ATTIRE, SURGICAL SCRUB, GOWNING and GLOVING

Historical Background
Latter half of 19th century, many surgeons continued

to perform surgical procedures while wearing street clothes under pus- and blood-encrusted aprons despite the expansion of germ theory knowledge. The first use of caps and sterile gowns occurred in Germany while English surgeon Joseph Listers (18271912) principles of antiseptic surgery were still being debated. The use of sterile gowns antedated the routine use of caps, gloves and masks, although in 1883 Gustav Neuber (28500-1932) insisted that team members wear caps also. Various styles of turbans and shower cap-style head coverings were worn from about 1908 to the 1930s, when hair was generally acknowledged to be an attraction for and shedder of bacteria.

 In 1897, American surgeon

of surgery at Johns Hopkins, designed a semicircular instrument table to separate himself , in sterile gown and gloves, from observes in street clothes who watched him operate. Rubber surgical gloves were introduced, not to protect the patient but to protect the wearers hands from the harsh, irritating antiseptic solutions and hand soaks of 1870s and 1880s. The use of gloves was not popularized until the 1890s, when Halsteds scrub nurse, Caroline Hampton (whom he later married), complained dermatitis. Gauze masks were advocated by Johann von Mikulicz in 1897, when the droplet theory of infection was demonstrated. It was not until 1926, when wound infections yielded the same organisms as found in the nose and throats of surgeons and nurses, that masks become obligatory.

William Halsted (1852-1922), chief

 In 1924 one of the surgical nursing texts described the

attire of the OR nurses: the circulator wore an OR cap, but no mask, and a gown with a pocket for a pad and pencil; the scrub nurse wore both a mask and a gown, but had extra pockets in front for the surgeons instruments. By the 1930s and 1940s, scrub dresses began to replace nurses regular uniforms, heretofore worn under the sterile gown.1n 1960s, full skirts were replaced by closefitting scrub dresses and pantsuits that reduced the hazard of brushing against a sterile table when near or passing by it. In 1950, as safety restrictions became more rigid, OR personnel were required to change shoes when entering the OR suite and to wear those shoes only when within the suite.

SURGICAL SCRUB and HAND CLEANSING

Microbiology of the Skin The skin is inhabited by the following organisms: Transient organisms acquired by direct contact. Usually loosely attached to the skin surface, they are almost completely removed by thorough washing with soap or detergent and water. Resident organisms below the skin surface in hair follicles and in sebaceous and sweat glands. They are more adherent and therefore more resistant to removal. In scrubbing, the skin is skin is cleaned of as many microorganisms as possible. Two processes are commonly used: 1. Mechanical. The process removes soil and transient organisms with friction. 2.Chemical. The process reduces resident florae and inactivates microorganisms with an antimicrobial or antiseptic agent.

Purpose The purpose of surgical hand and arm cleansing is to remove or deactivate soil, debris, natural skin oils, hand lotions, and transient microorganisms from the hands and forearms of sterile team members. More specifically, the purposes are as follows: To decrease the number of resident microorganisms on skin to an irreducible minimum. To keep the population of microorganisms minimal during the surgical procedure by suppression of growth. To reduce hazard of microbial contamination of the surgical wound by skin florae.

Scrub Sink The scrub room is adjacent to the OR for safety and convenience. Individually enclosed scrub sinks with automatic sensor controls or foot-orknee-operated faucets are preferred to eliminate the hazard of contaminating the hands after cleansing. The sink should be deep, wide, and low enough to prevent splash. It should be used only for scrubbing or handwashing. They should not be used to clean or rinse contaminated instruments or equipment.

Equipment Plastic, single-use disposable nail cleaning products are available and are usually supplied with disposable scrub brushes. Orangewood sticks are not used to clean under the fingernails, because the wood may splinter and harbor Pseudomonas organisms. Sterilized reusable scrub brushes or disposable sponges may be used. Biologic material may be difficult to remove from reusable brushes. If reusable brushes are taken from the dispenser in which they were sterilized, each brush should be removed without contaminating others. Single-use disposable products may be brush-sponge combination and are preferred. The scrubbing solution is dispensed onto the brush sponge pr sponge by a foot pedal from a container attached or adjacent to the sink. Six drops of solution (2-3 ml) is sufficient to generate a lather for the scrub procedure.

