Hand washing is essential to prevent the transmission of infections. Proper hand washing procedures include wetting hands, applying soap, rubbing hands together for 20 seconds, rinsing with water, and drying hands. For surgery, a surgical hand wash is performed which includes washing hands and forearms with an antimicrobial soap, cleaning under fingernails, and scrubbing for 5 minutes. Alcohol-based hand rubs are preferred over soap and water in most situations due to their effectiveness and convenience. Correct hand hygiene is vital both for patient safety and the prevention of spread of antimicrobial resistance.

1. Procedures of Hand washing.
Dr. P K Maharana.

2. Introduction
• Human hands are the most important tools
for caring.
• Hands feel, diagnose, cure and provoke as
they are placed upon each patient who is
hoping for answers; understanding the disease
and healing remedies.
• The hands can also be a portal and transmitter
of infection.

3. Dose the hands play a role in the
transmission of Diseases?
• The link between hand washing and contact transmission of
infection was first established by Oliver Wendell Holmes in the US
(1843) and in Europe by Semmelweiss (1861) (Horton, 2002).
It was again well supported by Larson (1981).
• They both showed a drop in the rate of puerperal sepsis and its
associated mortality when medical staff washed their hands
between examining women during childbirth.
• Hands are the principle route by which cross infection occurs (Elliot
- 1992).
• The Strategy for the Control of Antimicrobial Resistance in Ireland
(SARI) was launched in 2001 and is available in the Mercy University
Hospital Library and the Health Protection Surveillance Centre.

4. What Are Your Hands Carrying?
 Micro-organisms found on the skin are of two categories:
(A) Resident Micro-Organisms (normal flora)
These are usually deep seated in the epidermis, are not readily removed and
do not readily cause infections.
However, during surgery/invasive procedures, they may enter deep tissues
and establish an infection.
(B) Transient Micro-Organisms
These are organisms that are not part of the normal flora and represent recent
contamination, that usually survives for a limited period of time only.
They are easily removed by a good hand washing technique.
They include most of the organisms responsible for cross infection, e.g. Gram-
negative bacilli (E.coli, Klebsiella, Pseudomonas spp, Salmonella spp., Staph
aureus, MRSA and viruses e.g. rotaviruses (Damani, N.N. (1997)).

6. What is hand hygiene?
 Hand hygiene is a way of cleaning one’s hands that substantially reduces potential
pathogens (harmful microorganisms) on the hands.
o Hand hygiene is considered a primary measure for reducing the risk of transmitting
infection among patients and health care personnel.
o Hand hygiene procedures include the use of alcohol-based hand rubs (containing
60%–95% alcohol) and hand washing with soap and water.
 For surgical procedures, performing a surgical hand wash and putting on sterile
surgeon’s gloves necessary.
• For routine examinations and nonsurgical procedures, use an alcohol-based hand
rub or use water and plain or antimicrobial soap specific for health care settings
recommended.
• Unless hands are visibly soiled (e.g., dirt, blood, body fluids), an alcohol-based
hand rub is preferred over soap and water in most clinical situations.
 While handwashing may be the simplest way to control infection, it is often not
practiced where warranted.

7. Different Levels of Hand Hygiene
 A. Social Hand Hygiene- Routine Hand Washing
The aim of social (routine) hand washing with soap and warm water is to remove dirt and organic
material, dead skin and most transient organisms. On visibly clean hands it can be undertaken using
an alcohol hand rub, and this will remove transient organisms.
 B. Antiseptic Hand Hygiene
 Antiseptic hand disinfection with an antiseptic hand wash agent i.e. Hydrex is generally carried out
for aseptic procedures on the ward and for areas of Isolation.
 Hygienic hand disinfection will remove and kill most transient micro- organisms.
 Indications for use
 During outbreaks of infection where contact with blood/body fluids or situations where microbial
contamination is likely to occur.
 In “high” risk areas e.g. isolation, ICU etc.
 Before/after performing an invasive procedure.
 Before/after wound care, urethral or IV catheters etc.
 C. Surgical Hand Hygiene
o Surgical hand washing requires the removal and killing of transient micro-organisms and substantial
reduction and suppuration of the resident flora of the surgical team for the duration of the
operation, in case a surgical glove is punctured/torn.
o Ensure that fingernails are kept short and clean. Wrist watches and jewellery MUST be removed
before surgical hand disinfection (Bernthal E, 1997).

