be limited to a plain band (e.g. wedding ring) and this should be moved about on the finger during hand hygiene practices. In high-risk settings such as operating suites/rooms, any jewellery, even a plain band, should not be worn.


Do you have any information on the moments of hand hygiene in theatres?

Since November 2019 the Australian Commission on Safety and Quality in Health Care has had responsibility for the National Hand Hygiene imitative  in Australian health service organisations. There are specific obligations that health service organisations have including assessment of local hand hygiene compliance. These obligations may differ between jurisdictions and so I would also recommend you review materials specific for NSW on the Clinical Excellence Commission’s website specifically at http://cec.health.nsw.gov.au/keep-patients-safe/infection-prevention-and-control/healthcare-associated-infections/hand-hygiene  

ACSQHC’s resources for hand hygiene can be accessed free of charge at https://www.safetyandquality.gov.au/our-work/infection-prevention-and-control/national-hand-hygiene-initiative-nhhi/what-hand-hygiene

ACORN has produced a series of 12 Practice audit tools (PATs) specific to the perioperative environment. PAT 3 is for Surgical hand antisepsis, donning and gloving. The ACORN PATs are available for purchase as a set of 12. More information is available at https://www.acorn.org.au/practiceaudittools


I am just wondering whether ACORN has any recommendations regarding the use of surgical scrubs? I am currently looking at comparing Isopropyl Alcohol 90%  to others such as chlorhexidine and iodine to provide evidence to management in our theatres to perhaps introduce it as an alternative scrub throughout the day.

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. There are also important issues such as staff tolerance to the active ingredients in a solution used for surgical hand antisepsis. Care should be taken in selecting that solution as sensitivities may develop. Both iodine and chlorhexidine (CHG) are excellent antiseptics, the main benefit for chlorhexidine is persistence. It should be in combination with alcohol so that immediate kill is achieved (by the alcohol) and persistence (by the CHG) are attained.

As you suggest ACORN’s general recommendations are described in the Surgical hand antisepsis, gowning and gloving standard. The only stipulation is that the scrub used for surgical hand antisepsis has antimicrobial properties and is used only as per manufacturer’s instructions.

For more information you may find the National Hand Hygiene Initiative Manual useful. More information about the national hand hygience initiative is available at https://www.safetyandquality.gov.au/publications-and-resources/resource-library/national-hand-hygiene-initiative-manual

I also refer you to the 2019 Australian Guidelines for the Prevention and Control of Infection in Healthcare. The guidelines are accessible at www.nhmrc.gov.au and the following definitions are taken from it.

Surgical ABHR: Antiseptic hand rub performed preoperatively by the surgical team following the surgical pre-wash to eliminate transient flora and reduce resident skin flora. Such antiseptics often have persistent antimicrobial activity. Use should be in accordance with manufacturers’ instructions. Surgical ABHRs are often a waterless and high percent alcohol solution.

Surgical hand preparation: The process of eliminating transient and reducing resident flora prior to surgery. This comprises removal of hand jewellery, performing hand hygiene with liquid soap if hands are visibly soiled, removing debris from underneath fingernails and scrubbing hands and forearms using a suitable antimicrobial formulation


I just wanted to clarify something from the standard for surgical hand antisepsis. It states in there that surgical hand scrub and surgical hand rub should not be used sequentially. What is the rationale behind this? I am unable to access the full text article that is referenced for this statement. Medical staff in particular in our facility are doing this regularly, doing a traditional scrub then applying the waterless hand rub. We are hoping to change their practice but know they will want some more information.

This is an interesting question and it has been asked of ACORN on at least one other occasion in the past 12 months which has prompted ACORN to revise the wording of the recommendation. In our new 16th edition of the ACORN Standards those sections of the standard have been re-worded to:

"3.11 Do not combine surgical hand scrub and alcohol-based surgical hand rub 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.

3.12 Generally, hand washing prior to applying an alcohol-based surgical hand rub is not necessary and it may dilute the effectiveness of the surgical hand rub and can predipose users' hands to irritation. However, if hands are visibly soiled or dirty, they should be washed with a non-antimicrobial soap before surgical hand preparation and must be completely dry before applying the alcohol-based surgical hand rub solution."

The other important information is that if two different types of antimicrobial agents are used sequentially the first may reduce the efficacy of the second. These rationales are well described in the Kampf article1. Also please check the World Health Organization. Guidelines on hand hygiene in health care. First global patient safety challenge: Clean care is safe care. Geneva: WHO; 2009. as it also helps explain this recommendation.

1. Kampf G, Löffler H. 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


In the "Surgical hand antisepsis, gowning and gloving" standard section 3.5 where it says that surgical antiseptic hand scrub agents and alcohol base surgical hand rub should not be used sequentially does this mean that if you do your 5 min scrub at the start of the day using antimicrobial hand-wash the following hand washes after that cannot be a 90 second Skinman alcohol hand rub? It must be a 3 min washes continuing using the chosen antimicrobial hand wash? If we chose to use the 90 second Skinman alcohol antiseptic hand rub we must use that at the start of the day in-replace of our 5 min scrub and continue to use that all day for the sequential washes?

ACORN’s recommendation is:

3.5 Antimicrobial surgical hand scrub agents and alcohol-based surgical hand rub agents should not be combined sequentially2,p.153. If you choose to use a surgical hand scrub you must continue using that same antiseptic for all subsequent scrubs.