Antimicrobial Skin-Cleansing Agent Various antimicrobial (antiseptic) detergents are used for surgical hand washing. The following are desirable characteristics of antimicrobial agents: Broad spectrum Fast-acting and effective Nonirritating and nonsentisizing Prolonged action Independent of cumulative action Frequent cleansing with the same agent tends to inhibit reestablishment of resident florae. The Centers for Disease Control and Prevention (CDC) indicates the most of the studies performed to date have focused on measuring hand bacterial counts and not focused on the impact of any scrub agent choice on surgical-site infection.

Chlorhexidine Gluconate. A 4% aqueous concentration of

chlorhexidine gluconate (CHG) in a soap base or 0.5% in alcohol exerts an antimicrobial effect against gram-positive and gramnegative, fungal, and viral microorganism. Iodophor. A povidine-iodine complex in detergent fulfils the criteria for an effective surgical scrub. It is available in 10%, 7.5%, 2% and 0.5 %. Triclosan. A solution of 1% triclosan is nontoxic, nonirritating, intermediate antimicrobial agent that inhibits inhibits growth of a wide range of gram-positive and gram negative and TB microorganisms. Alcohol. Ethyl or isoprophyl alcohol(60% to 90%) is rapidly antimicrobial against all microorganisms. Hexachlorophene. In concentration up to 3%, hexachlorophene is most effective after buildup of cumulative suppressive action. Parachlorometaxylenol. Used in a concentration of 1% to 3.75%, parachlorometaxylenol does not substantially reduce microorganisms immediately.

Preparation for Surgical Hand Cleansing

General Prepartion 1. The skin and nails should be kept clean and in good condition, and the cuticles should be uncut. If hand lotion is used to protect the skin, a non-oil based product is recommended. Oil can weaken the integrity of gloves. 2. Fingernails should not reach beyond the fingertip to avoid glove puncture. 3. Fingernail polish should not be chipped or cracked. Freshly applied may be worn if permitted by facility policy. 4. Artificial devices should not cover natural fingernails. Artificial nails harbour microorganisms such as bacteria and fungi. 5. All jewelry should be removed from the fingers, wrists, and neck. Jewelry harbour microorganisms.

Preparations Immediately before Surgical Hand Cleansing 1. Open sterile gown and gloves on a separate surface from the main sterile field. 2. Inspect the hands for cuts and abrasions. Skin integrity of the hands and forearms should be intact. 3. Be sure all hair is covered by headwear. Pierced-ear studs should be contained by the head cover. They are a potential foreign body in the surgical site. 4. Adjust the disposable mask snugly and comfortably over the nose and mouth. 5. Clean eyeglasses if worn. Adjust protective eyewear or the face shield comfortably in relation to the mask. 6. Adjust water to a comfortable temperature.

Surgical Hand and Arm Scrub with a Brush

A vigorous 2- to 5- minute scrub with a reliable

agent is effective. A counted brush-stroke method is equally effective in decreasing the microbial count in the skin. Too short a scrub may be equally ineffectual. Every member of the surgical team should scrub according to a standardized written procedure. When gloves are removed at the end of the surgical procedure, the hands are considered contaminated and should be immediately washed.

 Persons who scrub should think of their fingers, hands,

and arms as having four sides or surfaces. Both method follow an anatomic pattern of scrubbing: the four surfaces of each finger, beginning with the thumb and moving from one finger to the next, down the outer edge of the fifth finger, over the dorsal (back) surface of the hand, then the palmar surface of the hand, or vice versa, from the small finger to the thumb, over the wrists and up the arm, in thirds, ending 2 inches above the elbow. Because the hands are in most direct contact with the sterile field, all steps of the scrub process begin with cleaning the fingernails and hands and ends with the elbows. During and after scrubbing, keep the hands higher than the elbows to allow water and suds to flow from the cleanest area-the hands- to the marginal area of the upper arms.

Brushless/Waterless Surgical Hand Cleansing

Most brushless cleansing agents have an alcohol

base with an antimicrobial ingredient such as CHG or triclosan. Care is taken to allow the agent to completely dry before donning the sterile gown and gloves.

