Surgical hand hygiene (SHH) is a rigorous, standardized procedure performed by the surgical team immediately before an operation. This multi-step process is a foundational requirement for patient safety inside the operating room. The primary goal is to significantly reduce the number of microorganisms on the hands and forearms of personnel to minimize the risk of infection during invasive procedures. It involves a precise technique and the use of specialized antiseptic agents to achieve a level of cleanliness that goes beyond routine hand washing. The execution of this protocol protects the patient from potential pathogens introduced from the surgical staff’s skin.
Distinguishing Surgical from Routine Hand Hygiene
Surgical hand preparation differs from routine hand hygiene in both its objective and execution. Routine hand washing, typically performed with non-antimicrobial soap and water, aims to remove transient microorganisms and physical dirt. In contrast, SHH is designed to eliminate transient flora and substantially reduce resident flora, which are the deeper-seated microorganisms that live beneath the skin’s surface.
The anatomical area covered is broader, extending from the fingertips up to two inches above the elbow. Most significantly, SHH must achieve a persistent microbial reduction, meaning the antiseptic agent must continue to kill bacteria for the duration of the surgical procedure. This sustained activity is necessary because surgical gloves can develop microscopic tears or punctures, creating a pathway for bacteria to reach the patient’s surgical site.
The Types of Surgical Preparation Agents
Two primary methods are used for surgical hand preparation: the traditional surgical scrub and the antiseptic hand rub. The traditional scrub involves water and an antiseptic soap or detergent, most commonly containing chlorhexidine gluconate (CHG) or povidone-iodine. Chlorhexidine gluconate is a broad-spectrum agent known for its residual activity, allowing it to remain active on the skin and inhibit bacterial regrowth for hours after application.
Povidone-iodine is another widely used aqueous agent, though it generally lacks the long-acting residual effect of CHG. The alternative method, the waterless antiseptic hand rub, utilizes an alcohol-based solution, typically ethyl or isopropyl alcohol, often at a concentration between 60% and 95%. Alcohol is fast-acting and highly effective at immediately reducing microbial counts, often surpassing the immediate efficacy of traditional scrubs.
Alcohol-based hand rubs are increasingly favored due to their speed and reduced tendency to cause skin irritation compared to the friction and drying associated with the water-based scrub. However, to ensure a persistent effect, alcohol rubs are frequently combined with a residual agent like a low concentration of CHG. Both methods must meet stringent performance criteria set by regulatory bodies for immediate bacterial kill and sustained efficacy under the surgical glove.
Step-by-Step Protocol for the Surgical Scrub
The standardized protocol for the surgical scrub begins with removing all jewelry from hands and forearms, as well as inspecting the skin for any cuts or abrasions. Personnel must first perform a pre-wash with soap and water if their hands are visibly soiled or before the first procedure of the day.
- Debris is meticulously cleared from underneath the fingernails using a disposable nail cleaner under running water.
- The hands and forearms are wetted, and the antimicrobial agent is applied. Ensure that the hands are held higher than the elbows to allow water to run off toward the least clean area.
- The scrubbing phase, which typically lasts between two and six minutes depending on the agent and institutional guidelines, must cover all four surfaces of each finger, the hands, and the forearms up to the elbow. Standards are set by the World Health Organization and the Centers for Disease Control and Prevention.
- After the required scrub time, the hands and forearms are rinsed thoroughly under running water, maintaining the hands-up position to prevent water from running back down from the elbow.
- The final step is the sterile drying technique. A sterile towel is used to dry one hand and arm completely before using a different section of the towel for the other. The towel is then discarded without touching non-sterile surfaces, preparing the person for donning a sterile gown and gloves.
The Role of Hygiene in Preventing Surgical Site Infections
The disciplined practice of surgical hand hygiene is directly linked to preventing Surgical Site Infections (SSIs) in patients. SSIs are among the most common healthcare-associated infections and can lead to significant patient harm. The procedure minimizes the transfer of microorganisms from the surgical team’s skin to the patient’s open wound.
The rigorous reduction of both transient and resident skin flora ensures that even if a surgical glove is compromised during the operation, the number of bacteria released into the sterile field remains low. A successful SHH protocol reduces the risk of SSI, which can otherwise cause prolonged hospital stays, increased healthcare costs, and higher rates of morbidity and mortality for the patient. The sustained efficacy of the antiseptic agents is the primary defense against introducing pathogens that could develop into a postoperative infection.