Scott Foley is returning to NBC’s comedy “Scrubs.”

Foley, who first appeared on the medical sitcom in its freshman season, is set to reprise his role as a fumbling, insecure patient who developed a crush on his doctor, Elliot Reid (Sarah Chalke).

He is set to guest star in six episodes this fall, beginning with the season premiere.

“Scrubs” is returning for a third season this fall in the 7:30 p.m. Thursday slot.

“Felicity” co-star Foley is preparing for his role in Manhattan Theatre Club’s production of “The Violet Hour” on Broadway this fall.

His wife, “Alias” star Jennifer Garner, filed for divorce in May after a six-week separation. They have been married since 2000.

Surgical scrubbing is a mainstay and the foundation of aseptic technique in the OR. It would be folly to suggest that it is not necessary for surgical team members to scrub. Currently, however, scrubbing–the way it is performed and the products used–is being examined in a new light.

This article discusses some of the historical antecedents and recent health care changes that have influenced present-day scrubbing techniques, along with old and new topical antimicrobial agents used to scrub and effects of using a brush versus not using a brush. The article presents a case for brushless scrubbing and using alcohol formulations with this scrubbing technique.

HISTORY OF SURGICAL SCRUBBING

A few articles record scrubbing procedures and agents used during the 1800s and 1900s. Carbolic acid was the preferred antiseptic in the late 1880s. One researcher described scrubbing during the 1890s, suggesting that surgeons and their assistants use hot water, soap, a nail brush, and a penknife without subsequently placing their fingers in their noses, eyes, or ears. (1) According to this researcher, potash soap and water were the primary agents used. Rinsing the hands in alcohol, followed by a final immersion in bichloride solution, also was suggested.

Another researcher described surgery conditions during the Civil War, where surgery often was performed in field tents rather than in hospitals because fresh air was thought to hasten recovery. (2) In the 1950s, hand scrubbing required the use of rough brushes with stiff bristles that abraded the skin and frequently increased bacterial counts. Disposable sponge brushes, better packaging, and advanced technology, however, made such practices obsolete. (3)

In an article published in 1966, one researcher described a new product–a sterile polyurethane sponge impregnated with an antibacterial soap (ie, 3% hexachlorophene [HCP]) that was expected to yield adequate and equal disinfection without the trauma of abrasive brushes. The author’s cost analysis revealed the experimental sponge to be more economical than the traditional scrub brush in terms of initial cost, staff member labor, brush reprocessing and sterilizing, and the elimination of “unsightly” brush holders, solutions, and their dispensers. (4)

HE IS renowned for his drunken off-screen antics and womanising ways.

But now Colin Farrell is to cash in on his bad boy image.

The 28-year-old actor is translating his natural talents to the TV screen for his latest role.

The Irish hellraiser’s exploits in Hollywood have prompted tales of wild nights involving strippers, smoking and foul language in newspapers on both sides of the Atlantic.

His reputation was further enhanced when it was recently revealed that he was being sued for Pounds 2,500 by a former sex chat worker over harassing phone calls and sordid text messages.

However, all this has failed to halt his meteoric rise in Hollywood.

And Farrell is now set to star in an all-too-familiar role as a harddrinking Irishman in American television’s medical comedy Scrubs.

The star of films including Alexander and Phone Booth plays Billy Callahan - a man who punches a drinker unconscious in a bar brawl before being taken to the sitcom’s hospital.

There he wastes no time flirting with the female stars and showing his romantic side.

The episode, Farrell’s US TV debut, will go on air in America late next month.

The Dublin-born actor has pledged to cut down on his own hellraising after Kim Brodenave, the mother of his year-old son, James, urged him to moderate his partying.

Sue Callaway’s $16 million-a-year business all started 11 years ago when she worked in a San Diego hospital and decided to replace her nurse whites with colorful, carefree, homemade garments. Soon, co-workers were flooding her with orders for her casual wear.

The result is S.C.R.U.B.S. (Simply Comfortable Really Unique Basic Scrubs), a mail-order and retail-store enterprise based in nearby Santee.

