Introduction to Surgical Hand Antisepsis
Effective surgical hand antisepsis is a critical component of infection prevention in any healthcare setting. The World Health Organization (WHO) provides authoritative guidelines to standardize these procedures globally, ensuring patient safety and minimizing the risk of surgical site infections (SSIs). The key takeaway from the WHO's recommendations is the emphasis on proper technique and product selection rather than a strict, standardized duration for all methods. The guidelines offer flexibility while maintaining high standards of microbial reduction on the hands and forearms of surgical staff.
Water-Based Surgical Scrub Technique
Historically, the traditional water-based surgical scrub was the standard. This method involves the use of an antimicrobial soap and running water, typically lasting between two and five minutes, depending on the product manufacturer's instructions. Long scrub times, such as 10 minutes, are not necessary and can increase skin irritation.
Step-by-Step Water-Based Procedure
Before beginning, all jewelry must be removed from the hands and wrists, and artificial nails are prohibited. If hands are visibly soiled, a preliminary wash with plain soap is required.
- Preparation: Start by wetting hands and forearms under clean, running water.
- Nails: Use a nail cleaner to remove debris from under the fingernails, doing this preferably under running water.
- Application: Apply the manufacturer's recommended amount of antimicrobial soap to hands and forearms.
- Scrubbing: Vigorously scrub all surfaces of the hands, fingers (including between them), palms, backs of hands, and forearms up to the elbows. Pay careful attention to the four sides of each finger, hand, and forearm.
- Rinsing: Rinse hands and forearms thoroughly under running water, keeping hands elevated above elbows to ensure water flows from the cleaner area (fingertips) to the dirtier area (elbows).
- Drying: Use a sterile towel to dry hands and forearms completely before donning sterile gloves.
Alcohol-Based Surgical Hand Rub (ABHR) Technique
The waterless method using an alcohol-based hand rub (ABHR) with sustained activity is a highly effective alternative to the traditional scrub, especially when water quality is not assured. This method is generally less irritating to the skin and often results in higher adherence rates among staff.
Step-by-Step Waterless Procedure
Similar to the water-based method, remove all jewelry and ensure hands are clean and dry before starting. The technique must follow the specific instructions and application times recommended by the product manufacturer.
- Dispense: Apply the required amount of ABHR into the palm of one hand.
- Nail beds: Dip the fingertips of the opposite hand into the solution to decontaminate under the nails.
- Application: Spread the solution over the hand and forearm, ensuring all surfaces are covered. Rub until dry.
- Repeat: Repeat the process for the other hand and forearm.
- Final rub: Dispense an additional amount of product and rub both hands up to the wrists, continuing until dry.
- Drying: Allow hands and forearms to dry thoroughly before donning sterile gloves.
Comparing Water-Based and Waterless Methods
WHO supports both methods, and the choice often depends on institutional protocol, product availability, and specific surgical circumstances. Here is a comparison:
| Feature | Water-Based Scrub | Alcohol-Based Hand Rub (ABHR) |
|---|---|---|
| Product | Antimicrobial soap (e.g., chlorhexidine or iodophor) | Alcohol-based rub with sustained activity |
| Procedure Time | 2–5 minutes, per manufacturer instructions | Varies per manufacturer, generally shorter than water-based scrub |
| Equipment | Running water, sink, scrub brush/sponge (for nails only), sterile towel | Dispenser for ABHR, sterile towel |
| Skin Impact | Higher risk of irritant dermatitis with frequent use | Often less irritating and drying to the skin |
| Requirement | Hands must be visibly soiled to initiate wash | Can be used on hands that are not visibly soiled |
| Efficacy | Effective at reducing bacterial load on skin | Preferred means for routine antisepsis, often more effective at killing germs |
| Limitations | Requires adequate water supply and infrastructure | Flammability concerns require safe storage |
Key Considerations and Best Practices
Beyond the specific technique, WHO guidelines include other critical recommendations for surgical hand preparation:
- No Brushes: The use of brushes is generally not recommended for surgical hand preparation, as they can cause skin damage. They may only be used for cleaning under fingernails.
- Nail Care: Natural nails must be kept short (tips less than 0.5 cm). Artificial nails and extenders are not permitted, as they can harbor microbes.
- Sequential Use: Do not combine antimicrobial soaps with alcohol-based products sequentially, as this can cause skin irritation.
- Drying: Allow hands and forearms to dry completely after any scrub or rub before donning sterile gloves. This is particularly important for alcohol-based products to be fully effective.
Conclusion
Adherence to the Who guidelines surgical scrub is non-negotiable for safe surgical practice. By following the correct procedural steps for either the water-based or alcohol-based hand antisepsis methods, healthcare professionals can significantly reduce the risk of surgical site infections. Choosing the appropriate method depends on the clinical context and institutional policy, but the fundamental principles of preparation, meticulous technique, and complete drying remain constant. Continuous training and education on these guidelines are essential for maintaining the highest standards of patient care.
For a comprehensive overview of the full range of hand hygiene practices, including non-surgical scenarios, healthcare providers can refer to the official WHO Hand Hygiene Guidelines, accessible on the National Center for Biotechnology Information (NCBI) website.
