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Surgical asepsis: Hand scrub

Reviewed: May 22, 2023

Introduction

A surgical hand scrub is the most effective method for preventing infections in
patients undergoing surgical procedures. The purpose of the scrub is to remove
soil and transient microorganisms and to limit the growth of resident
microorganisms. 1 The skin can never be completely sterile, but a surgical hand
scrub reduces the microbial count to as close to zero as possible and leaves an
antimicrobial residue that prevents microbial growth for several hours, leaving the
hands surgically clean. Performing an antiseptic surgical hand scrub or antiseptic
hand scrub with surgical antiseptic hand rub results in surgical hand
asepsis. 1 2 3

Equipment

• Disposable nail cleaner

• Hands-free scrub sink with hands-free antimicrobial soap dispenser
• Surgical mask

For antiseptic surgical hand scrub using water, a scrub sponge, and antimicrobial
soap

• Surgical scrub sponge

• Sterile towel

For antiseptic hand scrub using waterless, brushless, surgical antiseptic hand rub

• Waterless surgical antiseptic hand rub

Preparation of Equipment

Inspect all equipment and supplies. If a product is expired, is defective, or has

compromised integrity, remove it from patient use, label it as expired or defective,
and report the expiration or defect as directed by your facility.

Implementation

• Perform hand hygiene before and after each patient contact, when contact
has been made with a contaminated source, and after removing
gloves. 1 4 5 6 7 8
• Examine your fingernails to ensure that they're clean, healthy, and short
(tips no more than 2 mm [0.08"] long) because the areas underneath the
fingernails have the largest numbers of microorganisms on the hands, and
long fingernails can prohibit proper hygiene. 1

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long fingernails can prohibit proper hygiene.

• Inspect your hands for cuts, abrasions, dermatitis, and hangnails. Alterations
in skin integrity may be a risk factor for acquiring or transmitting
infections. 1 9
• Remove jewelry from your hands and forearms, including rings, bracelets,
and watches, because they may contain microorganisms and can interfere
with effective cleaning. 1 6
• Put on a surgical mask. 1
• Turn on the hands-free sink faucet and bring the water to a comfortable
temperature. 1

Clinical alert: Avoid repeated use of hot water during hand hygiene because it
can irritate the skin and subsequently cause dermatitis or bacterial colonization.
Note that the temperature range at which these complications occur more
frequently has not been defined. 1

• Wet your hands and forearms.

• Use a hands-free pump to dispense the amount of antimicrobial soap
needed to cover all surfaces of your hands. 1 Add enough water to make a
lather.
• Wash your hands and forearms with antimicrobial soap and running water
for at least 15 seconds to remove surface debris. 1
• Rub your hands together vigorously, covering all surfaces of the hands and
fingers (as shown below) to loosen and remove dirt and transient
microorganisms.

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• Clean under your nails using a disposable nail cleaner (as shown below)
under running water. 1 6 10

• Before beginning the surgical scrub, rinse well to remove all soap. 1

Antiseptic surgical hand scrub using water, a scrub sponge, and

antimicrobial soap

• Open the packaged scrub sponge and run it under water to moisten it.
• Dispense the amount of antimicrobial soap recommended by the
manufacturer, and use the soft, nonabrasive sponge to rub it onto your
hands and forearms. 1

Clinical alert: When performing the surgical hand scrub, don't use a brush,
which may damage skin and increase the amount of bacteria shed from the
hands. 1

• Picture your fingers, hands, and arms as having four sides and thoroughly
scrub each side with the sponge while keeping the hands elevated. 1
• Start with your fingernails and work your way up the fingers, paying
particular attention to the webbed area between each finger because
bacteria and dirt can collect in this area. 9
• Scrub the hand and then proceed to the wrist and forearm, finishing 2″ (5
cm) above the elbow. 9
• Keep your hands above your elbows to allow the water and debris to flow

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from clean to dirty. 1 10

• Repeat the sequence with your other hand and arm.

• Complete a timed scrub for the length of time recommended by the
manufacturer to provide adequate contact between the product and the
skin. 1
• Avoid splashing your surgical attire. 1
• Drop the sponge into an appropriate container without touching the
container with your hands or arms to avoid contaminating your newly
scrubbed hands. 1
• Rinse both hands and arms thoroughly, keeping your hands above your
elbows to ensure that water from your unwashed upper arms doesn't flow
onto your clean forearms and hands. Always rinse from fingertips to elbows
(as shown below). 1

• Holding your hands and arms in front of your body with your elbows slightly
flexed to keep your hands above your elbows, enter the operating suite. 10

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• In the operating suite, thoroughly dry your hands and forearms with a sterile
towel. 1
◦ Grasp the folded towel near the corner and extend your arms to open
the towel out to full length and width.
◦ Blot dry one hand using one-half of the towel and use a circular motion
to dry the forearm up to the elbow (as shown below).
◦ Dry the other hand and arm using the opposite end of the towel in the
same manner.
◦ Discard the towel in an appropriate receptacle.

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Antiseptic hand scrub using waterless, brushless, surgical antiseptic

hand rub

• After performing hand hygiene, dry the hands thoroughly. 1

• Apply the appropriate amount of waterless, brushless, surgical antiseptic
hand rub to the hands and arms according to the manufacturer's
directions. 1
• Allow the hands to dry completely. 1

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• Holding your hands and arms up in front of your body with your elbows
slightly flexed to keep hands above your elbows, enter the operating suite.