8. The CDC Guideline for Hand Hygiene in
Healthcare Settings .
 Recommendations:
– When cleaning your hands with soap and water, wet your hands
first with water, apply the amount of product recommended by
the manufacturer to your hands, and rub your hands together
vigorously for at least 15 seconds, covering all surfaces of the
hands and fingers.
– Rinse your hands with water and use disposable towels to dry.
Use towel to turn off the faucet.
– Avoid using hot water, to prevent drying of skin.
• Other entities have recommended that cleaning your hands
with soap and water should take around 20 seconds.
• Either time is acceptable. The focus should be on cleaning
your hands at the right times.

9. Medical & surgical Hand washing
• Medical hand washing: A hand wash
performed before and after examining a
patient.
• Surgical Hand washing : Hand washing
performed before performing a surgical
procedure.

10. Routine hand hygiene should always be
performed .
Before:
• > every patient contact.
• > performing a procedure e.g. wound dressing,
emptying a catheter/drain, venepuncture, changing an
IV flask, delivery of IV/IM medications.
• > preparing all medication (including oral, nasogastric,
PEG & intravenous).
• > handling or preparing food.
• > donning (putting on) gloves or other personal
protective equipment (PPE).
• > taking a break.

11. Hand hygiene should be performed
After:
• > every patient contact.
• > touching a patient’s environment.
• > performing a procedure or a body fluid exposure risk
e.g. handling a catheter bag, venepuncture.
• > doffing (taking off) gloves or other PPE.
• > going to the toilet.
• > taking a break.
• > Contact with own respiratory secretions (i.e. blowing
nose, coughing, sneezing).

13. Surgical hand wash.
 Performing surgical hand antisepsis using
either an antimicrobial soap or an alcohol-
based hand sanitizer with persistent
activity is recommended before donning
sterile gloves when performing surgical
procedures.

14. Objectives of Surgical hand wash.
 1.To remove debris and dart.
 2. Reduce the resident bacterial flora on the surface of
the skin of the hand to the minimum possible limit.
 3.Prevent rapid re-growth of bacterial flora under
gloves.
 4.In addition, there is a risk of a glove breaking for any
reason: from manufacturing defects to accidental cuts
with sharp material.
 The skin flora, mainly coagulase-negative
staphylococci, Propionibacterium spp., and Corynebacteria spp., are
rarely responsible for SSI, but in the presence of a foreign body or
necrotic tissue even inoculate as low as 100 CFU can trigger such
infection.

15. Prior to Hand wash.
Remove rings, watches, and bracelets before
beginning the surgical hand wash.
Remove debris from underneath fingernails
using a nail cleaner under running water.
( Nailbrushes should not be used as they may damage the skin and
encourage shedding of cells. If used, nailbrushes must be sterile,
once only (single use).
 Keep nails short as far as possible.

16. Artificial fingernail.
• Germs can live under artificial fingernails both before and
after using an alcohol-based hand sanitizer and hand
washing.
• It is recommended that healthcare providers do not wear
artificial fingernails or extensions when having direct
contact with patients at high risk (e.g., those in intensive-
care units or operating rooms)
• Keep natural nail tips less than ¼ inch long.
• Some studies have shown that skin underneath rings
contains more germs than comparable areas of skin on
fingers without rings
• Further studies are needed to determine if wearing rings
results in an increased spread of potentially deadly germs

17. How should you wash your hands?
FIVE STEPS.
• 1.Wet your hands with clean, running water (warm or
cold), turn off the tap, and apply soap.
• 2.Lather your hands by rubbing them together with the
soap. Be sure to lather the backs of your hands,
between your fingers, and under your nails.
• 3.Scrub your hands for at least 20 seconds. Need a
timer? Hum the “Happy Birthday” song from beginning
to end twice.
• 4.Rinse your hands well under clean, running water.
• 5.Dry your hands using a clean towel or air dry them.

