5.2 Surgical Hand Antisepsis, Gowning, Gloving & Draping Standards

Surgical Hand Antisepsis, Gowning, Gloving & Draping Standards

Core Principle: The surgical scrub, gown, and gloves form the primary personal barrier separating the perioperative team's microflora from the patient's open wound. Surgical hand antisepsis significantly reduces transient microorganisms and suppresses resident flora for the duration of the operative procedure. In the ambulatory surgery environment, adherence to rigorous antisepsis and draping protocols prevents exogenous contamination and protects both the patient and healthcare personnel.

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Surgical Hand Antisepsis: Transient vs. Resident Microflora

The skin of the human hand and forearm hosts two distinct biological categories of microorganisms:

• Transient Flora: Organisms that colonize the superficial layers of skin through contact with patients, equipment, and environmental surfaces (e.g., Staphylococcus aureus, Escherichia coli, Pseudomonas aeruginosa). Transient organisms are easily transferred to surgical wounds, causing acute surgical site infections (SSIs). However, because they reside on the surface, they are readily loosened and removed by mechanical washing and chemical antisepsis.
• Resident Flora: Organisms deeply seated in the stratum corneum, hair follicles, and sebaceous glands (e.g., Staphylococcus epidermidis, Corynebacterium species, Cutibacterium acnes). Resident microflora cannot be completely sterilized without destroying living tissue. The clinical objective of surgical hand antisepsis is to eliminate 100% of transient flora and substantially suppress resident flora, inhibiting microbial regrowth under warm, moist surgical gloves throughout prolonged procedures.

Fingernail Hygiene & Professional Dress Guidelines

The subungual space beneath fingernails harbors the highest concentration of microorganisms on the human body, particularly Gram-negative rods and yeast species.

• Nail Length: Natural fingernails must be kept short, clean, and neatly trimmed to no longer than 1/4 inch (2 mm) past the fingertip. Long nails puncture surgical gloves and harbor dense microbial biofilms.
• Prohibition of Artificial Enhancements: AORN, CDC, and WHO guidelines strictly prohibit all forms of artificial fingernail enhancements—including acrylics, gel overlays, shellac, silk wraps, and dip powder—for any personnel entering the restricted surgical environment. Numerous clinical studies and epidemiological outbreak investigations have linked artificial nails to lethal post-surgical outbreaks of Serratia marcescens, Pseudomonas aeruginosa, and Candida species.
• Nail Polish: If permitted by institutional policy, nail polish must be natural, unchipped, and freshly applied within the preceding 4 days. Chipped nail polish creates microscopic crevices that shield pathogens from chemical antiseptics.

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Water-Assisted Scrub vs. Waterless Alcohol-Based Surgical Hand Rub

Ambulatory surgical centers utilize two approved modalities for surgical hand antisepsis: traditional water-assisted scrubs with antimicrobial soaps and waterless alcohol-based surgical hand rubs (ABHR).

┌────────────────────────────────────────────────────────────────────────┐
│            CRITICAL DRYING TECHNIQUE FOR WATER-ASSISTED SCRUB          │
├────────────────────────────────────────────────────────────────────────┤
│ 1. Pick up sterile towel by the folded edge; do not drip water onto   │
│    the sterile gown wrapper.                                           │
│ 2. Step back from the sterile field and lean forward at the waist      │
│    to prevent towel contact with the non-sterile scrub suit.           │
│ 3. Unfold towel fully. Use the top half/end to dry one hand, working   │
│    from fingers to wrist to elbow using a blotting, circular motion.   │
│ 4. NEVER retrace from the elbow back up to the clean hand.            │
│ 5. Rotate the towel to use the clean, dry opposite half/end for the    │
│    second hand and forearm, again drying fingers to elbow.             │
│ 6. Discard towel into the kick bucket or hamper without lowering arms. │
└────────────────────────────────────────────────────────────────────────┘

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Gowning and Gloving Standards & Double-Gloving Rationale

Proper gowning and gloving prevent transfer of microorganisms between the surgical team and the sterile field. Cuffs must remain intact, and gloves must completely envelope the gown sleeves.

