SURGICAL HAND WASHING: OBJECTIVE AND PROCEDURE - MEDICINE - 2025

The surgical hand washing is a compulsory routine for less than 150 years ago. This washing seeks to eliminate the greatest amount of harmful microorganisms present on the hands and forearms before performing a surgical operation. Until the mid-nineteenth century, hand washing was not a routine practice.

Some people even indicated that it could be a source of complications. It was not considered of great importance until the observations of the Hungarian doctor Ignác Semmelweis, who managed to reduce the rates of puerperal fever dramatically just by washing the hands.

However, this great discovery would be scorned by the scientific community of the time as "lacking scientific support", so it would take several more years for the microbiological bases that supported Semmelweis' findings to be described.

Much progress has been made since then and hand washing is now a mandatory routine in all operating rooms around the world.

Purpose of surgical handwashing

The main objective of surgical hand washing is to minimize the load of germs (especially bacteria) that can be found on the skin of the hands and arms of the surgical team.

Some people question the importance of hand washing since surgeons wear gloves. However, these latex gloves are fragile and can sometimes present microscopic pores that, although they do not allow the passage of blood and other fluids, constitute a great exit door for the germs that live on the surgeon's skin.

Latex gloves.

In addition, there is the risk of a glove breaking from any cause: from manufacturing defects to accidental cuts with sharp material.

Because of this, surgical hand washing is not only important, but it is also the first line of defense in the fight against postoperative infections.

It is widely known that saprophytic microorganisms live on the skin, but in the case of healthcare personnel, pathogenic bacteria and fungi can also be found (capable of causing infections) that, although they do not affect them directly, can be transmitted to patients.

Hence the importance of hand washing before and after evaluating patients, being particularly important in the case of invasive procedures such as surgery.

Implements

Despite its importance, surgical hand washing is a fairly simple procedure that has not changed substantially with respect to its first descriptions and for which it is not necessary to have high-tech materials or implements; instead a few commonly used items are sufficient:

- Sink with water flow control with foot, leg or infrared actuator element.

- Surgical brush.

- Antiseptic solution.

- Adequate knowledge of the surgical hand washing technique.

Sink

Perhaps this is the most complex element, since it must meet certain characteristics in order to be installed in the operating room area.

Since the personnel involved in surgery cannot have contact with any surface once they have washed their hands, the sinks must be of such dimensions that they allow the hands and forearms to be washed without touching the faucet or the walls of the room. sink.

In addition, the tap must be a gooseneck, so that the water falls from above and there is enough space to wash without coming into contact with it. In addition, it is necessary that the water flow can be regulated with a leg or foot switch, since the hands cannot touch any type of handle.

Gooseneck faucet.

In centers where state-of-the-art technology is available, the sinks have a sensor that automatically opens and closes the water flow once the hands are placed near the tap.

In any case, the special switches and sensors are not a limitation since you can always count on the support of an assistant to turn on and off the water.

Surgical brush

Surgical brushes are sterile plastic devices specially designed for surgical hand washing.

They have two parts: a sponge and a brush. The sponge is used to wash the thinner and more delicate skin areas such as the forearms, while the brush is used to rub the palms and backs of the hands, as well as to clean the area under the nails.

Some brushes have a special device to remove dirt that accumulates under the nails, although it is not essential since proper brushing is enough to remove any trace of dirt that may have accumulated in that area.

Surgical brushes can be dry (they do not have any antiseptic) or be soaked in some antiseptic solution approved for use in the operating room.

Antiseptic solutions

Whether embedded in the surgical brush or taken from a dispenser (with foot pump), surgical hand washing should be done with some type of antiseptic solution in order to combine the mechanical effect of brushing with the physical effect. antiseptic chemical.

In this sense, povidone-iodine soap solutions are often very popular due to their high effectiveness and low cost. Chlorhexidine compounds are also available, a very useful alternative in cases where some of the members of the surgical team are allergic to iodine.

Chlorhexidine Skottniss / CC BY-SA (https://creativecommons.org/licenses/by-sa/4.0)

Knowledge of the technique

It does not matter if the sink is correct, the effective antiseptic solution and the optimal quality brush; If the correct surgical hand washing technique is not respected, the reduction of the bacterial load will not be optimal.

For this reason, so much emphasis is placed not only on learning the technique, but also on practicing it until exhaustion so that its execution is automatic and systematic, without skipping any step, in order to guarantee its correct execution.

