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References and further reading

• A

l-Naam

i MY, A

njum M

N, A

fzal MF ,A

l-Yami M

S, Al-Q

ahtani SM, A

l-Dohayan A

D, El-Tinay O

FY, KarimA

AA

, Khairy GA

, Al-Saif A

A, Zubaidi A

M, A

l-Obaid O

A, A

l-Saif FA 2009 A

lcohol-based hand-rub versus traditional surgical scrub and the risk of surgical site infection: a random

ized controlled equivalent trial EWM

A Journal 9 (3) 5-10

• A

ssociation for Perioperative Practice 2016 Standards and Recomm

endations for Safe Perioperative Practice 3rd edition Harrogate, A

fPP

• A

ssociation of periOperative Room

Nurses 2014 Perioperative Standards and Recom

mended Practices D

enver AORN

• Ayli�e G

AJ, Fraise A

P, Geddes A

M, M

itchell K 2000 Control of Hospital Infection: A

practical handbook 4th edition London, Arnold

• Centers for D

isease Control and Prevention 2002 Guideline for H

and Hygiene in H

ealth-Care Settings: Recomm

endations of the Healthcare Infection Control Practices A

dvisory Comm

ittee and the HICPA

C/SHEA

/APIC/ID

SA

Hand H

ygiene Task Force Available from: https://w

ww

.cdc.gov/mm

wr/PD

F/rr/rr5116.pdf [Accessed May 2017]

• M

archand R, Theoret S, Dion D

, Pellerin M 2008 Clinical im

plementation of a scrubless chlorhexidine/ethanol pre-operative surgical hand rub Canadian O

perating Room N

ursing Journal 26 (2) 21-2, 26, 29-31

• N

ational Institute for Health and Care Excellence 2008 Clinical G

uideline 74 – Surgical Site Infection: Prevention and treatment of surgical site infection London, N

ICE

• N

ational Institute for Health and Care Excellence 2013 Surgical site infection: evidence update 43 Available from

: http://ww

w.nice.org.uk/guidance/cg74/evidence/evidence-update-241969645 [Accessed M

ay 2017]

• Parvizi J, G

ehrke T, Chen AF 2013 Speciality U

pdate: Arthroplasty – Proceedings of the International Consensus on Perioperative Joint Infection The Bone &

Joint Journal 95–B (11) 1450-2

• Paulson D

S 2004 Hand scrub products - perform

ance requirements versus clinical relevance AO

RN Journal 80 (2) 225-8, 230-1, 233-4

• Petterw

ood J, Shridhar V 2009 Water conservation in surgery: a com

parison of two surgical scrub techniques dem

onstrating the amount of w

ater saved using a ‘taps on/taps o�’ technique Australian Journal of Rural H

ealth 17 (4) 214-7

• Som

ner JEA, Stone N

, Koukkoulli A, Scott KM

, Field AR, Zygm

unt J 2008 Surgical scrubbing: can we clean up our carbon footprints by w

ashing our hands? Journal of Hospital Infection 70 (3) 212-215

• Tanner J, Khan O

, Walsh S, Chernova J, Lam

ont S, Laurent T 2009 Brushes and picks used on nails during the surgical scrub to reduce bacteria: a randomised trial Journal of H

ospital Infection 71 (3) 234-238

• Tanner J, Parkinson H

2006 Double gloving to reduce surgical cross-infection Cochrane D

atabase of Systematic Review

s, Issue 3. Art. N

o.: CD003087. D

OI: 10.1002/14651858.CD

003087.pub2 Available from: http://onlinelibrary.w

iley.com/

doi/10.1002/14651858.CD003087.pub2/abstract [Accessed July 2017]

• Tanner J, Sw

arbrook S, Stuart J 2008 Surgical hand antisepsis to reduce surgical site infection Cochrane Database of System

atic Reviews, Issue 1. A

rt. No.: CD

004288. DO

I: 10.1002/14651858.CD004288.pub2 Available from

: http://onlineli-brary.w

iley.com/doi/10.1002/14651858.CD

004288.pub2/pdf [Accessed July 2017]

• Tanner J, D

umville JC, N

orman G

, Fortnam M

2016 Surgical hand antisepsis to reduce surgical site infection Cochrane Database of System

atic Reviews D

OI: 10.1002/14651858.CD

004288.pub3 Available from: http://onlinelibrary.

wiley.com

/doi/10.1002/14651858.CD004288.pub3/full [Accessed July 2017]