Gloving Modalities

1. Closed Gloving (Gold Standard for Initial Gowning):
   • Executed with the scrub person's hands retained entirely within the knit cuffs of the sterile gown sleeves.
   • The glove is placed palm-down on the gown cuff, with glove fingers pointing toward the shoulder and the glove cuff facing the gown cuff.
   • The glove cuff is grasped through the sleeve and pulled over the knit cuff, and the hand is advanced into the glove fingers.
   • Advantage: Eliminates any contact between bare skin and the exterior of the sterile gown or glove. AORN designates closed gloving as the safest, required method for initial sterile entry.
2. Open Gloving:
   • Used for minor procedures not requiring a sterile gown (e.g., central line insertion, regional block placement, urinary catheterization) or during specific glove changes.
   • The scrubbed person touches only the inner turned-back cuff of the glove with bare skin.
   • Limitation: High risk of accidental skin contact with the glove exterior. It should never be used for initial gowning when a gown is worn.
3. Assisted Gloving:
   • A sterile, scrubbed team member stretches the sterile glove opening widely with their fingers tucked beneath the glove's turned-down cuff (cuffing their own gloves) while orienting the thumb toward the recipient.
   • The recipient inserts their hand directly into the expanded glove opening.
   • Clinical Role: Preferred method for gowning fellow surgical team members and the gold-standard method for changing contaminated gloves intraoperatively.

The Double-Gloving Imperative

Single-gloving is an outdated practice that leaves surgical personnel and patients vulnerable to cross-contamination. AORN, the American College of Surgeons (ACS), OSHA, and CDC advocate routine double gloving for all invasive surgical procedures.

• Reduction in Exposure: Double gloving reduces bloodborne pathogen exposure (HIV, Hepatitis B, Hepatitis C) from sharps injuries and suture needle punctures by 70% to 90%.
• Inner Glove Protection: In orthopedic and reconstructive surgery, outer glove perforation rates range from 15% to 35%. When double-gloved, the inner glove remains intact in 80% to 95% of outer perforations, preventing direct blood-to-skin contact.
• Perforation Indicator Systems: Modern surgical practice utilizes an indicator glove system consisting of a darker, brightly colored inner glove (e.g., deep green or cobalt blue) worn beneath a standard semi-translucent or white outer glove. When fluid or mechanical trauma breaches the outer glove, moisture between the layers produces an immediate, high-contrast dark stain, alerting the scrubbed person to the puncture in under 30 seconds (compared to >50% of single-glove perforations that go completely unnoticed until case completion).

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Managing Intraoperative Glove Perforations & Contamination

A punctured, torn, or contaminated glove represents an immediate breach in sterile technique that must be resolved without hesitation.

Step-by-Step Glove Replacement Protocol

┌────────────────────────────────────────────────────────────────────────┐
│         INTRAOPERATIVE CONTAMINATED GLOVE MANAGEMENT WORKFLOW          │
├────────────────────────────────────────────────────────────────────────┤
│ 1. Step Back: Immediately remove hands from surgical incision/field.   │
│ 2. Contain: Keep hands elevated above waist and notify the circulator. │
│ 3. Glove Removal:                                                      │
│    • Circulating nurse dons clean gloves.                              │
│    • Circulator grasps the outer glove cuff below the gown sleeve.     │
│    • Circulator peels the contaminated glove off inside-out.           │
│    • CRITICAL: Do NOT pull the gown knit cuff down over the wrist.     │
│ 4. Cuff Evaluation:                                                    │
│    • If the knit cuff remained untouched and covered: Proceed.         │
│    • If the knit cuff slipped down over bare skin: GOWN & GLOVES       │
│      MUST BE COMPLETELY REMOVED AND REPLACED.                          │
│ 5. Regloving:                                                          │
│    • PREFERRED: Assisted regloving by another scrubbed team member.    │
│    • ALTERNATIVE (if alone): Closed regloving (pull hand inside cuff)   │
│      or open-gloving with extreme care not to touch the gown cuff.    │
└────────────────────────────────────────────────────────────────────────┘

