4.4 Surgical Hand Scrub, Gowning, and Gloving

Surgical Hand Scrub, Gowning, and Gloving

Quick Answer: Surgical hand antisepsis is accomplished via the counted stroke method (30 strokes for nails, 20 per plane of fingers/hands/arms) or waterless alcohol rubs (Avagard). Key rules: hands must be kept elevated above elbows at all times, dry with a sterile towel using separate ends for each arm (never returning to hands), execute closed gloving for initial gowning, and practice routine double gloving. Remember: the sterile gown is sterile only from mid-chest to table level in front and from fingertips to 2 inches above the elbow; the back, neckline, shoulders, and knit cuffs are non-sterile.

The surgical hand scrub, gowning, and gloving sequence transforms the non-sterile surgical technologist and perioperative team into sterile members of the sterile field. Strict adherence to aseptic technique during this process is essential to prevent the introduction of pathogens into the operative wound.

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1. Pre-Scrub Preparation & Surgical Attire

Prior to approaching the surgical scrub sink, all personnel must be outfitted in required Operating Room attire:

                         SURGICAL ATTIRE CHECKLIST

  [X] Bouffant Cap / Hood    -> All hair, sideburns, and nape covered completely
  [X] Surgical Scrub Suit    -> Top tucked into scrub pants; clean daily
  [X] Warm-Up Jacket         -> Long sleeves, cuffs snapped, front fully closed
  [X] Eye Protection         -> Mask with face shield or goggles with side shields
  [X] Surgical Mask          -> Secure fit over nose and mouth; pliable nose wire
  [X] Dedicated OR Shoes     -> Fluid-resistant, non-slip, enclosed heels/toes

Personal Hygiene & Hand Health

• Jewelry: All rings, watches, bracelets, and fitness bands must be removed. Jewelry harbors high concentrations of Staphylococcus and Pseudomonas species and prevents thorough antisepsis.
• Fingernails: Natural nails must be clean, trimmed short (<1/4 inch or 6 mm past the fingertip), and free of artificial nails, overlays, gels, or chipped polish. Artificial nails are proven vectors for fungal and gram-negative bacterial outbreaks in surgical suites.
• Skin Integrity: Skin must be free from open cuts, weeping dermatitis, or active paronychia. Any break in skin integrity mandates covering with a waterproof occlusive barrier or exclusion from the sterile field.

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2. Surgical Hand Scrub Methods

                         SURGICAL SCRUB FLUID DYNAMICS

                                  (Cleanest)
                                 [Fingertips]
                                      |
                                      v
                                   [Hands]
                                      |
                                      v
                                  [Wrists]
                                      |
                                      v
                                  [Forearms]
                                      |
                                      v
                                  [Elbows]
                                 (Dirtiest)

          [Rule: Hands held elevated above elbows continuously!]

Method A: Counted Stroke Anatomical Scrub

1. Pre-Wash: Wet hands and forearms up to 2 inches above the elbows with warm running water. Wash with non-medicated or antimicrobial soap, rinse, and clean subungual spaces under fingernails using a disposable nail cleaner under running water.
2. Brush Technique: Open sterile scrub brush impregnated with CHG or iodophor.
3. Fingernails: Scrub the subungual area of all 10 fingers for 30 strokes.
4. Fingers & Hands: Treat each finger as having 4 anatomical surfaces (palmar, dorsal, radial, ulnar). Scrub each plane for 20 strokes. Scrub the palm (20 strokes) and dorsum of the hand (20 strokes).
5. Forearms: Divide the forearm into three horizontal sections (lower third/wrist, middle third, upper third to 2 inches above the elbow). Scrub each of the 4 planes of each section for 20 strokes.
6. Repeat: Repeat the identical process on the opposite hand and arm.
7. Rinse: Rinse under running water in one continuous direction from fingertips to elbows, keeping hands elevated. Never move hands back and forth through the water stream.

Method B: Waterless Alcohol-Based Surgical Hand Rub (e.g., Avagard)

1. Perform a 1-minute non-antimicrobial hand wash and nail pick cleaning at the beginning of the shift; dry hands thoroughly with paper towels.
2. Dispense manufacturer-measured volume of alcohol rub (typically 2 mL / 1 pump) into palm; dip fingertips of opposite hand into rub for 5 seconds to coat subunguals, then spread remaining rub up forearm to elbow.
3. Dispense second pump; repeat for opposite hand and forearm.
4. Dispense third pump; rub thoroughly over both hands and wrists until completely dry.
5. Crucial Rule: Allow hands to air dry completely before donning sterile gown and gloves. Do NOT use a towel to dry alcohol rubs.

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3. Drying Hands, Gowning, and Closed Gloving

                         STERILE TOWEL DRYING TECHNIQUE

        Step 1: Pick up towel by corner; step back from unsterile sink.
        Step 2: Unfold towel fully without touching unsterile scrubs.
        