• W

orld Health O

rganization 2009 WH

O G

uidelines on Hand H

ygiene in Health Care (revised Aug 2009) Available from

: http://ww

w.w

ho.int/gpsc/5may/tools/9789241597906/en/ [Accessed July 2017]

• W

orld Health O

rganization 2014 My 5 M

oments for H

and Hygiene and other resources Available from

: http://ww

w.w

ho.int/infection-prevention/campaigns/clean-hands/5m

oments/en [Accessed July 2017]

• W

orld Health O

rganization 2016 Global G

uidelines on the Prevention of Surgical Site Infection Available from: http://w

ww

.who.int/gpsc/ssi-prevention-guidelines/en [Accessed July 2017]

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Job:118740 AfPP Surgical Hand Antisepsis Poster Package

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A Guide to Surgical Hand AntisepsisThe aim of the surgical hand antisepsis is to remove or destroy transient microorganisms and inhibit the growth of resident microorganisms (AfPP 2016).

Step OneWet hands and forearms. Apply the speci�ed amount of appropriate solution, according to the manufacturer’s recommendations, from dispenser (one downward stroke action).Work into hands palm to palm, and then encompass all areas of the hands and arms to just below the elbows as shown in steps 2-9. Perform the same manoeuvres if using ABHR but without water and rinsing.

Step TwoRight palm over back of left and vice versa with �ngers interlaced.

Step ThreeRub palm to palm, �ngers interlaced.

Step FourRotational rubbing backwards and forwards with clasped �ngers of right hand into left palm and vice versa.

Step FiveRotational rubbing of right thumb clasped in left hand and vice versa.

Step SixRub �nger tips on palms for both hands.

Step SevenContinue with rotating action down opposing arms, working to just below the elbows - do not move back towards wrist. If using ABHR an additional dose may be required here, one for each arm.

© AfPP June 2017www.afpp.org.uk

Step EightRinse and repeat steps 1-7 keeping hands raised above elbows at all times. This wash should now 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.

Supported by

Step Nine - Ending Scrub

If using a solution, rinse hands under running water - clean to dirty area. Turn o� tap using elbows if necessary. Open gown pack onto a clean surface and take a hand towel. Hands are dried �rst by placing the opposite hand behind the towel and blotting the skin, then, using a corkscrew movement, to dry from hand to elbow - do not move back down towards wrist. Discard towel. Using a second towel, repeat the process on other hand and forearm before discarding.If using ABHR, allow hands and forearms to dry completely before donning sterile gloves (WHO 2009, 2016).

ProcessEach step of surgical ‘scrubbing’ consists of �ve strokes rubbing backwards and forwards and adapts Ayli�e’s six step technique (Ayli�e et al 2000) into nine steps. Sources of evidence drawn on include AfPP’s Standards and Recommendations for Safe Perioperative Practice (AfPP 2016), AORN’s recommended practices (Paulson 2004), Ayli�e’s six step hand washing technique (Ayli�e et al 2000) and WHO guidelines (2016).

Preparation of personnelAll sta� should be in the appropriate theatre attire before commencing surgical hand antisepsis. Keep nails short and remove all jewellery, arti�cial nails or nail polish before surgical hand preparation.

Surgical hand antisepsisSurgical hand antisepsis should be performed using either (but not combined) alcohol-based hand rub (ABHR) or a suitable antimicrobial antiseptic solution before donning sterile gloves (WHO 2009, 2016). Hands and forearms should be washed for the length of time recommended by the manufacturer, usually 2–5 minutes (WHO 2009, 2016). If using an antimicrobial solution, the temperature and �ow of the water must be adjusted before the procedure is started to achieve comfort and avoid getting the scrub suit wet.

Ensuring that no part of the sink or taps is touched wet the hands and arms up to the elbow working from the �ngertips towards the elbow in one direction only, keeping the hands higher than the elbows. During each of the following steps keep hands (clean area) above the elbows (dirty area) allowing water to drain away; avoid splashing surgical attire.

Preliminary washThe hands of the surgical team should be clean before entering the operating room by washing with a non-medicated soap and running water. If hands are visibly soiled, use pick to gently remove debris from underneath tips of nails on each hand, and then discard.

WHO (2016) guidelines recommend washing hands and removing debris from underneath �ngernails using a nail cleaner (not brushes) under running water (sinks should be designed to reduce the risk of splashes). Rinse hands and forearms up to elbows.

© AfPP September 2017www.afpp.org.uk

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