1.5 Surgical Hand Scrub, Gowning, and Gloving
Key Takeaways
- The surgical scrub removes transient flora and reduces resident flora but does not sterilize the hands.
- The timed scrub method requires a specific duration (usually 3 to 5 minutes), whereas the counted brush stroke method requires a specific number of strokes per surface.
- Scrubbed personnel must keep their hands above the waist and below the mid-chest, in constant view.
- Closed gloving is performed immediately after gowning when the hands are still inside the gown cuffs, offering the lowest risk of contamination.
- Open gloving is used for minor procedures or when changing a contaminated glove during a procedure without changing the gown.
The surgical hand scrub, gowning, and gloving are foundational skills for the Certified Surgical First Assistant. These actions form the primary barrier between the non-sterile environment of the human body and the sterile surgical field. Like the patient's skin prep, the surgical hand scrub cannot sterilize the skin. Its purpose is to mechanically and chemically remove transient organisms and reduce resident flora to an irreducible minimum, while providing a residual antimicrobial effect to suppress regrowth during the procedure.
The Surgical Hand Scrub
Before beginning the scrub, the CSFA must don proper operating room attire, including a head covering, mask, and eye protection. All jewelry must be removed, and fingernails must be short, clean, and free of artificial nails or chipped polish, as these harbor immense bacterial loads.
There are two primary methods for the traditional surgical scrub: the timed method and the counted brush stroke method. In both methods, the process begins by washing the hands and forearms with soap and water and cleaning the subungual areas (under the fingernails) with a disposable nail pick under running water.
Counted Brush Stroke Method
This method assigns a specific number of strokes to each surface of the hands and arms. A common protocol requires 30 strokes for the fingernails and 10 strokes for each plane of the fingers, hands, and arms. The anatomy is divided into four planes (dorsal, palmar, medial, lateral). The scrub proceeds systematically from the fingertips down to two inches above the elbow. Once a section is scrubbed, the brush must never return to that section, maintaining the principle of moving from the cleanest area (the hands, which will touch the sterile field) to the least clean (the elbows).
Timed Method
The timed method relies on exposing the skin to the antiseptic for a specific duration, typically 3 to 5 minutes, depending on the facility's policy and the manufacturer's instructions for the scrub solution. The anatomical progression remains the same: fingers, hands, wrists, and forearms up to two inches above the elbows.
Waterless Surgical Hand Rubs
Avagard and similar alcohol-based surgical hand rubs are increasingly popular due to their efficacy and skin-protecting emollients. Before the first case of the day, a traditional hand wash with a nail pick is still required. The rub is then applied according to the manufacturer's instructions, usually involving applying the product to the hands, rubbing it up the forearms, and allowing it to air dry completely before gowning.
When performing a traditional surgical hand scrub using the counted brush stroke method, what is the correct anatomical sequence?
Drying and Gowning
After the scrub, the CSFA enters the operating room with hands elevated above the elbows to prevent water from running down from the unsterile upper arms to the clean hands.
The CSFA approaches the sterile field and grasps the sterile towel. It is imperative to step back from the sterile field to avoid dripping water onto the sterile drapes. The towel is used to dry the hands and arms using a blotting motion, never a rubbing motion, which causes desquamation (shedding of skin cells). One half of the towel is used for one arm, moving from the hand to the elbow. The towel is then carefully flipped to use the dry half for the other arm.
The sterile gown is picked up by the inside neckline and allowed to unfold in a safe, open area. The CSFA slides both arms into the sleeves simultaneously. To prepare for closed gloving, the hands must not be pushed through the stockinette cuffs; they must remain inside the sleeves.
Gloving Techniques
Gloving can be performed using the closed or open technique, depending on the scenario.
| Gloving Technique | Primary Application | Key Steps / Safety |
|---|---|---|
| Closed Gloving | Initial donning of sterile gown and gloves for surgical case | Hands remain inside gown cuffs. Glove is placed palm-to-palm, fingers pointing toward elbow. |
| Open Gloving | Minor procedures (no gown, e.g., catheter insertion) or changing a contaminated glove during surgery | Hands extend beyond cuffs. Touch only the inside folded cuff of first glove; use gloved hand to slide under cuff of second glove. |
Closed Gloving
Closed gloving is performed immediately after donning the sterile gown. Because the bare hands never emerge from the sterile gown cuffs, this method offers the lowest risk of contamination and is the standard for initiating a surgical case. Working through the fabric of the gown cuffs, the CSFA places the glove on the forearm with the glove's fingers pointing toward the elbow, palm to palm and thumb to thumb. The cuff of the glove is stretched over the open end of the gown cuff, and the hand is pushed into the glove.
Open Gloving
Open gloving is used when a sterile gown is not required (e.g., for minor skin procedures, placing a Foley catheter) or when a glove becomes contaminated during surgery and the gown remains sterile. In this technique, the bare hand touches only the folded inside cuff of the first glove. Once the first glove is on, the sterile gloved fingers slip under the cuff of the second glove to don it. If a glove tears during surgery, the CSFA must step away from the sterile field, extend the contaminated hand for the circulator to remove the torn glove, and then use the open gloving technique to apply a new one.
Through precise execution of the scrub, gowning, and gloving, the CSFA maintains the critical sterile barrier required for safe surgery.
During a surgical procedure, the CSFA accidentally touches an unsterile IV pole, contaminating their right glove. The gown remains sterile. Which of the following is the most appropriate action?