Special Considerations

• Don't wear artificial nails or extenders because they have been linked to
contamination and outbreaks. 1
• Follow the rules of your facility regarding nail polish. Some facilities don't
allow nail polish because of potential harms such as the harboring of
microorganisms. If nail polish is permitted, ensure that it is freshly applied
and without chips. 1 9
• Use facility-approved skin moisturizers because some lotions contain oils or
other ingredients that weaken latex gloves. 1
• Follow the manufacturer's directions for the amount of antiseptic hand scrub
to use, the length of time required for the scrub, and the need to repeat the
scrub. 1 6 10

Documentation

Documentation isn't needed.

Related Procedures
• Drying hands and arms, OR
• Gowning and gloving, assisting
• Hand antisepsis, OR
• Sterile field management, OR
• Sterile technique, basic
• Sterile technique, basic, home care
• Surgical asepsis: Maintaining a sterile field
• Surgical asepsis: Surgical attire
• Surgical attire, donning
• Surgical hand scrub, neonatal
• Surgical scrub, OR

References
(Rating System for the Hierarchy of Evidence for Intervention/Treatment Questions)
1. Guideline for perioperative practice: Hand hygiene. (2023). In E. Kyle (Ed.),
Guidelines for perioperative practice, 2023 edition. AORN. (Level VII)
2. Craven, R. F., et al. (2021). Fundamentals of nursing: Concepts and
competencies for practice (9th ed.). Wolters Kluwer.

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Lippincott Procedures - Surgical asepsis: Hand scrub https://legacy-procedures.lww.com/lnp/view.do?pId=6527272

3. Gaspar, G. G., et al. (2018). Alcohol-based surgical hand preparation:

Translating scientific evidence into clinical practice. Antimicrobial Resistance
& Infection Control, 7, Article 80. Retrieved April 2023 from https://doi.org
/10.1186/s13756-018-0372-7 (Level VI)
4. The Joint Commission. (2023). Standard NPSG.07.01.01. Comprehensive
accreditation manual for hospitals. (Level VII)
5. World Health Organization (WHO). (2009). WHO guidelines on hand hygiene
in health care: First global patient safety challenge, clean care is safer care.
Retrieved April 2023 from https://apps.who.int/iris/bitstream/handle/10665
/44102/9789241597906_eng.pdf?sequence=1 (Level VII)
6. Centers for Disease Control and Prevention. (2002). Guideline for hand
hygiene in health-care settings: Recommendations of the Healthcare
Infection Control Practices Advisory Committee and the HICPAC/SHEA
/APIC/IDSA Hand Hygiene Task Force. MMWR Recommendations and
Reports, 51(RR-16), 1–45. Retrieved April 2023 from https://www.cdc.gov
/mmwr/pdf/rr/rr5116.pdf (Level VII)
7. Accreditation Commission for Health Care. (2021). Standard 07.01.21.
Healthcare Facilities Accreditation Program: Accreditation requirements for
acute care hospitals. (Level VII)
8. DNV GL-Healthcare USA, Inc. (2020). IC.1.SR.1. NIAHO® accreditation
requirements, interpretive guidelines and surveyor guidance – revision 20-1.
(Level VII)
9. Association of Surgical Technologists (AST). (2008). AST standards of
practice for surgical attire, surgical scrub, hand hygiene and hand washing.
Retrieved April 2023 from https://www.ast.org/uploadedFiles/Main_Site
/Content/About_Us/Standard_Surgical_Attire_Surgical_Scrub.pdf
10. Anderson, D. J., et al. (2014). Strategies to prevent surgical site infections in
acute care hospitals: 2014 update. Infection Control and Hospital
Epidemiology, 35(6), 605–627. Retrieved April 2023 from https://doi.org
/10.1086/676022 (Level I)
Abstract | Complete Reference

Additional References
• Fry, D. E. (2019). Operating room hand preparation: To scrub or to rub?
Surgical Infections, 20(2), 129–134. Retrieved April 2023 from
https://doi.org/10.1089/sur.2018.302 (Level V)
Abstract | Complete Reference

Rating System for the Hierarchy of Evidence for

Intervention/Treatment Questions
The following leveling system is from Evidence-Based Practice in Nursing and
Healthcare: A Guide to Best Practice (2nd ed.) by Bernadette Mazurek Melnyk
and Ellen Fineout-Overholt.

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Level I: Evidence from a systematic review or meta-analysis of all

relevant randomized controlled trials (RCTs)
Level II: Evidence obtained from well-designed RCTs
Level III: Evidence obtained from well-designed controlled trials without
randomization
Level IV: Evidence from well-designed case-control and cohort studies
Level V: Evidence from systematic reviews of descriptive and qualitative
studies
Level VI: Evidence from single descriptive or qualitative studies
Level VII: Evidence from the opinion of authorities and/or reports of
expert committees
Modified from Guyatt, G. & Rennie, D. (2002). Users' Guides to the Medical Literature.
Chicago, IL: American Medical Association; Harris, R.P., Hefland, M., Woolf, S.H., Lohr,
K.N., Mulrow, C.D., Teutsch, S.M., et al. (2001). Current Methods of the U.S. Preventive
Services Task Force: A Review of the Process. American Journal of Preventive Medicine,
20, 21-35.

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