Surgical Hand Antisepsis

A measure with high importance in infection prevention

Why surgical hand preparation is crucial in SSI prevention

Illustration of a person desinfecting hands

"Surgical hand preparation is vitally important to maintain the lowest possible contamination of the surgical field, especially in the event of sterile glove puncture during the procedure." (WHO)1

Aim of surgical hand antisepsis:1–3

  • elimination of transient microorganisms
  • reduction of the resident microbial skin flora

for the duration of the surgery.

Look closer into the Guidelines

Due to space constraints, only one aspect is presented here.
Guidelines
GuidelineRecommendationCategory (if mentioned)
WHO1
(Uses the term “Surgical hand preparation”)		“The panel recommends that surgical hand preparation be performed either by rubbing with a suitable antimicrobial soap and water or using a suitable alcohol based hand rub before donning sterile gloves.“Strong recommendation, moderate quality of evidence
NICE4
(Uses the term “Hand decontamination”)		“Before subsequent operations, hands should be washed using either an alcoholic hand rub or an antiseptic surgical solution.“

CDC5
(Uses the term “Surgical hand antisepsis”)		“Surgical hand antisepsis using either an antimicrobial soap or an alcohol-based hand rub with persistent activity is recommended before donning sterile gloves when performing surgical procedures.“IB
KRINKO2,3
(Uses the term “Surgical hand disinfection”)		Alcohol-based preparations approved for medicinal use should be used as the agents of choice for surgical hand disinfection.
The addition of a remanent antiseptic is not necessary and increases the risk of side effects.		IB

II

Portrait of Denise Leistenschneider, Senior Clinical Consultant
In the OR (operating room), the hands of the surgical team are their most valuable assets.
Denise Leistenschneider, Senior Clinical Consultant

Process & instructions

General

Icon of hand

Hands and nail

  • keep nails short1,2 and avoid artificial nails1,2,4 and nail polish1,2,4
  • clean hands and nails prior to performing the first hand antisepsisand operation of the day2,4
Icon of a ring

Jewelery

  • remove hand or arm jewelery1,2,4,5
Icon oh hand wash

Washing2

  • wash and dry hands thoroughly
  • wait 10 minutes
  • perform surgical hand disinfection
  • wash your hands again only when there is visible contamination

When to perform surgical hand antisepsis

  • before donning surgical gowns and gloves2,6
  • before other interventions with the same asepsis requirements2

Performing surgical hand antisepsis

At least 10 minutes interval from the last hand washing*

Illustration of human not washing his hands

No washing directly before surgical hand disinfection*

Illustration of human hands

Condition of hands** okay

Illustration of human with a short sleeves shirt

Sleeves are short or rolled up

Illustration of hands disinfectant application

Apply hand disinfectant

Illustration of disinfectant application on arms

Wet hands and forearms completely

Illustration of applying disinfectant to hands and fingertips

Rub hands carefully with special attention to fingertips and thumbs

Illustration of a timer

Rub-in time: 1.5 minutes, keep hands and forearms moist, reapply hand disinfectant if necessary

Illustration of disinfectant dripping onto the floor

Do not let disinfectant drip ontothe floor – risk of slipping

Illustration of a human drying their hands

Before putting on the surgical gloves, hands must be air dry

Pay particular attention to these critical moments to prevent infections.

* Wash hands only once before starting work or when dirty.
** Condition of hands: no jewelry, no nail varnish, fingernails short and round, no
injuries, no artificial fingernails, no gel nails.

Why surgical hand antisepsis matters

Glove perforations with subsequent contamination pose a real risk of infection to staff and patients!7

Perforation rates for main categories of surgery7

Illustration of a graph

Perforations after wearing time8

Illustration of a graph

Food for thoughts:
Savings potential due to switch from scrub to rub?

Switching to modern surgical hand preparation carries enormous savings potential:9–27

Chlorhexidine (CHX) for routine surgical hand disinfection?

Why alcohol-based hand rubs should be preferred

“Alcohol-based hand rubs are often preferred to antimicrobial soaps based on chlorhexidine or PVP iodine because:”32

  • have a broader spectrum of activity
  • act faster
  • have a better skin tolerance