Callaway’s all-cotton tops, drawstring pants, and accessories–including surgical caps and stethoscope covers–offer nurses, doctors, dentists, and veterinary workers good reason to leave behind their white polyester uniforms and blue or green scrubs.

Many of her creations are graced with playful dogs, happy dolphins, or smiling teddy bears in vibrant purples, teals, or royal blues. For a softer look, there are stonewashed denims and pastels reminiscent of Monet’s garden.

“Our garments help healthcare workers express themselves and have their own identity,” Callaway says.

The flying pigs, seascapes, and fantasy themes on her firm’s garments calm patients and “bring some humanity to a very sterile environment,” says Dr. Juan F. Gutierrez-Mazorra, chief of anesthesiology at Children’s Hospital of Birmingham in Birmingham, Ala. “Her scrubs are like props. They help us transport children into another world,”

Gutierrez-Mazorra recalls the day he wore a S.C.R.U.B.S. top and surgical cap covered with clowns to take a frightened child to surgery. “The boy knew he was going to have surgery. But he was so taken with my clown outfit that we walked together to the operating room and talked about clowns,” Gutierrez-Mazorra says. “To give care with compassion, you have to get down to a child’s level. Sue’s garments are terrific because they help us do just that.”

Moreover, the clothing is not just for pediatric settings. It can draw a smile or ease anxieties regardless of the patient’s age.

Callaway, 38, was a nurse in the neonatal intensive-care unit at Children’s Hospital and Health Center in San Diego in 1988 when she wore her first handmade scrubs to work–and then began getting orders for them. An avid seamstress, she started Callaway Casuals in her home and trained neighbors and friends to help cut and assemble garments.

After four years, “Scrubs” characters still resemble smarty- pants 12-year-olds. You never know if they’re about to act out a karate fantasy to the tune of “Kung Fu Fighting,” or describe “triathlon” as “Greek for ‘vomit until your stomach is the size of a kitten’s scrotum.’ ” They’re like pratfalling Gilligans with medical degrees in fart jokes.

The karate and “triathlon” bits are just two of dozens and dozens of silly and smart gags in upcoming episodes of the hospital comedy’s new season. But as imaginative as “Scrubs” is, it’s been around for a while, so it’s not a pleasant surprise anymore.

That helps explain why it has lost popular buzz. And maybe that accounts for why NBC left “Scrubs” off its fall schedule to make way for new buzz shows “My Name Is Earl” and “The Office.” “Scrubs” is just now getting slotted on Tuesdays,
Bad things happen to former buzz shows. The media stops talking about them and they lose support. But “Scrubs” is still one of the few comedies that makes me laugh out loud. The actors, writers, directors, camera operators and sound effects zoom around with the frantic sobriety of preteens snorting pure oxygen.

NBC sent TV critics review copies of next week’s shows, but not of tonight’s shows. Make of that decision what you want.

So next week, J.D. (Zach Braff, 30) is about to turn 30, and he wants to accomplish one of the items on his list of things to do by 30. Will he run a triathlon? Invent a cereal? Or will he, like a 12- year-old in social studies, finally “learn the difference between a senator and a representative”?

There’s a dedication to physical and unflattering comedy among Braff and his castmates. Also next week, Braff wears a tiny red Speedo and behaves like a goober. Walking into frigid water, he sputters, “Oh Jehovah that’s cold.” His friend and ex-lover Elliot (Sarah Chalke) bites her lip like a sex kitten in distress, while describing a sexual fantasy involving Mexican apple thieves.

The US Food and Drug Administration (FDA) regulates antimicrobial label claims for surgical hand scrub products used in the United States. These products must meet rigorous performance criteria to be labeled surgical scrub products. The FDA’s criteria, however, may not be relevant to clinical use of these products. This article details the FDA’s simulated in-use clinical testing regimen and discusses product performance in regard to actual clinical use.

