Professional Documents
Culture Documents
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.
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
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:
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:
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.
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.
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