Chapter 2: Table of Contents
Hand preparation is typically performed using a commercial hand brush. The purpose of the surgical hand scrub is to reduce the amount of bacteria that could possibly come in contact with the patient during surgery should a glove puncture occur. A proper hand scrub will ensure a low risk of contamination of the surgical field if a glove is punctured. All jewelry should be removed as it can harbor bacteria and cause damage to gloves or tissues during surgery. Nail polish and artificial nails should not be worn to perform surgery as they too can harbor larger numbers of bacteria. Commercial hand brushes have a sponge side and a bristle side, and come with a nail-cleaning tool within the package. They are often soaked with chlorhexidine or iodine soap solutions but others are also available. Scrubbing will effectively reduce the amount of dirt and oils present on the hands and arms, the number of transient bacteria and the endogenous bacterial flora of the skin. The soaps or detergents used for surgical scrubbing should be non-irritating to the skin, fast acting, have a broad spectrum of activity and ideally have good residual activity to prevent a rapid rebound of microbial growth on the gloved skin. Chlorhexidine gluconate, povidone-iodine, and hexachlorophene are most commonly used for surgical hand scrub. The two accepted methods of scrubbing are the anatomic timed scrub (i.e. 5-6 minute scrub) and the counted brush stroke scrub (strokes per surface area of skin); the anatomic timed scrub is taught here). Both methods can be utilized as they ensure sufficient exposure of the surgeon’s hands and forearms to the disinfectant solution but the timed scrub is used at the OVC. Hand scrubbing should be performed for 5-6 minutes but should not be excessively long or aggressive (do not use the bristle side of the brush on the skin, only on your nails) as this will result in damage to the cornified layer of the skin and subsequent release of bacteria. Studies have shown that bacterial cultures of the skin after 10 minute scrubs result in more positive cultures than after a normal 5-6 minute scrub. If scrubbing multiple times in the same day, a 3-5 minute scrub is sufficient between consecutive cases. Brush packs and nail clippers are found near the washing station. Fingernails should be trimmed short to prevent excessive damage to the gloves and because dirt and bacteria lodged at the base of longer nails are harder to reach during scrubbing. Nails should also be free of polish (even if clear) as they too can harbor bacteria. Scrubbing is performed using either an individually packed disposable scrub brush that may already contain an antiseptic soap or autoclavable scrub brushes which are reusable and are soaked with antiseptic soap at the time of use. **More recently, alcohol based rubs have gained favour and replaced the use of a scrub brush to scrub hands resulting in shortened scrub times (see Alcohol Based Hand-Rubs below).
The Anatomic Timed Scrub
1) Open the sponge pack and leave the brush inside the package in an area where it is easily accessible and is least likely to become grossly contaminated. Wet your hands, apply soap (0.3% Triclosan is used at the OVC for this step) from the soap dispenser and create suds along your hands and forearms. This begins the contact time between the antiseptic and your skin. Be certain not to touch your hands or arms on any part of the sink or tap during the scrubbing procedure as this will require additional scrubbing time to that area (1 extra minute) due to contamination. Scrub sinks are usually activated using motion sensors or foot peddles to allow rinsing without contamination.
2) Pickup the nail-cleaning tool from the sponge package and clean your nails thoroughly. This can be done under running water. Then rinse off the remaining soap from your hands and arms and discard the nail-cleaning tool.
3) Note the starting time on a clock.
4) Scrub brushes have two sides, a sponge side which contains the antimicrobial soap of choice used to form a lather on the hands and forearms and a bristle brush side which can be used to scrub the nails but should not be used to scrub the skin.
5) Soak the scrub brush with running water – do not ring it out in the sink or you will lose much of the antiseptic soap. Ideally, the sponge side should first be used to apply suds over the hands and forearms ensuring enough contact time betwen the antiseptic and your skin. Then, you can use the bristle side of the sponge to scrub your nails only. Once this is done, use the sponge side of the brush to scrub each area of your hands and forearms as follows: nails, fingers (all four sides), palm and top of the first hand followed by the wrist of the first hand (2 minutes). Add water to the brush and repeat on the second hand (2 minutes). Once each hand and wrist have been scrubbed, scrub each forearm up to 1 inch above the elbow (1 minute each) keeping your hands above the elbow at all times to prevent dripping towards your hands. Using this timed scrub technique, the total scrub time (soap contact time) should be 5-6 minutes. Do not return to the hands once you have scrubbed more proximally (unless you contaminate yourself on the scrub sink and have to begin again, in this instance, scrub the contaminated area for 1 additional minute.
6) While maintaining eye contact with your hands / arms to prevent contact with the sink or faucet, 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. Remember to keep your hands up to prevent water from running from the elbow area (which is not as clean) towards your hands. Do not shake your hands to remove excess water. Let the water drip off your arms before returning to the surgery suite to prevent water accumulating on the floor or contaminating your gown pack.
Points to Remember:
- At all times during the scrubbing process, the hands and wrists should be held higher than the forearms and elbows (even during rinsing) to prevent the tracking of bacteria from the forearms to the hand.
- The surgeon should moisten the scrub brush in order to create adequate lather during scrubbing. Then, using the sponge side of the brush begin scrubbing the first hand.
- The scrub begins with the nails and fingers. In order to do this properly the surgeon should divide each finger and thumb into four sides and meticulously sponge all sides and the web of the fingers. The nails and fingers of the second hand should then be sponged.
- Do not brush an entire hand and forearm from fingers to elbow and then proceed to brush the other hand as this will contaminate the fingers of the second hand with bacteria from the first forearm scrubbed.
- The surgeon should be careful to ensure the hands and wrist are always at a level higher than the forearms, to ensure there is no tracking of bacteria to the hands.
Alcohol-Based Hand Rubs
Hand rubs are a newer alternative to hand scrubbing. This technique uses an alcohol based antiseptic solution that is rubbed onto dry, clean skin and is not scrubbed, rinsed or dried with a towel. These solutions are proven to provide rapid and wide spectrum antimicrobial activity, to decrease skin irritation, to improve compliance and to reduce the risk of hand contamination by rinsing water (Parienti 2002, Widmer 2010). Alcohol based rubs have been shown to have the same immediate effect as chlorhexidine scrub but to last longer (Verwilghen 2011) and are associated with similar infection rates as traditional scrub techniques (Parienti 2002). The technique for hand rubs may vary from brand to brand. We currently use Avaguard® (main ingredients are chlorhexidine and alcohol) and Sterillium®(main ingredient is alcohol) using the following technique:
1) Wash hands with soap (not a soap scrub brush) and clean nails with the nail pick (under running water)
2) Dry hands completely (very important)
3) Apply the first dose into one palm
4) Soak opposite fingertips and rub into fingernails, then the palm and hand, and along the arm to just above the level of the elbow.
5) Repeat on the other hand (second dose)
6) Apply a third dose and spread over all areas of both hands and wrists
7) Continue to rub until dry (*do NOT use a towel)