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)
Ensure you ask the LeadSurgeon whether or not they would mind you scrubbing in, then make your way to the scrub area.
You must openyourgown and gloves before youscrub, so as not to contaminate your hands:
First, openthegown. Carefully use the edges of the paper to openthepacket and expose the surgical gown.
Next, chooseyourgloves. Peel the plastic glove packet open overthegown and dropthegloves onto the sterile gown withouttouchingthem.
This will ensure your gloves and gown are untouched, and therefore sterile.
Finally, put on a surgicalmask and eyewearprotection. Make sure you are comfortable, as you cannot adjust these once you are scrubbed.
1. Runthetap to an adequate temperature and flow (to avoid water splashing). Then testthewater 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 scrubsolution and work up a heavylather, then wash the hands and arms to the elbows.
Cleansing solutions are non-irritating to most people and include:
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 sterilenailbrush and nailpick from the opened package. Clean under the nails with the nailpick 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 antimicrobialsolution 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 nailbrush, scrub the spaces under the fingernails of the right or left hand. Repeat the process on the other hand.
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 fivestrokes rubbing backwards and forwards.
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 palmtopalm, creating a lather.
Rub the rightpalm over the backof the left and vice versa with the fingersinterlaced.
Rub hands palmtopalm, with fingersinterlaced.
Perform rotationalrubbing backwards and forwards with claspedfingers of the right hand into the left palm hand and vice versa.
Perform rotationalrubbing of the right thumb clasped in the left hand and vice versa.
Rub the fingertips of the left hand on the palm of the right hand and vice versa.
Continue with the rotatingaction down opposingarms, working to just below the elbows.
Rinse and repeat steps 1-7 keeping hands raised above elbows at all times.
The secondwash 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 wristsonly.
The scrub procedure should last for 5 minutes, with further scrubs during the day lasting 3 minutes.
Rinse the hands under running water, allowing the water to run from fingertips to elbows.
Turnthetapoff (if necessary) with your elbow and keep your handsup, allowing water to dripfromyourelbows.
Pick up onehandtowel from the top of the gown pack and stepback from the surface.
Grasp the towel and openit 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.
Holding one end of the towel with one hand dry the fingers of the opposite hand using a blottingrotationalmotion.
Move to the dryarea of the towel and continue in this manner down the forearm to the elbow.
Ensure you donotretrace from the forearm back up to the hands and donotwipe 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 othertowel from the pack for the otherhand and arm.
If you accidentally touch the tap or any surrounding objects, you must re-scrub.
Picking up the gown
1. With one hand, pickup the entire foldedgown from the wrapper by grasping the gown through all layers, being careful to touch only the insidetoplayer which is exposed.
2. Once your hands are securely pinchingthegown in these slots, stepback from the shelf and allow the gown to drop.
3. Make sure the gown doesnottouch any surroundingunsterileobjects.
Inserting your arms into the sleeves of the gown
4. Grasp the insideshoulderseams and open the gown with the armholesfacingyou.
5. Carefully insertyourarms part way into the gown oneatatime, 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 indexfinger. Be careful that no part of the hand protrudes from the sleeve cuff.
Fastening the gown
7. A theatre assistant will fastenthegown 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 securethegown at the neck and upperback. Gowns differ in how they are secured, but most with have either ties, buttons or velcrotabs.
Open the inner glove packet that you previously dropped onto your sterile field.
Pick up one glove by the folded cuff edge with your sleeve-covered hand.
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.
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.
While holding the glove’s cuff edge with one hand, grasp the uppermost edge of the glove’s cuff with the opposite hand.
Continuing to grasp the glove, stretch the cuff of the glove over the hand.
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.
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.
Adjust the fingers of each glove as necessary so that they fit appropriately.
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!
1. There is a cardboardslip holding twotiestogether across the frontofthegown.
2. Detach the cardboardslip from the shorttie, ensuring you keepholdoftheshorttie in your lefthand.
3. Now passthe cardboard slip to the theatreassistant, ensuring not to make direct contact with their hand.
4. They will passthe tie around your back – now takethetie, and letthempullthecardboardoff the tie so that you can tie a bow at your waist.
Medical student and illustrator
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]