How To Perform Surgical Hand Scrubs

Human hands are the most important tools for caring. Hands feel, diagnose, cure, prod, and provoke as they are placed upon each patient who is hoping for answers, understanding, and healing remedies. The hands can also be a portal and transmitter of infection. While handwashing may be the simplest way to control infection, it is often not practiced where warranted.

Surgical site infections greatly contribute to nosocomial infections. Some of the risk factors for nosocomial infections include the behavior of OR personnel regarding decontamination practices, hand hygiene/antisepsis, and compliance with universal precautions. Most surgical professionals agree on the importance of good surgical hand-washing practices in infection prevention. Hand transmission is a critical factor in the spread of bacteria, pathogens, viruses that cause disease, and nosocomial infections in general.

The purpose of surgical hand scrub is to:

• Remove debris and transient microorganisms from the nails, hands, and forearms,
• Reduce the resident microbial count to a minimum, and
• Inhibit rapid rebound growth of microorganisms.¹

Surgical Scrub Techniques

All sterile team members should perform the hand and arm scrub before entering the surgical suite. The basic principle of the scrub is to wash the hands thoroughly, and then to wash from a clean area (the hand) to a less clean area (the arm). A systematic approach to the scrub is an efficient way to ensure proper technique.

There are two methods of scrub procedure. One is a numbered stroke method, in which a certain number of brush strokes are designated for each finger, palm, back of hand, and arm. The alternative method is the timed scrub, and each scrub should last from three to five minutes, depending on facility protocol.

The procedure for the timed five minute scrub consists of:

• Remove all jewelry (rings, watches, bracelets).
• Wash hands and arms with anitmicrobial soap. Excessively hot water is harder on the skin, dries the skin, and is too uncomfortable to wash with for the recommended amount of time. However, because cold water prevents soap from lathering properly, soil and germs may not be washed away.
• Clean subungual areas with a nail file.
• Start timing. Scrub each side of each finger, between the fingers, and the back and front of the hand for two minutes.
• Proceed to scrub the arms, keeping the hand higher than the arm at all times. This prevents bacteria-laden soap and water from contaminating the hand.
• Wash each side of the arm to three inches above the elbow for one minute.
• Repeat the process on the other hand and arm, keeping hands above elbows at all times. If the hand touches anything except the brush at any time, the scrub must be lengthened by one minute for the area that has been contaminated.
• Rinse hands and arms by passing them through the water in one direction only, from fingertips to elbow. Do not move the arm back and forth through the water.
• Proceed to the operating room suite holding hands above elbows.²
• If the hands and arms are grossly soiled, the scrub time should be lengthened. However, vigorous scrubbing that causes the skin to become abraded should be avoided.
• At all times during the scrub procedure care should be taken not to splash water onto surgical attire.²
• Once in the operating room suite, hands and arms should be dried using a sterile towel and aseptic technique. You are now ready to don your gown and sterile gloves.

When gowning oneself, grasp the gown firmly and bring it away from the table. It has already been folded so that the outside faces away. Holding the gown at the shoulders, allow it to unfold gently. Do not shake the gown.

Place hands inside the armholes and guide each arm through the sleeves by raising and spreading the arms. Do not allow hands to slide outside the gown cuff. The circulator will assist by pulling the gown up over the shoulders and tying it.

To glove, lay the glove palm down over the cuff of the gown. The fingers of the glove face toward you. Working through the gown sleeve, grasp the cuff of the glove and bring it over the open cuff of the sleeve. Unroll the glove cuff so that it covers the sleeve cuff. Proceed with the opposite hand, using the same technique. Never allow the bare hand to contact the gown cuff edge or outside of glove.

The scrubbed technologist or nurse gowns the surgeon after he or she has performed the hand and arm scrub. After handing the surgeon a towel for drying, the technologist or nurse allows the gown to unfold gently, making sure that there is enough room to prevent contamination by nonsterile equipment. To glove another person, the rules of asepsis must be observed. One person's sterile hands should not touch the nonsterile surface of the person being gloved.

• Pick up the right glove and place the palm away from you. Slide the fingers under the glove cuff and spread them so that a wide opening is created. Keep thumbs under the cuff.
• The surgeon will thrust his or her hand into the glove. Do not release the glove yet.
• Gently release the cuff (do not allow the cuff to snap sharply) while unrolling it over the wrist. Proceed with the left glove, using the same technique.