             TOP END OF TOWEL                   BOTTOM END OF TOWEL
        +-----------------------+              +-----------------------+
        | Hand A -> Forearm A   |              | Hand B -> Forearm B   |
        +-----------------------+              +-----------------------+
                   |                                      |
                   v                                      v
        (Dry from fingers to elbow)            (Bend forward, flip towel,
                                                dry opposite arm with
                                                UNUSED bottom end)

Drying Protocol

• Step away from the sterile table to avoid dripping water onto sterile packs.
• Grasp the sterile hand towel by the exposed corner, lifting straight up without touching the gown wrapper.
• Bend slightly at the waist to keep the towel from brushing against unsterile scrub attire.
• Use one end of the towel to dry Hand #1, wrist, and forearm in a firm patting motion moving toward the elbow.
• Transfer the opposite (unused) end of the towel to the dry hand. Dry Hand #2 and forearm to the elbow. Discard towel in linen/waste hamper without lowering hands below waist level.

Self-Gowning Technique

• Grasp the sterile gown firmly at the inside neckline, lift straight up, and step into an open area.
• Allow the gown to unfold gently downward without shaking or flapping.
• Slip both hands and arms into the sleeves simultaneously, guiding arms forward.
• For Closed Gloving: Do NOT push hands through the white knitted stockinette cuffs; keep hands positioned roughly 1 inch inside the sleeve cuffs.
• The circulating nurse approaches from behind, positions the gown over shoulders, fastens the neck closure, and ties the inner waist ties.

Closed Gloving Technique (Gold Standard for Initial Donning)

                            CLOSED GLOVING SEQUENCE

   1. ORIENTATION:                      2. STRETCH:          3. ADVANCE:
      Glove palm-to-palm,                  Stretch glove        Push hand forward
      Thumb-to-thumb,                      cuff over gown       through cuff into
      Fingers pointing to elbow.           stockinette.         sterile glove.

     [Gown Sleeve]                      [Gown Sleeve]        [Gown Sleeve]
     +------------+                     +------------+       +------------+
     | (Hand In)  | ===>                |  [Glove]   | ===>  |   [Hand]   |
     | [GLOVE]    | (Grasp cuff         |  over cuff |       |  in Glove  |
     +------------+  through sleeve)    +------------+       +------------+

1. Working entirely within the sleeve cuff, open the sterile glove package.
2. Grasp the right glove with the left hand (through the gown sleeve).
3. Lay the glove palm-down against the right sleeve: palm-to-palm, thumb-to-thumb, with the glove fingers pointing proximally toward your elbow.
4. Grasp the glove cuff with both hands (through the sleeves) and stretch the glove cuff completely over the white knitted gown cuff.
5. Advance your right hand forward through the sleeve cuff into the glove fingers.
6. Repeat the exact process for the left hand using the sterile right-gloved hand.

Turning the Gown (The Wrap-Around)

• After both gloves are donned and cuffs adjusted, grasp the cardboard transfer tab connected to the waist tie.
• Hand the transfer tab to the circulating nurse (or another sterile team member).
• The circulating nurse grasps the plastic/cardboard tab with sterile forceps or bare hands, holding it stationary while the surgical technologist performs a 360-degree turn to the left.
• The surgical technologist pulls the tie out of the transfer card (leaving the card in the circulator's possession) and ties the waist cords securely in front.

4. Gloving Variations & Sterile Field Boundaries

Double Gloving Standards

• AORN & American College of Surgeons (ACS) Standard: Double gloving is mandatory for all surgical procedures.
• Mechanism: Wear a colored indicator underglove (typically 0.5 size larger or regular size) beneath a standard sterile outer glove.
• Clinical Benefit: In the event of a micro-puncture, fluid seepage between gloves produces a high-contrast visual color change, alerting the scrub team immediately. Reduces inner glove puncture rates and bloodborne pathogen exposure by up to 87%.

Sterile Boundaries of the Surgical Gown

                        STERILE GOWN BOUNDARIES
                        
                         [ Neck / Collar ] -> NON-STERILE
                         [   Shoulders   ] -> NON-STERILE
                                 |
             +-------------------+-------------------+
             |           [ Mid-Chest ]               | (Axillary Region -> NON-STERILE)
             |                 |                     |
    STERILE  |                 v                     | STERILE
    SLEEVES  |        ====================           | SLEEVES
   (2" above |       |                    |          | (2" above
    elbow to |       |   STERILE ZONE     |          |  elbow to
    cuff edge|       |                    |          |  cuff edge)
             |        ====================           |
             |                 |                     |
             +-----------------+---------------------+
                         [ Table Level ]
                               |
                               v
                  Below Table / Waist -> NON-STERILE
                  Entire Back of Gown -> NON-STERILE
                  Knitted Stockinette Cuffs -> NON-STERILE

• Sterile Zones: Front of the gown from mid-chest to the level of the sterile field (table level), and the sleeves from fingertips to 2 inches above the elbow.
• Non-Sterile Zones:
  • Neckline, collar, and shoulders (harbor sweat, friction, respiratory fallout).
  • Axillary regions (high moisture, friction, sweat glands).
  • Back of the gown (even wrap-around gowns are non-sterile because they cannot be continuously observed).
  • Stockinette knitted cuffs (absorbent fabric traps sweat and becomes non-sterile once hands emerge).
  • Any portion of the gown below the level of the operating table.

Managing Intraoperative Contamination

• If a glove is punctured or contaminated during surgery: immediately step back from the sterile field.
• The circulating nurse grasps the contaminated glove cuff and pulls it off inside-out, ensuring the underlying knit gown cuff is not pulled down or contaminated.
• The surgical technologist regloves using assisted gloving by a sterile colleague, or open gloving if no assistant is available.