ASSISTED GOWNING AND GLOVING OF A TEAM MEMBER

A team member in sterile gown and gloves, usually the scrub person, may assist the surgeon or another team member in gowning and gloving by taking the following steps: 1. Open the hand towel, and lay one end on the freshly scrubbed team members hand, being careful not to touch the hand. Do not hand a towel from a bloody back table or hand a towel with contaminated gloves. 2. Lift the gown, and unfold it carefully with the sterile outside toward you and the unsterile inside toward the person being gowned, holding it open at the shoulders and neckline by cuffing over the hands. Do not hand a gown from a back table when the case is in progress. The drapes and gowns on the field in progress are considered biologically contaminated and could contaminate the wearer.

3. Keeping your hands on the sterile side of the gown under a protective cuff of the neck and shoulder area, offer the inside of the gown for the team member to don. He or she slips the arms into the sleeves. Take care not to let the sleeves make contact with unsterile areas 4. Release the gown when it is secured by the person being gowned. The team member holds arms outstretched while the circulator pulls the gown onto the shoulders and adjusts the sleeves so that the cuffs are properly slid back to expose the hands. In doing so, the circulator touches only the inside of the gown at the seams.

GLOVING A TEAM MEMBER

Pick up the right glove, and grasp it firmly with the fingers of both hands under the everted cuff on the sterile side. Hold the palm of the glove toward the person being gloved. 2. Stretch the cuff sufficiently open for the other to introduce the right hand, avoid touching the hand by holding your thumbs out. 3. Exert upward pressure as the person slides the hand into the glove. 4. Pull the glove cuff up and over the cuff of the right sleeve.
1.

5. Repeat for the left hand. The person being gloved can facilitate the process by supinating the gloved right hand and flexing the fingers like a hook to hold open the cuff of the glove being donned. 6. If a sterile vest is needed, hold it for the surgeon to slip the hands onto the armholes. Be careful not to contaminate the gloves at the neck level. If the gown is a wraparound, assist the person to tie in. Remember that the back of the gown is not considered sterile even if a sterile vest is worn.

REMOVING OR CHANGING CONTAMINATED GOWN AND GLOVES

The contaminated team member steps away from the field, and the circulator unfastens the neck and waist ties of the soiled gown. The contaminated person grasps the front of the gown at the shoulders below the neckline. The gown is removed before the gloves. Clean arms and scrub suit are protected from contaminate outside of the gown. Do not reach behind the gown to untie the back strings. The gown is removed as follows: 1. With gloves on, grasp the front shoulder of gown and pull forward . 2. In pulling gown off arms, be sure that gown sleeve is turned inside out to prevent contamination of scrub attire. 3. The other shoulder is grasped with the other hand, and gown is removed entirely by pulling it off inside out and rolling it away from the body.

The gloves are removed using a glove-to glove and then skin-to-skin technique. The cuffs of the gloves usually turn down as the gown is pulled off the arms. A glove-to glove, then skin-to skin technique is used to protect the clean hands from the contaminated outside of the gloves, which bear blood and body fluid of the patient. The gloves are removed as follows: 1. Grasp the cuff of the left glove with the gloved fingers of the right hand, and pull it off inside out. 2. Slip the ungloved fingers of the left hand under the cuff of the right glove, and slip it off inside out. 3. Discard the gloves in a trash receptacle. 4. Wash hands.

CHANGING GLOVES DURING THE SURGICAL PROCEDURE

If a glove becomes contaminated for any reason during a surgical procedure, it must be changed immediately. If stepping away immediately is not feasible, the contaminated hand and any object involved in the contamination should be held away from the sterile area. The glove is changed as follows: 1. Turn away from the sterile field. 2. Extend the contaminated hand to the circulator who, wearing protective gloves, grasp the contaminated objects and sets them aside. The circulator then grasps the outside of the contaminated glove cuff about 2 inches below the top of the glove, toward the palm and pulls the glove off inside out. 3. Preferably, a sterile team member gloves another. If this is not possible, step aside and glove the hand, using the open gloving technique.

The closed gloving technique is inappropriate for a glove change during a surgical procedure, because contamination of the new glove by the cuff of the gown is inevitable. the scrub person should change his or her own gloves before gowning and gloving another team member to avoid exposing the team member to contamination.