18. Surgical hand wash Protocol
 Use a TGA approved antimicrobial skin cleanser.
o 1. Wet hands and forearms with water.
o 2. Apply antimicrobial skin cleanser as per directions and rub on
hands and forearms up to elbow ensuring fingertips;
interdigital areas and thumbs are given adequate attention.
o 3. Rinse hands and forearms under running water. Ensure that
water flows from finger-tips to elbow.
o 4. Thoroughly dry hands with sterile towel one for each hand.
 First wash of the day: 5 minutes (includes cleaning fingernails).
 Subsequent washes: 3 minutes (omit cleaning fingernails).
 Always Note start & completion timing

19. Different logistics for hand wash

20. Six steps of hand wash
1. Palm to palm.
2. Right palm over left dorsum & left
palm over right dorsum.
3. Palm to palm fingers interlaced.
4. Back of fingers to opposite palms
with fingers interlocked.
5. Rotational rubbing of right thumb
clasped in left palm and vice
versa.
6. Rotational rubbing backwards and
forwards with clasped fingers of
right hand in left palm and vice
versa.
Each step consists of five strokes
forward and five backward.

21. Steps of surgical handwash.

23. The procedure for the timed five minute
scrub consists of:
• Wash hands and arms with antimicrobial soap.
• Clean subungual areas with a nail file.
 Start timing.
Scrub each side of each finger, between the fingers, and the
back and front of the hand.( for two minutes).
• Proceed to scrub the arms, keeping the hand higher than the
arm at all times. This prevents bacteria-laden soap and water
from contaminating the hand.
• Wash each side of the arm to three inches above the elbow
for one minute.
• Repeat the process on the other hand and arm, keeping
hands above elbows at all times.
• If the hand touches anything except the brush at any time,
the scrub must be lengthened by one minute for the area
that has been contaminated.

24. Timing of handwash
Institutions opting to use the WHO-recommended
formulations for surgical hand preparation should
ensure that a minimum of three applications are used,
if not more, for a period of 3 to 5 minutes.
For surgical procedures of more than a two hours’
duration, ideally surgeons should practice a second
hand rub of approximately 1 minute, even though more
research is needed on this aspect.
Long scrub times (e.g., 10 minutes) are not necessary,
as do not offer any extra advantage.

25. Timing
• On this basis, for example, the typical scrub procedure for a PVPI-
containing product based on manufacturer's labelling would require
the use of a scrub brush and two applications of five minutes each,
whereas the typical procedure for a CHG-based product would
require a three-minute scrub followed by a three-minute wash.
• In actual practice, however, variations in surgical hand scrubbing
times may be of shorter duration than manufacturer's
recommendations for a number of reasons:
• In 1939, Price suggested a 7-minute hand wash with soap, water,
and a brush, followed by 70% ethanol for 3 minutes after drying the
hands with a towel.
• In the second half of the 20th century, the recommended time for
surgical hand preparation decreased from >10 minutes to 5
minutes.
• Even today, 5-minute protocols are common.

26. What are scrub agents?
 Surgical scrub agents come in many forms. Not all forms meet all
characteristics.
1. Liquid or foam soaps. These are the most common products for
surgical scrubs and are used in conjunction with water and dry
scrub brushes or sponges. The most common antimicrobial agents
in these products are CHG (chlorhexidine gluconate), iodophor, or
PCMX (parachlorometaxylenol). These agents are very drying and with
repeated scrubbing with the scrub brush can cause skin damage.
2. Impregnated scrub brushes/sponges. Scrub brushes/sponges are
preloaded with CHG, iodophor, or PCMX and are water-aided
products.
3. Brush-free surgical scrub. These products use an antimicrobial
agent and water but no scrub brush.

27. Alcohol-based hand rub is preferred
over soap and water
• Is more effective than soap at killing
potentially deadly germs on hands.
• Requires less time.
• Is more accessible than handwashing sinks.
• Produces reduced bacterial counts on hands.
• Improves skin condition with less irritation and
dryness than soap and water.

28. Use of hand brush
• Members of the surgical team who have
contaminated their hands before entering the
hospital may wish to use a sponge or brush to
render their hands visibly clean before
entering the operating room area.
• Almost all studies discourage the use of
brushes.

