Removal of nail polish and finger rings to prevent surgical infection

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It has been estimated that approximately one in ten patients in acute hospital settings have a hospital‐acquired infection (HAI). In addition, an unquantifiable number of patients discharged from hospital into the community have an infection related to their hospital stay (NINSS 1999).

Analysing the cost of HAIs is complex. The cost to the patient may range from a few extra days absence from work, to considerable pain and immobility, while the social and economic burdens of lost earnings and productivity ‐ as well as social security payments ‐ attributable to HAIs are difficult to quantify (NINSS 1999). Deaths from HAIs are also difficult to quantify because infection may be one of several contributory factors (Wilson 1995). As previously mentioned, studies have indicated that one in ten patients in acute hospitals have an HAI, and, assuming that England has a similar mortality rate to that in the USA, it is estimated that one per cent of these patients will die as a direct result of their infection, and that HAIs will be a contributory cause in the deaths of a further three per cent (NINSS 1999). In addition, the direct and indirect cost of hospital treatment must also be considered. Patients with HAIs may require further surgery, additional nursing care, drug therapy and consumables. HAIs also increase the length of hospital stay by an average of four to ten days, and so prevent the admission of other patients needing care and treatment (Wilson 1995). It has been calculated that a ten per cent reduction in the incidence rate of HAIs in England would deliver a £93 million saving in expenditure (Plowman 1999). The National Priorities Guidance (1999/00‐2001/02) emphasised the obligation of the National Health Service to ensure the continuing and effective protection of the public’s health against communicable disease, including HAIs (NINSS 1999). This review of finger rings and nail polish, may contribute to the development of effective guidelines and policies on HAIs.


Surgical wound infection accounts for up to 20% of all HAIs, most of which occur because of microbial contamination of the wound during surgery (Ayliffe 1999). The incidence of surgical infection varies according to surgical site and between hospitals (NINSS 1999). Infections may derive from the resident flora or transient microbiological flora found on the hands of health care workers (Wilson 1995). Resident flora are microbes that live deep in the crevices of the skin, in hair follicles and sebaceous glands. Transient flora are microbes acquired on the surface of the skin through contact with other people, objects, or the environment (Price 1938; Wilson 1995). The composition of transient flora varies, but reflects the extent of contact with patients, their environments, and the micro‐organisms that are prevalent (Wilson 1995).

Generally, it is recognised that the hands of hospital staff are the most common vehicles by which micro‐organisms are transmitted between patients (Gould 1997; Kerr 1998; May 1998), although Ayliffe 1999 suggested that there was little statistical evidence to support this view. Despite this view, Ayliffe 1999 also concurred that hand washing or disinfection is the most important technique for prevention of cross‐infection.

Pathogenic micro‐organisms are acquired in the greatest number when handling moist, heavily‐contaminated substances such as body fluids. These fluids frequently contain large numbers of micro‐organisms, and are a major source of the pathogens that cause HAIs. Team members within the environment of the operating theatre are frequently, and routinely, exposed to a variety of potentially pathogenic micro‐organisms during the handling body fluids, specimens and contaminated instruments. These, alongside the resident skin flora on the hands of the theatre team, put staff at risk of transmitting infection to patients, and are of particular concern at the surgical scrub stage in the surgical procedure.

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Prior to surgical procedures, a particular form of hand washing ‐ the surgical scrub ‐ is used before putting on sterile surgical gloves. Most people use antiseptic formulations for surgical scrubbing that are highly effective in removing or destroying bacteria that might pass through punctured or damaged gloves during surgery (Ayliffe 1999). It is believed that the presence of finger rings and nail polish (also called nail varnish) may reduce the efficacy of the scrub, because an increased number of micro‐organisms may be harboured in the microscopic imperfections on the surface of nail polish and on the skin beneath rings. Rings may also harbour bacteria, and rip surgical gloves. As a result, the reluctance of theatre staff to remove rings or nail polish is an issue.

There is a lack of uniformity in guidelines and policies regarding the optimum technique for scrubbing (AORN 1999), specifically scrubbing agent, duration of hand scrubbing, nail length, and whether wearing nail polish and rings on the fingers is acceptable. If we can identify evidence for an association between the removal of finger rings, and nail polish, and a subsequent reduction in the number of surgical wound infections, the potential benefit for patients could be high, whilst the cost of changing clinical practice would be comparatively low.


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