SURGICAL SCRUBBING

Surgical hand scrubbing has been demonstrated to reduce the risk of surgical site infections. (1) It prevents or greatly reduces direct transfer of pathogenic transient and resident opportunistic microorganisms residing on surgical staff members’ hands into surgical site wounds. Surgical hand scrubbing has been practiced routinely for only 150 years. In the 1840s, Ignaz Semmelweis, a Hungarian obstetrician, and Oliver Wendell Holmes, an American physician and poet, concurrently discovered that antiseptic hand scrubbing drastically reduced the incidence of maternal mortality from the streptococcal disease puerperal fever. (2-6)

Over the years, surgical hand scrub products have been manufactured with an increased spectrum of antimicrobial effectiveness, and in general, they are faster acting than previous products. The current industry trend has focused on replacing the traditional sponge brush, eight- to 10-minute scrub with a two- to three-minute hand scrub that does not require a sponge brush. Newer generations of hand scrub products do not even require that hands be rinsed after their use. These products are applied after hands are washed with soap and water, rubbed into the skin, and allowed to dry. This can vastly shorten staff members’ surgical hand scrub time, allowing them to attend to patient needs almost immediately.

As a form of risk management, healthcare financial managers need to know more about the elements of risk and the ways that risk is managed. (a)

In malpractice cases involving physicians, a healthcare organization’s credentialing process becomes an important element of the discovery process. Lawyers for both plaintiff patients and defendant physicians have a vested interest in tying healthcare organizations to the physician’s negligence. Lawyers for plaintiff patients view healthcare organizations as “deep pockets” in possible recoveries of damages, while lawyers for defendant physicians may want to redirect culpability from the physicians to healthcare organizations. Some defendant physicians settle early and later testify against the healthcare organization. Healthcare organizations, on the other hand, often prefer not to testify against the physicians to avoid any inference that the organization was negligent and to show support for their medical staff.

Lessons in Negligence

To prove negligence, the plaintiff’s lawyers must prove the following:
* A legal duty existed between the plaintiff and the defendant.

* The defendant breached that duty.

* The plaintiff received an injury.

* A causal relationship existed between the defendant’s breach of duty and the plaintiff’s injury.

Healthcare organizations can be held negligent in a variety of ways. Under the legal doctrine of respondent superior, organizations can be held liable for the negligent acts of employees if the employees were acting within the framework of their job descriptions and/or practice acts and were working on assigned shifts. Under the legal doctrine of ostensible agency, organizations can be held liable for the negligent acts of apparent or ostensible agents, such as physicians and others who have a working relationship with but are not employed by the healthcare organization. Under the legal doctrine of corporate negligence, organizations can be held liable for their own negligence.

The key issue in establishing an agency relation ship is defining the extent to which the patient perceived the physician to be under the organization’s control. The following questions are often used to establish the organization-to-physician relationship from the patient’s perspective:

* Did the patient rely on the healthcare organization for selection of the physician, such as emergency department physicians, pathologists, radiologists?

* Did the organization make any representations, such as advertisements or announcements, Io the patient regarding the physician’s status?

* Did the physician’s actions indicate organizational control to the patient (e.g., wearing the organization’s lab coat or scrubs, using the organization’s prescription pad, maintaining an office in the organization’s building)?

Under corporate negligence, which often results in the largest recoveries for plaintiff patients, organizations can be held liable for their own negligence by breaching a duty owed to patients. In proving corporate negligence based on a breach of the credentialing duty, plaintiff patients must prove the following:

* Their physician was negligent, and the negligence resulted in injury.

* The organization credentialed the physician and therefore owed the patient a duty to exercise reasonable care in the selection and supervision of the physician.

* The organization failed to exercise reasonable care because it knew or should have known that the physician was incompetent or unfit.

* The organization’s negligence in selection and supervision was a proximate cause of the injuries suffered by the patient (i.e., had the organization not credentialed the physician, the physician would not have been available to injure the patient).

Case law in corporate negligence is well established, with the organization’s duty to select competent physicians established in Johnson v. Misericordia Community Hospital, 294 N.W. 2d 501 (1980), and the organization’s duty to supervise physicians established in Darling v. Charleston Community Memorial Hospital, 383 U.S. 946 (1966).

