The surgical hand scrub is a highly standardized procedure designed to drastically reduce the microbial count on the hands and forearms of surgical personnel. Its primary purpose is the removal of transient microorganisms, which are loosely attached to the skin surface, and the significant reduction of resident flora, which live in the deeper layers of the epidermis. This meticulous process plays a fundamental role in maintaining sterility throughout an operation, thereby minimizing the risk of surgical site infections for the patient. Adherence to this strict protocol is a foundational requirement for any team member preparing to enter the sterile field.
Principles of Asepsis and Sterility
Asepsis refers to the practice of reducing or eliminating microorganisms to prevent infection. Medical asepsis, often called the “clean technique,” involves procedures that reduce the number of microbes and prevent their spread, such as routine handwashing or using clean gloves for non-surgical procedures. Surgical asepsis, in contrast, is the “sterile technique,” which aims to eliminate all microorganisms and spores from an area, creating the sterile field necessary for surgery. This higher standard requires the rigorous preparation of personnel and equipment.
The sterile field is a designated area maintained free of all microorganisms, and the hand scrub is the preparatory step for team members to enter this zone. The skin naturally harbors two types of microbes: transient flora, which are acquired through contact and are easily removed with soap and water, and resident flora, which reside in the deeper layers of the skin. The surgical scrub uses specialized antiseptic agents to penetrate and significantly suppress this resident population. This suppression is necessary to ensure that fewer microbes are shed into the surgical wound during the operation.
Initial Preparation Before the Scrub
Before approaching the scrub sink, surgical team members must complete preparations to prevent contamination. Proper operating room attire is required, including donning a surgical cap to contain all hair, a face mask to cover the nose and mouth, and shoe covers. These items are necessary because they reduce the shedding of skin cells and microorganisms into the environment, which is crucial for maintaining the overall cleanliness of the surgical suite.
The complete removal of all jewelry, including rings, watches, and bracelets, is required before beginning the scrub, as these items harbor microorganisms that cannot be effectively sterilized by the antiseptic agents. Fingernails must be kept short and free of polish, since chipped polish can flake off and harbor bacteria, and long nails are difficult to clean thoroughly. Furthermore, the hands and forearms should be inspected for any cuts, abrasions, or open lesions, which could contraindicate scrubbing and require alternative preparation methods.
The scrub area itself should be organized, with warm running water, antiseptic dispensers, and any necessary sterile sponge-brushes readily accessible. The hands must be pre-wetted up to the elbow. A preliminary wash with a non-antiseptic soap is often performed to remove gross debris and surface contaminants before starting the antiseptic phase of the scrub.
The Antiseptic Surgical Hand Scrub Technique
The actual antiseptic scrub begins after the initial rinse and pre-wash, ensuring the hands and forearms are wet. The accepted procedure follows one of two standardized methods to ensure comprehensive coverage and sufficient contact time with the antiseptic agent.
Timed Scrub
This method requires a specific duration, typically ranging from three to five minutes for each hand and forearm.
Counted Stroke Method
This alternative specifies a set number of brush strokes for each surface of the hand and arm. This usually dictates 30 strokes for the fingernails and 20 strokes for each of the four planes of the fingers, hands, and arms.
Throughout the entire scrubbing process, the hands must always be held higher than the elbows, allowing water and antiseptic solution to flow down the arms. This gravitational flow ensures that contaminated water moves away from the more thoroughly scrubbed hands toward the less-clean elbow area. The scrub must cover the entire area from the fingertips up to two inches above the elbow, ensuring sufficient sterile coverage for gowning.
Commonly used antiseptic solutions include Chlorhexidine Gluconate (CHG) or Iodophor solutions, which are chosen for their broad-spectrum antimicrobial activity and persistent residual effect on the skin. The scrubbing action begins systematically at the fingernails, using a sterile nail cleaner to address the subungual space. The process then continues sequentially to the fingers, moving from the thumb to the pinky. The scrub then proceeds to the palm, the back of the hand, and finally the forearm, working circumferentially toward the elbow before moving to the opposite arm.
Proper Rinsing and Hand Position
Following the completion of the scrub, the rinsing phase requires a strict technique to maintain the cleanliness achieved. The hands must be positioned under the running water so that the flow moves only from the fingertips downward to the elbows. This one-way flow is essential because it prevents water that has passed over the less-clean elbow area from running back onto the hands, which are considered the cleanest part of the scrubbed area.
Care must be taken to avoid touching the sink basin or any unsterile surface with the hands or forearms during the rinsing process. Once rinsing begins, the hands must be lifted and kept in a high position, held up in front of the body and close to the chest. This posture keeps the scrubbed hands away from the unsterile surgical attire and prevents accidental contact with the body or other unsterile objects while moving to the operating room.
Entering the Operating Room and Gowning
After the final rinse, the surgical team member must back away from the sink area to avoid touching the wet, unsterile surfaces. The hands remain elevated in the mandatory position, held high and away from the body, while entering the sterile environment of the operating room. The next step involves receiving a sterile towel from a circulating nurse.
The sterile towel must be grasped at one corner, unfolded, and held away from the body to prevent contamination. A precise drying technique is then employed to ensure the hands and arms are completely dry before gowning. One half of the towel is used to thoroughly dry one hand and forearm, beginning at the fingertips and working up to the elbow. The towel is then inverted, and the unused, opposite half is used to dry the second hand and forearm using the same motion, ensuring no cross-contamination occurs.
The used towel is then discarded without touching unsterile objects, and the individual proceeds immediately to the process of donning the sterile surgical gown. This is followed by the closed-gloving technique, where the hands never exit the cuff of the gown. This method completes the transition into the fully sterile attire required for participation in the surgical procedure.