ACORN’s recommendation makes no mention of a specific duration as we are aware that in all cases manufacturer’s IFUs should be followed and they may differ depending on which agent is used. The statement states that if you start your first scrub of the day using a scrub agent (solution A) then you cannot change to a different agent for your subsequent scrubs. Simply put you must continue to use Solution A for the remaining scrubs for the day. This is because of incompatibilities between surgical scrub and alcohol-based rubs solutions that render the agents to be less effective. This recommendation is based on WHO’s recommendation World Health Organization. Guidelines on hand hygiene in health care. First global patient safety challenge: Clean care is safe care. Geneva: WHO; 2009 See page 153. Page 153 reads:

" H. When using an alcohol-based surgical handrub product with sustained activity, follow the manufacturer’s instructions for application times. Apply the product to

dry hands only (IB). Do not combine surgical hand scrub and surgical handrub with alcohol-based products sequentially (II)."

You may also wish to undertake further discussions with your local perioperative leaders and your infection control team. ACORN will never provide manufacturer-specific advice. Instead you should seek a recommendation and gaurantee from the manufacturer that your proposed use of hand hygiene solutions is optimal, safe and does not reduce patient or staff safety. Please appreciate that ACORN’s recommendations are necessarily broad and over-arching whereas you may have specific local or jurisdictional obligations that override ACORN’s recommendations.


I am wanting clarification on the new standards of scrubbing, my understanding of the standard is that we no longer have to do a first 5 minute scrub of the day. I read it as you can simply arrive and use the alcohol scrub rub and then gown and glove, without any real hand washing.

ACORN is not sure what you mean by the term “real hand washing”. The current NHMRC national infection control guidelines use the term “surgical hand preparation”. Please review their recommendations on page 176 which I have reproduced below.

"Hand hygiene for surgery

Surgical hand preparation should reduce the release of skin bacteria from the hands of the surgical team for the duration of the procedure; in case of an unnoticed puncture of the surgical glove that releases bacteria to the open wound. Surgical hand preparation must eliminate the transient and reduce the resident flora. There are special surgical scrub formulations available for use, although any product used within Australia should preferably be listed on the Australian Register of Therapeutic Goods (ARTG). Current WHO guidelines recommend the use of an alcohol-based formulation for preoperative surgical hand preparation, given its superior antimicrobial efficacy compared to other methods. Specific policies and procedures on products and methods of surgical hand preparation should be developed locally."

Manufacturers’ instructions for use are critical and for waterless surgical hand preparation they should be followed. Further the American AORN recommend that:

“A standardized surgical hand scrub with a soap (antimicrobial agent), nonabrasive sponge, and water does not have to be the first surgical hand scrub of the day before an alcohol-based surgical hand rub product is used, unless it is recommended in the manufacturer's instructions for use. The surgical hand scrub reduces the transient and resident flora of the hands, which also may reduce health care-associated infections. A standardized surgical hand scrub using an alcohol-based hand rub product will decrease transient and resident flora on the hands. Hand washing does however need to be performed before the first surgical hand scrub of the day”.

AORN recommends hand washing before the first surgical hand scrub. Hand washing is defined by the ACSQHC National Hand Hygiene Initiative User Manual as the application of soap and water to the surface of the hands. The soap could be plain or antimicrobial. A critically important step is that before any surgical hand preparation is applied the healthcare worker’s hands must be dry. When the hands are dry and only then the surgical hand scrub using the skin antiseptic can be performed for the first surgical scrub. As per the ACORN Standards “The skin antiseptic used for the first surgical hand scrub of the day should continue to be used for subsequent scrubs because the beneficial, cumulative or sustained effects of skin antiseptics differ.”


Can you please define sequential in relation to the use of hand scrub and hand rub. We are undertaking our yearly assessments and want to ensure that if they do a 5 minute scrub, gown and glove they can then demonstrate practically use of the a specific product and go on to use their scrub/rub of choice for the rest of the day.

ACORN’s use of the word “sequential” is no different from its everyday usage ie. following in a logical order or sequence.

ACORN’s recommendation regarding hand hygiene and the sequence of hand hygiene solutions is as per the current standard:

"3.5 Antimicrobial surgical hand scrub agents and alcohol-based surgical hand rub agents should not be combined sequentially 2,p.153. If you choose to use a surgical hand scrub you must continue using that same antiseptic for all subsequent scrubs."

ACORN’s recommendation makes no mention of a specific duration as we are aware that in all cases manufacturer’s IFUs should be followed and they may differ depending on which agent is used. The statement states that if you start your first scrub of the day using a scrub agent (solution A) then you cannot change to a different agent for your subsequent scrubs. Simply put you must continue to use Solution A for the remaining scrubs for the day. This is because of incompatibilities between surgical scrub and alcohol-based rubs solutions that render the agents to be less effective. This recommendation is based on WHO’s recommendation World Health Organization. Guidelines on hand hygiene in health care. First global patient safety challenge: Clean care is safe care. Geneva: WHO; 2009 See page 153

Page 153 reads: "H. When using an alcohol-based surgical handrub product with sustained activity, follow the manufacturer’s instructions for application times. Apply the product to dry hands only (IB). Do not combine surgical hand scrub and surgical handrub with alcohol-based products sequentially (II)."


Gowning and gloving

As we can not source our usual 6.5 gloves from our current supplier our hospital is sourcing other companies. I have been asked what reference ACORN use for gloves I am presuming its reference the AS/NZS standard. I can not find any other reference in the Standards

Unfortunately, your question is vague and non-specific regarding the type of glove ie. non-sterile, sterile or reusable utility gloves you are enquiring about. Regardless please note that all ACORN recommendations for infection control are consistent with the requirements and recommendations included in the Australian Guidelines for the Prevention and Control of Infection in Healthcare (2019). Please refer to section 3.3 Personal protective equipment for glove-specific recommendations.

The document is available at https://www.nhmrc.gov.au/about-us/publications/australian-guidelines-prevention-and-control-infection-healthcare-2019