References
1. WHO (2016) Global guidelines for the prevention of surgical site infection. World Health Organization 2016.
2. KRINKO (2016) Händehygiene in Einrichtungen des Gesundheitswesens. Empfehlungen der Kommission für Krankenhaushygiene und Infektionsprävention. (KRINKO) beim Robert Koch-Institut (RKI). Bundesgesundheitsbl 59: 1189–1220016).
3. KRINKO (2018) Prävention postoperativer Wundinfektionen. Empfehlungen der Kommission für Krankenhaushygiene und Infektionsprävention (KRINKO) beim Robert Koch-Institut. Bundesgesundheitsbl 61: 448–473.
4. NICE (2019) Surgical site infections: prevention and treatment. NICE guidelines. Published 11 April 2019. www.nice.org.uk/guidance/ng125.
5. Centers for Disease Control and Prevention (2002) Guideline for Hand Hygiene in Health-Care Settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR 2002; 51.
6. CDC (1999) Guideline for Prevention of Surgical Site Infection. Infection Control and Hospital Epidemiology 20(4): 247–278.
7. Hagen GØ, Arntzen H. The risk of surgical glove perforations. Tidsskr Nor Laegeforen 2007; 127(7): 856–858.
8. Partecke LI, et al. (2009) Incidence of microperforation for surgical gloves depends on duration of wear. Infect Control Hosp Epidemiol 30(5): 409–414.
9. Meengs MR et al. (1994) Hand washing frequency in an emergency department. Ann EmergMed. 23:1307–1312.
10. Cimiotti JP et al. (2004) A cost comparison of hand hygiene regimens. Nurs Econ 22: 196-199.
11. Tavolacci MP et al. (2006) Surgical hand rubbing compared with surgical hand scrubbing: comparison of efficacy and costs.
J Hosp Infect 63: 55–59.
12. Ahmed A (2007) Surgical hand scrub: Lots of water wasted. Ann AfrMed 6: 31–33.
13. nahdran 01/07 (2007) Magazin der Aesculap AG & Co. KG und der BBD Aesculap GMBH.
14. Jehle K et al. (2008) Clean and Green: Saving Water in the Operating Theatre. Ann R Coll Surg Engl 90: 22–24.
15. Troncoso D (2010), Estudio económico HU Príncipe de Asturias. Unpublished data at BODE Chemie GmbH.
16. Fleischer W (2012) Dtsch Arztebl; 109(50):A-2555/B-2095/C-2047.
17. Waeschle RM et al., (2016) Die Anaesthesiologie 2/2016.
18. López Martín MB and Erice Calvo-Sotelo A (2017) Comparative study of presurgical hand hygiene with hydroalcoholic solution versus traditional presurgical hand hygiene. Enferm Clin. 27(4): 222–226.
19. Fry DE (2019) Operating Room Hand Preparation: To Scrub or to Rub? Surg Infect (Larchmt) 20: 129–134.
20. Javitt MJ et al. (2020) Association Between Eliminating Water From Surgical Hand Antisepsis at a Large Ophthalmic Surgical Hospital and Cost. JAMA Ophthalmol 138: 382–386.
21. Guertler A et al. (2020) Onset of occupational hand eczema among healthcare workers during the SARS-CoV-2 pandemic: Comparing a single surgical site with a COVID-19 intensive care unit. Contact Dermatitis. 83(2): 108–114.
22. Agudelo-Vera C et al. (2020) Drinking Water Temperature around the Globe: Understanding, Policies, Challenges and Opportunities. Water 12: 1049.
23. Ragusa R et al. (2021) Has the COVID 19 Virus Changed Adherence to Hand Washing among Healthcare Workers? Behavioral Sciences. 11(4): 53.
24. https://www.nature.com/scitable/blog/eyes-on-environment/water_world/ (accessed 03.04.2023)
25. https://ec.europa.eu/eurostat/statistics-explained/index.php?title=Electricity_price_statistics (accessed 03.04.2023)
26. https://www.globalpetrolprices.com/electricity_prices/ (accessed 03.04.2023)
27. https://www.xe.com/de/currencyconverter/convert/?Amount=1&From=USD&To=EUR (accessed 03.04.2023)
28. Stingeni L et al. (1995) Occupational hand dermatitis in hospital environments. Contact Dermatitis 33: 172–176.
29. Chiewchalermsri C et al. (2020) Chlorhexidine Allergy: Current Challenges and Future Prospects. J Asthma Allergy 13: 127–133.
30. Buxser S (2021) Has resistance to chlorhexidine increased among clinically-relevant bacteria? A systematic review of time course and subpopulation data.
PLoS One 16: e0256336.
31. Jehle K et al. (2008) Clean and Green: Saving Water in the Operating Theatre. Ann R Coll Surg Engl 90: 22–24.
32. Kampf G, et al. (2005) Surgical hand disinfection with a propanol-based hand rub: equivalence of shorter application times. Journal of Hospital Infection 59: 304–310.

In focus

Skin care

Consistent skin antisepsis of OR Team significantly reduces the risk of infection and is essential during invasive procedures.

Find out more about this aspect of infection prevention…

Double gloving

Is there evidence to formulate a clear recommendation for double gloving?

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