Process

Surgical hand washing should take about 5 minutes. It is standardized and must always be done in the same way and following the same sequence. The following describes the step-by-step procedure for surgical hand washing:

- Open the surgical brush.

- Soak it in an antiseptic solution (if the brush is no longer soaked in it).

- Turn on the water.

- Place your hands under the tap with the tips of the fingers towards the ceiling and the elbows towards the bottom of the sink.

- Let the water run to moisten all the skin of the fingers, hands and forearms; the water should drain from the fingers to the elbows.

- With the surgical brush, start brushing the area under the nails for at least one minute. The right hand brushes the left and vice versa.

- Even with the brush, clean the inside of all fingers for at least 15 seconds each; once again the right hand washes the left and vice versa.

- Repeat the previous operation, but this time cleaning the outside of the fingers.

- Proceed as described so far, but this time cleaning the back of the fingers for at least 15 seconds each.

- Once the backs of the fingers are completed, brush the back of the hand for 30 seconds in a circular manner, always cleaning one hand with the other.

- Proceed next to clean the ventral surface of the fingers, as described so far.

- Once the ventral surface of the fingers is complete, proceed to wash the palm of the hand, brushing vigorously with circular movements.

- Then, using the sponge, wash the forearms in front and behind, from the wrists to the elbows.

- At all times the hands must remain in the starting position, fingers up, elbows down.

- Once the whole process is completed, open the water again and let the jet drain from the tips of the fingers to the elbows. The antiseptic solution must be removed by water pressure and gravity. Hands should never be squeezed together.

- Once the antiseptic solution is removed, turn off the water and go to the drying area. From this moment on, the hands are held with the fingers up, the elbows down, the arms semi-flexed in front of the torso, and the palms pointing towards the surgeon's face.

- In the drying area, the hands should be dried with a sterile compress, following the same sequence described for washing. The left hand is dried with one side of the pad, and the right is dried with the other side.

- Discard the compress and avoid contact with any surface. Important to always maintain the correct position.

- Proceed to don the sterile gown with the help of an assistant, if available.

- Put on sterile gloves; from now on, the hands must always be on the sterile field or, failing that, in the initial position during washing.

References

1. 1. Bischoff, WE, Reynolds, TM, Sessler, CN, Edmond, MB, & Wenzel, RP (2000). Handwashing compliance by health care workers: the impact of introducing an accessible, alcohol-based hand antiseptic. Archives of internal medicine, 160 (7), 1017-1021.
   2. Semmelweis, I. (1988). The etiology, concept, and prophylaxis of childbed fever. Buck C, Llopis A, Najera E, Terris M. The challenge of epidemiology. Issues and selected readings. Scientific Publication, (505), 46-59.
   3. Doebbeling, BN, Stanley, GL, Sheetz, CT, Pfaller, MA, Houston, AK, Annis, L.,… & Wenzel, RP (1992). Comparative efficacy of alternative hand-washing agents in reducing nosocomial infections in intensive care units. New England Journal of Medicine, 327 (2), 88-93..Pittet, D., Dharan, S., Touveneau, S., Sauvan, V., & Perneger, TV (1999). Bacterial contamination of the hands of hospital staff during routine patient care. Archives of internal medicine, 159 (8), 821-826.
   4. Furukawa, K., Tajiri, T., Suzuki, H., & Norose, Y. (2005). Are sterile water and brushes necessary for hand washing before surgery in Japan ?. Journal of Nippon Medical School, 72 (3), 149-154.
   5. Ojajärvi, J., Mäkelä, P., & Rantasalo, I. (1977). Failure of hand disinfection with frequent hand washing: a need for prolonged field studies. Epidemiology & Infection, 79 (1), 107-119.
   6. Parienti, JJ, Thibon, P., Heller, R., Le Roux, Y., von Theobald, P., Bensadoun, H.,… & Le Coutour, X. (2002). Hand-rubbing with an aqueous alcoholic solution vs traditional surgical hand-scrubbing and 30-day surgical site infection rates: a randomized equivalence study. Jama, 288 (6), 722-727.
   7. Larson, EL (1995). APIC guidelines for handwashing and hand antisepsis in health care settings. American journal of infection control, 23 (4), 251-269.
   8. Hingst, V., Juditzki, I., Heeg, P., & Sonntag, HG (1992). Evaluation of the efficacy of surgical hand disinfection following a reduced application time of 3 instead of 5 min. Journal of Hospital Infection, 20 (2), 79-86.