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The surgical scrub is an important procedure required to reduce the risk of contamination by microorganisms during operative procedures.

The surgical scrub involves first decontaminating the hands, then donning a sterile surgical gown and pair of sterile gloves.

This guide will take you through the important considerations when scrubbing for theatre, in particular:

1. Preparing to scrub

2. Surgical hand wash

3. Gloving and gowning

Check out our surgical scrub, gowning and gloving OSCE mark scheme here

 


Preparing to scrub

You should be dressed appropriately to enter the operating theatre. Although this may vary from hospital to hospital, generally you must wear:

  • Surgical scrubs (bare below the elbows, including removing watches and rings)
  • Footwear such as clogs
  • Theatre hat (with hair tied up if necessary)
  • ID badge

Ensure you ask the Lead Surgeon whether or not they would mind you scrubbing in, then make your way to the scrub area.

You must open your gown and gloves before you scrub, so as not to contaminate your hands:

  • First, open the gown. Carefully use the edges of the paper to open the packet and expose the surgical gown.
  • Next, choose your gloves. Peel the plastic glove packet open over the gown and drop the gloves onto the sterile gown without touching them.
  • This will ensure your gloves and gown are untouched, and therefore sterile.
  • Finally, put on a surgical mask and eyewear protection. Make sure you are comfortable, as you cannot adjust these once you are scrubbed.

Surgical scrub

Pre-scrub wash

1. Run the tap to an adequate temperature and flow (to avoid water splashing). Then test the water before starting to scrub to ensure the temperature is comfortable.

2. Open the package containing the nail brush/scrub sponge and nail pick, then lie it on the back of the scrub sink still in the opened package.

3. Wet the hands and arms for an initial pre-scrub wash. Use several drops of scrub solution and work up a heavy lather, then wash the hands and arms to the elbows.

Cleansing solutions are non-irritating to most people and include:

  • Povidone Iodine
  • Chlorhexidine
  • Some hospitals use dispensable alcohol gel, which can be used between short, ‘clean’ procedures. Check with the operating surgeon if they are happy for you to use this.

 

4. Rinse the hands and arms thoroughly, allowing the water to run from the hands to the elbows.

5. Remove the sterile nail brush and nail pick from the opened package. Clean under the nails with the nail pick and then discard in the bin (making sure not to touch the bin by using a foot-pedal).

6. Moisten the nail brush and dispense antimicrobial solution onto the sponge-side.

7. Lather the fingertips with sponge-side of brush, washing all four sides of the fingers.

8. Then using the bristle side of the nail brush, scrub the spaces under the fingernails of the right or left hand. Repeat the process on the other hand.

 

 

Scrubbing procedure

During each of the following steps keep hands (clean area) above the elbows (dirty area) allowing water to drain away, making sure to avoid splashing surgical attire.

Each step of surgical ‘scrubbing’ consists of five strokes rubbing backwards and forwards.

Step 1

  • Wet the hands and forearms.
  • Apply the specified amount of appropriate antimicrobial solution, according to the manufacturer’s recommendations, from the dispenser (one downward stroke action).
  • Work the cleaning solution into the hands palm to palm, creating a lather.
Surgical scrub - rinse hands and forearms

Rinse hands and forearms

 

Step 2

  • Rub the right palm over the back of the left and vice versa with the fingers interlaced.
Surgical hand scrub

Rub the right palm over the back of the left and vice versa with the fingers interlaced

 

 

Step 3

  • Rub hands palm to palm, with fingers interlaced.

 

 

Surgical hand scrub - palm to palm

Rub hands palm to palm, with fingers interlaced.

Step 4

  • Perform rotational rubbing backwards and forwards with clasped fingers of the right hand into the left palm hand and vice versa.
Surgical hand scrub, clasped fingers

Perform rotational rubbing backwards and forwards with clasped fingers of the right hand into the left palm hand and vice versa.

 

Step 5

  • Perform rotational rubbing of the right thumb clasped in the left hand and vice versa.
Surgical hand scrub - clasp thumb

Perform rotational rubbing of the right thumb clasped in the left hand and vice versa.

 

Step 6

  • Rub the fingertips of the left hand on the palm of the right hand and vice versa.
Surgical hand scrub - fingertips

Rub the fingertips of the left hand on the palm of the right hand and vice versa.

 

 

Step 7

  • Continue with the rotating action down opposing arms, working to just below the elbows.

 

Surgical hand scrub - elbows

Continue with the rotating action down opposing arms, working to just below the elbows.

 

Step 8

  • Rinse and repeat steps 1-7 keeping hands raised above elbows at all times.
  • The second wash should only cover two-thirds of the forearms to avoid compromising cleanliness of hands.
  • Local policy may include repeating these steps a third time but to wrists only.
  • The scrub procedure should last for 5 minutes, with further scrubs during the day lasting 3 minutes.