29. Drying hands
• Sterile towels are recommended to dry hands
normally. One towel for each hand.

30. Characteristic of an ideal Antiseptics
• Antimicrobial action
• Long acting or Persistent action
• Safe to use
• Non irritant to skin
• Acceptability

31. What should you do if you don’t have soap
and clean, running water?
• Washing hands with soap and water is the best way to
reduce the number of germs on them in most
situations.
• If soap and water are not available, use an alcohol-
based hand sanitizer that contains at least 60% alcohol.
• Alcohol-based hand sanitizers can quickly reduce the
number of germs on hands in some situations, but
sanitizers do not eliminate all types of germs and might
not remove harmful chemicals.
• Hand sanitizers are not as effective when hands are
visibly dirty or greasy.

32. Alcohol Based surgical hand-scrub
When using an alcohol-based surgical hand-
scrub product with persistent activity, follow
the manufacturer’s instructions.
• Before applying the alcohol solution, prewash hands
and forearms with a non-antimicrobial soap and dry
hands and forearms completely.
• After application of the alcohol-based product as
recommended, allow hands and forearms to dry
thoroughly before donning sterile gloves.

33. Advantage of antibacterial hand scrub
• Bacteria on the hands of surgeons can cause wound
infections if introduced into the operative field during
surgery.
• Rapid multiplication of bacteria occurs under surgical
gloves if hands are washed with a non-antimicrobial
soap.
• Bacterial growth is slowed after preoperative scrubbing
with an antiseptic agent.
 Reducing resident skin flora on the hands of the surgical team
for the duration of a procedure reduces the risk of bacteria
being released into the surgical field if gloves become
punctured or torn during surgery.

34. Side-effects of surgical hand scrub
• Skin irritation and dermatitis are more
frequently observed after surgical hand scrub
with chlorhexidine than after use of surgical
hand antisepsis with an alcohol-based hand
rinse.

35. Types of antiseptic hand scrubs
• Plain soap: Plain soap has little antimicrobial activity,
but cleans hands by its detergent properties and
removes loosely adherent transient flora.
A neutral pH liquid soap is recommended for
clinical areas.
• Antimicrobial hand cleanser: Used for non-surgical
and surgical hand antisepsis, these cleansers may
contain chlorhexidine gluconate, hexachlorophene,
iodine, iodophors or triclosan as the active ingredient.

36. Hand Hygiene product dispensers
• Disposable liquid soap dispensers with cartridges and
nozzles are recommended.
• Refillable liquid soap containers are a potential source of
contamination and if used, should not be topped up, but rather
they should be cleaned when empty and refilled with fresh product.
• Evaluate dispenser systems to ensure they deliver an
appropriate volume of product.
• Cleaning of dispensers must be incorporated into the
routine cleaning program of the facility.
• Alcohol-based product containers should be designed
to minimize evaporation and should not be placed
adjacent to sinks

37. Alcohol-based products
• Alcohol solutions in the concentration range of 60-
80% give optimum antimicrobial activity.
• Evidence suggests alcohol-based rubs eliminate
micro-organisms more effectively and cause less skin
irritation than soap and water hand washing.
• Laboratory studies have found that AHBHR liquid
preparations are generally more effective than gels
that contain the equivalent concentration of alcohol.
 However, user acceptability and skin tolerance need to
be taken into account when choosing a suitable
product.

38. Chlorhexidine or Povidone-iodine
• Chlorhexidine or Povidone-iodine both are
effective with lower levels of toxicity, faster mode
of action and broader spectrum of activity.
• Warm water makes antiseptics and soap work
more effectively, while very hot water removes
more of the protective fatty acids from the skin.
• Therefore, washing with hot water should be
avoided.

39. How do you use hand sanitizers?
• Apply the product to the palm of one hand
(read the label to learn the correct amount).
• Rub your hands together.
• Rub the product over all surfaces of your
hands and fingers until your hands are dry.

40. Technique for the application of surgical hand preparation using alcohol-based
handrub

41. Performance characteristics for a surgical
scrub .
 Agent generally fall into four categories:
• 1. Antimicrobial Action--an ideal agent would have a broad spectrum of
antimicrobial activity against pathogenic organisms and would have to
work rapidly.
• 2. Persistent Activity--an agent offering persistent activity keeps the
bacterial count low under the gloves.( It is not unusual for a surgery to last
in excess of two hours. Studies have shown the rate of glove failures,
increases with the duration of surgery.
• 3. Safety--the ideal agent would be non-irritating and non-sensitizing. It
must have no appreciable ocular or oto toxicity, be safe for use on the
body, and not be damaging to the skin or environment.
• 4. Acceptance--probably most important to achieving compliance in using
a new product is its acceptance by the healthcare worker.