The Johnson ca se, while binding only in Wisconsin, provided the following valuable credentialing criteria:

* Require completion of the medical staff application, and verify the accuracy of the applicant’s statements.

* Solicit information from the applicant’s peers, including those not referenced in the application, who are knowledgeable about the applicant’s education, training, experience, health, competence, and ethical character.

* Determine whether the applicant is currently licensed to practice in the state and whether the license has been or is currently being challenged.

* Ask whether the applicant has been involved in any adverse malpractice action or has experienced a loss of medical staff membership or privileges at any other provider organizations.

In addition, the credentialing process should verify information from secondary sources, such as AMA Physician Masterfile, Federation of State Medical Board’s Physician Disciplinary Data Bank, U.S. Drug Enforcement Administration lists of violations, and the HCQIA Data Bank. The HCQIA Data Bank, established by the Health Care Quality Improvement Act (HCQIA) of 1986, requires the reporting of the following:

* Malpractice payments made on behalf of a physician or licensed healthcare practitioner

* Licensure actions taken by state licensing boards against physicians

* Adverse professional review actions taken by healthcare organizations against physicians

* Professional review actions taken by a professional society that adversely affect the physician’s membership in the society

Defenses to Corporate Negligence

When plaintiff patients bring corporate negligence lawsuits against healthcare organizations, the organizations can pursue a variety of defenses, both procedural and substantive. If plaintiff patients have waited too long to file the claim, healthcare organizations can invoke the statute of limitations. Statutes of limitations are state procedural rules that dictate time limits on the filing of lawsuits. Historically, depending on the state, plaintiff patients had to file a lawsuit within one to seven years of discovering the injury. More recently, in response to tort reform, many states have reduced the time to file to one to three years after discovering the injury.

Another procedural defense healthcare organizations can use is to support the physician’s defense, in effect rationalizing that if the physician was not negligent in treating the patient, the issue of whether the healthcare organization was negligent in the credentialing process becomes moot. Healthcare organizations should use this defense cautiously because the physician could, during the lengthy discovery process, admit negligence and settle with the plaintiff patient. When this happens, the plaintiff patient has a clear avenue to the “deep pockets” of the healthcare organization.

Hospitals also can use the HCQIA as a procedural defense. The IICQIA attempts to shield physicians engaged in the peer-review process from lawsuits against physicians the process is reviewing. The act provides protection from both federal and state lawsuits. Some argue that the act’s protection of the peer review process extends to hospitals. However, most argue that the act’s intent is to protect reviewing physicians, trot to protect the physician or the healthcare organization from lawsuits by patients.

Finally, healthcare organizations can use immunity provided by state statutes as a procedural defense. While attempting to balance the patient’s right to recovery with the public’s need to protect meaningful peer review, many states have enacted statutes that govern the release of peer–review proceedings. State laws vary widely on this subject, from prohibiting both the discovery of peer reviews and their use at trial to allowing the release of peer reviews in certain circumstances.

Details of former-Olympian Robert Howard’s suicide–and his slain wife–are still puzzling Little Rock, AR, police.

Howard, who made the Olympic finals in the triple jump twice at the 1996 Atlanta Games and again in Sydney in 2000, was a third-year medical student. He recently had been spotted late at night in blood-covered scrubs on the seventh-floor at the University of Arkansas for Medical Sciences. A few minutes later university police were notified that someone was trying to get into rooms on the 10th floor of a dormitory next to the hospital, school spokesman Leslie Taylor said.

Once in the dormitory, officers followed a blood trail to the room where they found Howard barricaded. By the time police were able to get in, the window was broken and Howard had jumped to his death.

When police went to tell his wife, Dr. Robin Mitchell, that her husband had committed suicide, they found her body stabbed nearly 50 times.

Officers also found a two-page, handwritten note from the 28-year-old Howard that police said was neatly written in the beginning but, by the end, was illegible.

“It was just a note from him saying he was sorry for the mistakes he made in his life and some things about his family,” Sgt. Terry Hastings said. “There’s not a mention in there that he killed her.” Yet, investigators are calling the deaths a murder-suicide.