 

Step 9

  • Rinse the hands under running water, allowing the water to run from fingertips to elbows.
  • Turn the tap off (if necessary) with your elbow and keep your hands up, allowing water to drip from your elbows.

 

Surgical scrub - rinse hands and forearms

Rinse hands and forearms

 

Step 10

  • Pick up one hand towel from the top of the gown pack and step back from the surface.
  • Grasp the towel and open it fully. Do not allow the towel to touch any unsterile object or unsterile parts of your body.
  • Hold your hands and arms above your elbow, and keep your arms away from your body.

 

Step 11

  • Holding one end of the towel with one hand dry the fingers of the opposite hand using a blotting rotational motion.
  • Move to the dry area of the towel and continue in this manner down the forearm to the elbow.
  • Ensure you do not retrace from the forearm back up to the hands and do not wipe the skin dry. This may contaminate your hands with micro-organisms from your proximal forearm – you will be asked to re-scrub.
  • Repeat with the other towel from the pack for the other hand and arm.
Surgical hand scrub - drying hands

Dry each arm, starting at the fingertips, working towards the elbow.

 

If you accidentally touch the tap or any surrounding objects, you must re-scrub.


Gowning

Picking up the gown

1. With one hand, pick up the entire folded gown from the wrapper by grasping the gown through all layers, being careful to touch only the inside top layer which is exposed.

2. Once your hands are securely pinching the gown in these slots, step back from the shelf and allow the gown to drop.

3. Make sure the gown does not touch any surrounding unsterile objects.

 

Inserting your arms into the sleeves of the gown

4. Grasp the inside shoulder seams and open the gown with the armholes facing you.

5. Carefully insert your arms part way into the gown one at a time, keeping hands at shoulder level away from the body.

6. Slide the arms further into the gown sleeves and when the fingertips are level with the proximal edge of the cuff, grasp the inside seam at the cuff hem using thumb and index finger. Be careful that no part of the hand protrudes from the sleeve cuff.

 

Fastening the gown

7. A theatre assistant will fasten the gown behind you, positioning it over the shoulders by grasping the inside surface of the gown at the shoulder seam. The theatre assistant’s hands should only ever be in contact with the inside surface of the gown.

8. The theatre assistant then prepares to secure the gown at the neck and upper back. Gowns differ in how they are secured, but most with have either ties, buttons or velcro tabs.


Gloving

1. Open the inner glove packet that you previously dropped onto your sterile field.

2. Pick up one glove by the folded cuff edge with your sleeve-covered hand.

3. Place the glove on the opposite gown sleeve facing palm down, with the glove fingers pointing towards you. The palm of the hand inside the gown sleeve must be facing upward toward the palm of the glove.

4. Place the glove’s rolled cuff edge at the seam that connects the sleeve to the gown cuff. Grasp the bottom rolled cuff edge of the glove with the thumb and index finger of the hand the glove is on top of.

5. While holding the glove’s cuff edge with one hand, grasp the uppermost edge of the glove’s cuff with the opposite hand.

6. Continuing to grasp the glove, stretch the cuff of the glove over the hand.

7. Using the opposite sleeve covered hand, grasp both the glove cuff and sleeve cuff seam and pull the glove onto the hand. Pull any excessive amount of glove sleeve from underneath the cuff of the glove.

8. Using the hand that is now gloved put on the second glove in the same manner. Check to make sure that each gown cuff is secured and covered completely by the cuff of the glove.

9. Adjust the fingers of each glove as necessary so that they fit appropriately.

 

Key Points

  • Keep your hands in your sleeves so that you do not touch the glove on the outside of the gown with your bare hands.
  • Keep your hands above your waist and in front of you
  • Ensure you do not touch anything around you that is not sterile – this includes your face, mask, and hat!

 


Final tie

1. There is a cardboard slip holding two ties together across the front of the gown.

2. Detach the cardboard slip from the short tie, ensuring you keep hold of the short tie in your left hand.

3. Now pass the cardboard slip to the theatre assistant, ensuring not to make direct contact with their hand.

4. They will pass the tie around your back – now take the tie, and let them pull the cardboard off the tie so that you can tie a bow at your waist.

 


ILLUSTRATOR

Aisha Ali

Medical student and illustrator

 


References

1. National Institute for Health and Care Excellence 2008 Clinical Guideline 74 – Surgical Site Infection: Prevention and treatment of surgical site infection London, NICE

2. World Health Organisation 2009 WHO Guidelines on Hand Hygiene in Health Care (revised Aug 2009) [online] www.who.int/gpsc/en [Accessed August 2018]

3. The Association for Perioperative Practice. A guide to surgical hand antisepsis 2014. [Accessed August 2018]


 

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