2.2 Surgical Hand Scrub, Gowning & Gloving

The Surgical Hand Scrub

The surgical hand scrub (surgical hand antisepsis) removes soil and transient microorganisms and reduces resident flora to as low a level as possible before gowning. Two accepted methods exist: a timed/anatomical scrub with an antimicrobial agent (commonly chlorhexidine gluconate, CHG, or a povidone-iodine scrub) using a sterile brush/sponge, and an approved alcohol-based waterless hand rub applied after a plain soap pre-wash.

Key rules of the traditional scrub:

• Perform a pre-scrub wash to the elbows, then clean subungual (under-the-nail) spaces with a nail cleaner under running water.
• Visualize each finger, hand, and arm as having four sides, scrubbing all surfaces; the anatomical scrub moves from fingertips to elbow.
• Keep hands higher than the elbows at all times so water and contaminants run away from the cleanest area (the fingertips) down toward the elbows and off.
• A timed scrub typically lasts 3–5 minutes; nails are short, and no jewelry or artificial nails are permitted.
• Rinse in one direction, fingertips first, and proceed into the OR holding the hands up and away from the body.

Drying, Gowning, and Closed Gloving

After scrubbing, the CST enters the OR and dries the hands first, then the arms, with a sterile towel, using opposite ends of the towel for each arm so a used (now contaminated) section never crosses to the clean arm. Gowning and gloving are performed off a separate sterile surface away from the main back table so a dropped item cannot contaminate the instrument setup.

To gown, the CST lifts the folded gown, allows it to unfold without touching anything, and slides both arms into the sleeves while a circulator ties the back.

In closed gloving — the preferred technique for initial gloving — the hands stay inside the gown sleeves, never emerging past the cuff. The glove is manipulated through the fabric, and the stockinette cuff is pulled over the wrist as the glove is rolled on. Because bare skin never touches the glove's sterile exterior, closed gloving offers the most reliable barrier and is the standard first-don method.

Open Gloving and Assisted Gloving

Open gloving is used when the hands must come out of the cuffs — for example, when changing a single contaminated glove intraoperatively, when no sterile gown is worn (procedures such as urinary catheterization or central-line placement), or when a sterile assistant is not available to re-glove someone. In open gloving the bare fingers touch only the inside (folded cuff) of the glove, never the sterile outer surface, and the gloved hand then touches only the outer surface of the second glove.

Assisted gloving lets one scrubbed person glove another: the assistant stretches the glove open with thumbs out (away from their own gloves) so the receiving team member can plunge the hand in cleanly. To change a contaminated glove during a case, the preferred method is to have a scrubbed teammate re-glove you (assisted), or the circulator pulls the glove off inside-out and you re-glove open or closed.

Remember the order of contamination risk: a glove punctured during the case must be changed immediately, and if the gown is contaminated, the gown is changed as well. The CST applies surgical conscience here — reporting and correcting any break even when unobserved.

Surgical Attire and Pre-Scrub Preparation

Proper surgical attire is donned before scrubbing and is the foundation of the whole sequence. The CST enters the restricted area in a clean scrub top and pants, with the top tucked in to prevent shedding skin squames, a bouffant or hood that covers all hair including sideburns and the nape, and a surgical mask that fully covers the nose and mouth and is tied snugly to prevent venting at the sides. Eye protection or a face shield is required whenever splash or aerosol is possible.

Shoe covers, jewelry removal, and short, natural, polish-free nails complete the attire, because artificial nails and chipped polish harbor pathogens such as Pseudomonas.

Donning sequence matters: mask and head covering go on first, before the scrub, so they are never adjusted with scrubbed hands. The mask is changed between cases or when it becomes moist, since a damp mask loses its filtering ability.

Only after attire is correct does the CST begin the hand scrub, ensuring no part of the sterile gowning and gloving sequence is compromised by an avoidable source of contamination.