“This may be a case that we never know,” Hastings said. “Probably, the two people who can tell us are dead.”

Mitchell, 31, was chief neurosurgery resident at the medical school’s teaching hospital and herself a track star in her hometown of Newburgh, NY.

Howard was a star athlete from Shea High School in Pawtucket, RI, and was a 10-time NCAA champion at the University of Arkansas, earning titles in the indoor and outdoor long jump and triple jump. He went on to finish seventh and eighth respectively in his Olympic appearances.

AFTER surgery, Peggy Piontkowski spent four years being a stay-at-home mom with a disability. One day, her daughter came home complaining about the stiff and scratchy scrub suits she had to wear in nursing school.

“She asked me to make her a scrub suit, and at that moment, I had the whole company vision,” said Piontkowski, president and founder of Sassy Scrubs, a company based in North Syracuse, N.Y. that designs scrub suits for real-life doctors and nurses, as well as for actors like George Clooney on the TV show “ER.”

Piontkowski relied on technical help from a little-known government program to get her company’s online sales effort off the ground. The Manufacturing Extension Partnership, a division of the National Institute of Standards and Technology (NIST) in Gaithersburg, Md., has a $104.2 million budget this year to help business owners around the United States.

“Women don’t usually start out with an idea to make something like automotive parts,” said Kevin Carr, director of the MEP. “They just end up in manufacturing because their product got so popular they were forced to mass produce it.”

MEP’s federally funded centers provide technical assistance and consulting services to all sorts of small manufacturers. It appears to be money well spent. A survey of 4,551 MEP client companies reported an increase in total revenues of $294 million and savings of $20 million in inventory based on the services provided by NIST MEP.

While many people think only big corporations make things, small companies supplying arts and equipment accounted for 55 percent of the value-added content of finished products, according to government research.

Learning more about manufacturing and online sales has helped Sassy Scrubs compete with much bigger companies. Piontkowski went to the Central New York Technology Development Organization in Syracuse, an NIST affiliate, when she decided to sell products on the Internet.

“They helped us register the name Cyberscrubs,” said Piontkowski. “Now, I rely on them to create more marketing and development strategies.”

Scrutinizing systems

Sassy Scrubs recently introduced scrub jackets made from fleece and printed corduroy. Each scrub suit piece sells for between $25 and $50 said Piontkowski, whose 10-year-old company now posts annual revenues of $1 million.

“I didn’t invent the scrub suit, I just made it better by taking out all the things that would drive me crazy about wearing a uniform,” said Piontkowski.

MEP’s Carr said the program helps business owners adopt the best manufacturing business practices to minimize costs. It also promotes new and better methods to mass-produce products.

“Business owners usually call a center when they have a problem with quality or overall output,” said Can. “We go in and look for the bottlenecks in their process and see where things could be streamlined.”

There is no fee for the initial assessment, but if the company decides to go further with the recommendations, they do pay a consulting fee based on the specific project.

“We don’t just target a specific machine that could be improved, we look at the total picture, the whole process, and the entire enterprise as it exists in a supply chain,” Carr explained.

According to Carr, most MEP clients need help figuring out what to buy to improve their manufacturing process.

“Clients come to us saying, ‘I need to buy something that does this, but I don’t know which one to get or where to buy it,’” said Carr.

Thanks to help from the MEP, more than 50 percent of Sassy Scrubs’ sales now come from the Web site. Piontkowski still works at home. She has 18 other employees working from their own homes, making 300 to 400 suit pieces a week at a rate of $6 an hour.

“It’s very rewarding for me to see so many people able to work from home because I would’ve liked to do that after I had my surgery,” said Piontkowski. “I want to keep it a cottage industry, although I can foresee, the day when we will have to build a plant.”

Going to the dogs

Many businesswomen become manufacturers based on a home-based hobby. Melissa Trombley took a recipe she had for all-natural dog biscuits and launched a small manufacturing business last year.

“For 18 years, I’d been making these biscuits for our dogs in my kitchen,” said Trombley, president of The Barking Bakers Inc., based in Syracuse, N.Y. “Then, I realized that there’s probably a market for this, so I rented some space in a commercial, bakery and started churning out 1,300 biscuits a day.”