42. Rinsing
• Rinse hands and arms by passing them through the
water in one direction only, from fingertips to elbow.
(Do not move the arm back and forth through the
water.)
• Proceed to the operating room suite holding hands
above elbows.
• If the hands and arms are grossly soiled, the scrub time
should be lengthened.
• However, vigorous scrubbing that causes the skin to
become abraded should be avoided.
• At all times during the scrub procedure care should be
taken not to splash water onto surgical attire.

43. Drying
• Once in the operating room suite, hands and
arms should be dried using a sterile towel and
aseptic technique.
• You are now ready to don your gown and
sterile gloves.

44. Gowning
• When gowning oneself, grasp the gown firmly
and bring it away from the table.
• It has already been folded so that the outside
faces away.
• Step -1: Holding the gown at the shoulders,
allow it to unfold gently.
Do not shake the gown.

45. Gowning ( Conti-i)
Step-2: Place hands inside the armholes and
guide each arm through the sleeves by raising
and spreading the arms.
• Do not allow hands to slide outside the gown
cuff.
• Step-3: The circulator will assist by pulling the
gown up over the shoulders and tying it.

46. Nurse Gowns the Surgeon.
• The scrubbed technologist or nurse gowns the
surgeon after he or she has performed the hand
and arm scrub.
• After handing the surgeon a towel for drying, the
technologist or nurse allows the gown to unfold
gently, making sure that there is enough room to
prevent contamination by nonsterile equipment.
• To glove another person, the rules of asepsis
must be observed.
• One person's sterile hands should not touch the
nonsterile surface of the person being gloved.

47. Nurse Gloving the surgeon
• Pick up the right glove and place the palm away
from you.
• Slide the fingers under the glove cuff and spread
them so that a wide opening is created. Keep
thumbs under the cuff.
• The surgeon will thrust his or her hand into the
glove. Do not release the glove yet.
• Gently release the cuff (do not allow the cuff to
snap sharply) while unrolling it over the wrist.
• Proceed with the left glove, using the same
technique.

48. Gloving
• To glove, lay the glove palm down over the cuff of the
gown.
• The fingers of the glove face toward you.
• Working through the gown sleeve, grasp the cuff of
the glove and bring it over the open cuff of the sleeve.
• Unroll the glove cuff so that it covers the sleeve cuff.
• Proceed with the opposite hand, using the same
technique.
• Never allow the bare hand to contact the gown cuff
edge or outside of glove.

49. Conclusion
o 1.No matter what agent is used, or which scrub technique
you practice, there is only one goal: infection prevention.
o 2.Effective surgical scrubs are one of the most powerful
strategies of infection prevention in the OR.
o 3. Glove usage gives a false sense of security against
bacteria.
o 4. Gloves provide an ideal environment for bacterial growth
because of moisture and warmth hence good hand-scrub
techniques and aseptic gowning and gloving are important
part of the total infection prevention platform.
o 5.It is important for healthcare management to help the
personnel understand the cause/effect cycle of surgical
scrubs as they relate to infection prevention.

50. True or false questions
1. Surgical site infections contribute to nosocomial infections.
2. A timed scrub should last for one to three minutes.
3. The best water temperature is very hot; this tends to kill bacteria more
quickly.
4. Vigorous scrubbing causes skin to become damaged and should be
avoided.
5. The surgeon is normally gloved and gowned by the circulating nurse.
6. The purpose of surgical hand scrub is to sterilize the hands prior to
gowning and gloving.
7. An ideal surgical scrub agent would have a broad spectrum of
antimicrobial activity against pathogenic organisms.
8. Bacteria grow faster under gloved than ungloved hands.
9. When donning sterile gloves, the surgical scrub becomes less important.
10. Effective surgical scrubs are one of the most powerful strategies of
infection prevention.

51. Answers
1. T.
2. F.
3. F.
4. T.
5. F.
6. F.
7. T.
8. T.
9. F.
10. T.