The surgical scrub is a formalized, meticulous process of hand and forearm antisepsis designed to dramatically reduce the microbial population on the skin of operating room personnel. This procedure is a foundational component of aseptic technique, which prevents microorganisms from contaminating a sterile field during surgery. The ultimate objective is the prevention of Surgical Site Infections (SSIs), which are a significant cause of patient illness. By cleansing the skin with specific chemical agents and mechanical friction, the surgical team minimizes the risk of introducing bacteria into the patient’s surgical wound. This practice is a standardized requirement before any team member contacts the sterile operative field.
Pre-Scrub Requirements and Aseptic Goals
Before approaching the scrub sink, surgical personnel must complete several preparatory steps to ensure the effectiveness of the antisepsis. All jewelry, including rings, watches, and bracelets, must be removed from the hands and forearms, as these items can harbor microorganisms. Fingernails must be kept short, clean, and free of artificial nails or polish, which host bacteria and increase the risk of glove punctures. Appropriate operating room attire, such as a scrub cap that covers all hair and a surgical mask, must be donned to contain potential sources of contamination.
The underlying goal of the scrub is to manage the two types of bacteria found on the skin: transient and resident flora. Transient flora colonizes the superficial layers of the skin and is relatively easy to remove through simple handwashing and friction. Conversely, resident flora is attached to the deeper layers of the epidermis and is more resistant to removal, requiring the persistent action of chemical agents. The surgical scrub aims to eliminate the transient organisms and significantly reduce the count of the resident microorganisms to minimize the risk of infection.
Step-by-Step Mechanical and Chemical Scrubbing
The surgical scrub begins with an initial wash of the hands and forearms with non-antimicrobial soap to remove gross soil. A disposable nail cleaner is then used to clean the areas under the fingernails while under running water. Throughout the scrubbing and rinsing process, the hands must be kept elevated above the elbows, which ensures that water flows from the cleaner area (hands) to the less clean area (elbows) and prevents backflow contamination. The water flow is typically controlled by knee or foot pedals, or sensors, to avoid touching non-sterile surfaces.
An antiseptic agent, such as Chlorhexidine gluconate (CHG) or Povidone-iodine (PVI), is then applied to the hands and forearms. The process involves a systematic application of friction, often using a timed method or a counted stroke method. Modern techniques often use a gentle, brushless friction method, though traditional sponge-brushes are still used, with the brush side used only for the nails or areas of visible soil.
The scrubbing proceeds sequentially, starting with the fingertips and the four sides of each finger, moving to the hands, and then extending to the forearms. The arm is scrubbed up to a point about two inches above the elbow. Depending on the specific facility protocol and the antiseptic product used, the total scrub time typically ranges from two to five minutes, with some protocols requiring a longer first scrub of the day. The hands and forearms must be kept wet with the antiseptic agent throughout the scrub to maintain its efficacy. Following the scrub, the arms are rinsed by passing them through the running water in one direction, from fingertips to elbow, while maintaining the hands-up posture.
Maintaining Sterility Post-Rinse
Immediately after the final rinse, maintaining the newly achieved state of high cleanliness is paramount, as the skin is now considered surgically clean, though not sterile. The scrubbed person must hold their hands and forearms up and away from their body, often in a position resembling prayer, to prevent contact with the non-sterile scrub attire. This posture ensures any residual water continues to run toward the elbows and away from the hands.
The scrubbed individual then proceeds into the operating room area, often backing in to avoid touching non-sterile surfaces. Drying the hands and arms must be done using a sterile towel, typically dispensed by a non-scrubbed assistant or found in the sterile gown pack. A specific aseptic technique is used for drying: one end of the towel is used for one hand and arm, and the opposite end is used for the second hand and arm. This one-hand-per-side method prevents the clean hand from contacting the area of the towel that has touched the less clean area of the other arm, leading directly into the donning of a sterile gown and gloves.