Trombley went to an NIST affiliate, the Technology Development Organization in Syracuse, N.Y., when she needed more production capability.

“I didn’t want to buy the equipment to produce a huge amount of biscuits,” said Trombley. “So they helped me find a good alternative in outsourcing.”

Trombley now relies on workers managed by the Association of Retarded Citizens to help her bake biscuits in their commercial kitchen.

“They learn skills that they can take out into the community to become productive citizens,” said Trombley. “I get help with the baking.”

Trombley sells her biscuits in grocery stores in five states; a box of 15 biscuits costs $5.99. She eventually plans to have her own production facility. The TDO continues to provide her free research assistance with her next idea — producing a biscuit cart (like a hot dog stand) to sell dog biscuits in parks.

“I’m trying to license the cart and the biscuits to county parks as a service they can provide to their community,” said Trombley. “If I could sell it to Central Park, I’d be making millions.”

Jane Applegate is the author of “201 Great Ideas for Your Small Business,” and is founder of ApplegateWay.com, a multimedia Web site for busy entrepreneurs.

QUESTION: In response to the recent joint Commission on Accreditation of Healthcare Organizations (JCAHO) sentinel event alert regarding surgical fires, our facility manager claims that we need fire blankets, not fire extinguishers, in the ORs. Should fire blankets be used in the OR instead of fire extinguishers?

ANSWER: Fire blankets are not recommended for use in the OR. Fire blankets usually are made of wool that is impregnated with a fire-retardant chemical. They are meant to be wrapped around the burning person to smother the fire. According to ECRI, fire blankets should not be placed in an OR or used for patient fires. Following are the many reasons for this strong statement.

* The fire could be sustained by oxygen delivered to the patient, preventing the blanket from being effective.

* A blanket traps the fire next to and under the patient, causing further injury.

* Placing a fire blanket on a patient may displace instruments and cause further injury.

* Fire blankets will burn if used in oxygen-enriched atmospheres.

* Blankets are less effective at extinguishing fires on a patient than other methods, such as the use of a carbon dioxide fire extinguisher.

* Their use on a patient can lead to additional complications, such as wound contamination or even spreading the fire.

* If the blanket is placed in the OR, staff members may assume that it is suitable to use to extinguish a surgical fire, placing the patient at further risk. (1,2)

The JCAHO sentinel event alert on preventing surgical fires does not suggest that fire blankets be used in the OR or that they should replace fire extinguishers. The joint Commission does recommend that health care organizations do the following things to prevent surgical fires.

* Inform all surgical personnel about the importance of controlling heat sources by adhering to laser and electro-surgical safety practices, managing fuels by allowing sufficient time for patient prep, and establishing guidelines for minimizing oxygen concentration under drapes.

* Develop, implement, and test procedures to ensure appropriate response by all surgical team members to fires in the OR.

* Report any instances of surgical fires to JCAHO, ECRI, the US Food and Drug Administration, and appropriate state agencies as a method of raising awareness and preventing the occurrence of fires in the future. (3)

Fire extinguishers should be located in or near the OR to deal with fires that engulf or have migrated off the patient. Staff members should know when, how, and why to use fire extinguishers to put out a fire. Water-based, carbon dioxide C[O.sub.2], and dry-powder fire extinguishers commonly are used in the OR. According to ECRI, a 5-Ib C[O.sub.2] extinguisher should be mounted just inside the entry of each OR. (1) Local authorities have jurisdiction over specific requirements for health care facility portable fire extinguishers. Requirements for each type of fire extinguisher vary from state to state. Each state authority for fire regulations is governed either by the fire marshal or the state department of health. Some states may have local or regional regulations as well. Facilities should contact the local fire district for specific regulations for their area. (4)

QUESTION: Our infection control officer has asked OR staff members to evaluate alcohol-based surgical hand scrub products to replace the iodophor impregnated scrub brushes that we have used for years. Are these new brushless, alcohol-based scrub products acceptable?