Formal guidelines and recommended practices for hand washing have been published by professional organizations (e.g., Association for Professionals in Infection Control (APIC), Association of periOperative Registered Nurses, Inc. (AORN). AORN recommends the use of a traditional standardized anatomical timed scrub or counted stroke method for surgical hand scrub and encourages institutions to follow the scrub agent manufacturer's written recommendations when establishing policies and procedures for scrub times. On this basis, for example, the typical scrub procedure for a PVPI-containing product based on manufacturer's labeling would require the use of a scrub brush and two applications of five minutes each, whereas the typical procedure for a CHG-based product would require a three-minute scrub followed by a three-minute wash. In actual practice, however, variations in surgical hand scrubbing times may be of shorter duration than manufacturer's recommendations for a number of reasons:

• Staff time constraints.
• Desire to reduce poor hand health.
• Acceptance of data from other sources suggesting those scrub times shorter than those recommended by manufactures are adequate.³

Hand condition is emerging as an increasingly important factor in personnel compliance and infection control. Frequent surgical scrubbing can cause dermatitis of the hands and arms. Most antimicrobial agents are drying to the skin, especially when coupled with a scrub brush.

Characteristics of a Surgical Scrub

Performance characteristics for a surgical scrub agent generally fall into four categories:

1. Antimicrobial Action--an ideal agent would have a broad spectrum of antimicrobial activity against pathogenic organisms. This agent would have to work rapidly. An agent that does not work rapidly may not provide adequate bacterial reduction before being rinsed off.

2. Persistent Activity--an agent offering persistent activity keeps the bacterial count low under the gloves. It is not unusual for a surgery to last in excess of two hours. Studies have shown the rate of glove failures (non-visible holes) increases with the duration of surgery.⁴ In addition, studies show bacteria grow faster under gloved than ungloved hands.^5,6,7

3. Safety--the ideal agent would be non-irritating and non-sensitizing. It must have no appreciable ocular or ototoxicity, be safe for use on the body, and not be damaging to the skin or environment.

4. Acceptance--probably most important to achieving compliance in using a new product is its acceptance by the healthcare worker. A product that has ideal antimicrobial action and an excellent safety profile is of little value to good infection control if the user population fails to support its use. Although each is important in its own right, all four characteristics should be present for a complete package.

Surgical scrub agents come in many forms. Not all forms meet all characteristics.

1. Liquid or foam soaps. These are the most common products for surgical scrubs and are used in conjunction with water and dry scrub brushes or sponges. The most common antimicrobial agents in these products are CHG (chlorhexidine gluconate), iodophor, or PCMX (parachlorometaxylenol). These agents are very drying and with repeated scrubbing with the scrub brush can cause skin damage.

2. Impregnated scrub brushes/sponges. Scrub brushes/sponges are preloaded with CHG, iodophor, or PCMX and are water-aided products.

3. Brush-free surgical scrub. These products use an antimicrobial agent and water but no scrub brush.

Conclusion

No matter what agent is used, or which scrub technique you practice, there is only one goal: infection prevention. Effective surgical scrubs are one of the most powerful strategies of infection prevention in the OR. Glove usage gives a false sense of security against bacteria. Gloves provide an ideal environment for bacterial growth, moisture and warmth, which makes good hand-scrub techniques and aseptic gowning and gloving an important part of the total infection prevention platform. It is important for healthcare management to help the personnel understand the cause/effect cycle of surgical scrubs as they relate to infection prevention.

Ellen Anderson-Manz, RN, BSN, a technical service specialist, and Deborah Gardner, LPN, OPAC, work for 3M Healthcare in St. Paul, Minn.

For a complete list of references visit www.infectioncontroltoday.com

Objectives

• To be able to list the three purposes of surgical hand scrubs.
• To describe correct scrub technique.
• To list the different characteristics of products used for surgical scrub.
• To be able to demonstrate the correct aseptic technique when gloving and gowning.

True or false questions

1. Surgical site infections contribute to nosocomial infections.
2. A timed scrub should last for one to three minutes.
3. The best water temperature is very hot; this tends to kill bacteria more quickly.
4. Vigorous scrubbing causes skin to become damaged and should be avoided.
5. The surgeon is normally gloved and gowned by the circulating nurse.
6. The purpose of surgical hand scrub is to sterilize the hands prior to gowning and gloving.
7. An ideal surgical scrub agent would have a broad spectrum of antimicrobial activity against pathogenic organisms.
8. Bacteria grow faster under gloved than ungloved hands.
9. When donning sterile gloves, the surgical scrub becomes less important.
10. Effective surgical scrubs are one of the most powerful strategies of infection prevention.

Answers

1. T.
2. F.
3. F.
4. T.
5. F.
6. F.
7. T.
8. T.
9. F.
10. T.

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