• Assisted Regloving (Preferred): The scrub person steps away from the field. The circulating nurse grasps the cuff of the punctured glove and pulls it off inside-out without touching the sterile gown cuff. Another scrubbed team member opens a new sterile glove, and the recipient inserts their hand. If both layers of a double-glove system are breached, both outer and inner gloves must be changed.
• Gown Cuff Exposure: If the knit wrist cuff is dragged down over the hand during glove removal, the cuff is considered contaminated by contact with skin flora and perspiration. The scrub person cannot simply pull the sleeve back up; they must remove the entire gown and gloves and re-gown and re-glove completely.

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Surgical Draping Principles & Barrier Isolation

Surgical draping establishes an impervious, aseptic barrier isolating the prepared operative site from the unsterile patient, anesthesia equipment, and operating table.

Core Rules of Draping

1. Handle with Care (No Shaking or Fanning): Drapes must be carried folded to the operating table, held compact, and allowed to unfold gently by gravity. Drapes must never be shaken, flapped, or fanned. Shaking creates turbulent air currents that lift settled skin flakes and lint into the sterile field.
2. Drape from Sterile to Unsterile: Drapes must be placed beginning at the sterile incision site and extended outward toward the non-sterile periphery. Never reach across an unsterile area to place a drape.
3. Cuff over Gloved Hands: The scrubbed person must cuff the edges of the drape back over their sterile gloved hands, forming a protective pocket. This prevents gloved fingers from accidentally touching unprepared patient skin, hair, or table attachments during placement.
4. The No-Repositioning Rule: Once a surgical drape is positioned on the patient's skin, it must NEVER be shifted, pulled, or repositioned toward the surgical site. Moving a drape toward the incision drags resident skin bacteria from unprepared surrounding tissue directly into the planned surgical field. If a drape is misplaced too far from the incision, it can only be moved away from the site or discarded entirely and replaced with a fresh drape.
5. Securement: Drapes should be secured using non-perforating towel clamps (e.g., plastic clamp or atraumatic clip). Perforating towel clips (e.g., Backhaus clamps) puncture drape layers; if a perforating clip is removed, its tips are contaminated and must be discarded, and the hole must be covered with an impervious drape patch.

Plastic Incise Drapes: Iodophor-Impregnated vs. Non-Antimicrobial

Plastic adhesive incise drapes are transparent polymeric films applied directly to the patient's skin after surgical site preparation to provide a sterile operating surface up to the wound edge.

• Skin Antiseptic Drying: Skin prep agents—especially alcohol-based preparations (CHG in 70% alcohol or PVP-I in alcohol)—must be allowed to completely air-dry (minimum 3 minutes on hairless skin; longer on hair-bearing tissue) prior to incise drape application.
  • Fire Safety: Applying plastic drapes over wet alcohol traps flammable vapors underneath, creating an explosive pocket susceptible to ignition by electrosurgical unit (ESU) arcing.
  • Adhesion & Blistering: Wet skin prep prevents the acrylic adhesive from bonding to the epidermis. Trapped liquid induces chemical burns and leads to drape lifting during surgery.
• Iodophor-Impregnated Drapes (e.g., Ioban): Contain slow-release elemental iodine incorporated into the adhesive matrix, providing continuous antimicrobial activity throughout lengthy cases. Studies demonstrate suppression of recolonizing skin microflora, especially in high-risk orthopedic and spine procedures.
• Tension-Free Application: Incise drapes must be smoothed onto the skin without tension or stretching. Stretching causes epidermal shear, resulting in postoperative blister formation and skin tears.