ANSWER: Surgical hand scrubs have been known to play a vital part in preventing surgical site infections for many years, beginning with the pioneering work of Ignaz Philipp Simmelweiss, MD, and Joseph Lister, MD, in the 1860s. Antiseptic products and techniques used to perform the surgical hand scrub have evolved and improved, reflecting the continuing advancement of medical and nursing science.

In recent years, manufacturers have begun to introduce new hand scrub products that are challenging traditional lengthy scrub routines that use water, brushes, and, most commonly, either iodophor or chlorhexidine gluconate preparations. In the 2002 “Guidelines for hand hygiene in health care settings,” the CDC suggested that health care providers also consider the use of alcohol-based surgical hand scrub products when selecting hand hygiene agents, citing studies demonstrating that hand scrub formulations containing 50% to 90% alcohol combined with chlorhexidine gluconate are more effective than chlorhexidine gluconate, iodophor, and plain soap alone. (5) The publication of this CDC guideline produced a flurry of interest in the new brushless, alcohol-based surgical hand scrub products.

Many infection control and perioperative professionals are interested in trying these new products. Adapting traditional practices to new technology and innovation should be encouraged but approached with informed caution. Selection of surgical hand scrub products should not be taken lightly, and changes in products and technique should be made only after careful consideration and evaluation.

Surgical hand scrub products should be evaluated first for their ability to substantially reduce microorganisms on intact skin. The product should have broad-spectrum activity, be effective immediately, and have persistent activity. (6) A cumulative effect, measured after multiple applications during five days, also is desirable. An important additional consideration is the effect on the user’s skin over time. The product should not be irritating or damage skin after frequent and long-term use.

Alcohol-based brushless scrub products generally combine an antimicrobial agent, such as chlorhexidine gluconate with 60% to 70% alcohol, and added moisturizing emollients. They may or may not require the use of water. Hands should be pre-washed and nails cleaned with a nail pick under running water to remove gross debris and superficial microorganisms before applying the alcohol-based scrub product. Water will dilute the product and reduce its effectiveness; therefore, hands and arms should be dried thoroughly before the alcohol-based scrub is applied. The product contains alcohol and is flammable, so it must be allowed to dry before an individual dons gown and gloves. The entire process requires approximately three to five minutes.

The benefits of selecting a brushless, alcohol-based surgical hand product may include

* fast and easy application,

* limited or decreased damage to the user’s skin,

* improved compliance with hand antisepsis protocols,

* simplified application technique, and

* reduced material waste (ie, water, brushes, packaging).

Disadvantages may include

* user training needed;

* failure of the user to properly wash his or her hands before applying the product; and

* potential fire hazard (eg, failure of the user to allow the alcohol to evaporate before he or she dons sterile gloves and gown, improper storage).

Improper use and application technique as a result of user unfamiliarity with manufacturer instructions can be a problem. Physicians and other personnel who are new to the facility or who practice in multiple facilities may not be familiar with the important differences between the traditional scrub routine using a brush and antiseptic solution and the brushless technique using an alcohol-based scrub product. New users may not understand that hands still must be washed and nails cleaned before the alcohol-based product is applied, even though the product itself may be waterless. They may not understand the importance of allowing the product to dry completely before donning gown and gloves. Although the brushless technique is easy to learn, old habits often are difficult to break. Introducing a brushless surgical scrub product requires additional staff member preparation and education.

Alcohol is flammable, and alcohol-based scrub products must be used and stored carefully to minimize fire hazard. Although alcohol-based products have been used in health care settings for general hand hygiene without incident for some time, the American Journal of Infection Control recently reported an incidence of flash fire associated with the use of an alcohol-based hand antiseptic agent[..sup.7] Flash fires associated with use of alcohol-based hand hygiene products can have potentially severe consequences for health care workers and their patients. Health care workers should ensure complete drying or evaporation of the product before they engage in other activities. Other risk reduction strategies include maintaining ambient humidity within recommended limit (8) and avoiding use of 100% polyester gowns and drapes. If polyester gowns and drapes are used, they should have an antistatic carbon fiber or an antistatic finish.