Surgical Hand Washing: Objective and Procedure Step by Step

He surgical washing of the hands It's a mandatory routine for less than 150 years. This wash seeks to eliminate the most harmful microorganisms present in hands and forearms before performing a surgical operation. Until the mid-19th century, hand washing was not a routine practice.

Even some people 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 diminish the rates of puerperal fever dramatically only with the washing of the hands.

However, this great discovery would be scorned by the scientific community of the time for"lack of scientific sustenance", so it would take several more years until the microbiological bases that supported Semmelweis' findings were described.

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

Purpose of surgical hand washing

The main objective of surgical hand washing is to reduce as much as possible of the germ load (especially bacteria) that may be found on the skin of the hands and arms of the surgical team.

Some people question the importance of hand washing since surgeons use gloves. However, these latex gloves are fragile and can sometimes have microscopic pores that, while not allowing the passage of blood and other fluids, are a great outlet for germs that live on the skin of the surgeon.

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

Due to the above, the washing of the surgical hands is not only important, but also constitutes 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 health personnel, pathogenic bacteria and fungi (capable of producing infections) can also be found that, although they do not directly affect them, can be transmitted to the sick.

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

Implements required

Despite its importance, surgical hand washing is a fairly simple procedure that has not varied 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:

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

- Surgical brush.

- Antiseptic solution.

- Adequate knowledge of the technique of surgical hand washing.

Sink

Perhaps this is the element with more complexity, since it must comply with certain characteristics to be installed in the operating room area.

Since the personnel that takes part of a surgery can not have contact with any surface once they have washed their hands, the sinks must have dimensions such as to wash their hands and forearms without touching the tap or the walls of the hands. sink.

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

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

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

Surgical brush

Surgical brushes are sterile plastic devices specially designed for the surgical washing of hands.

They have two parts: a sponge and a brush. The sponge is used to wash areas of thinner and more delicate skin like 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 the dirt that accumulates under the nails, although it is not essential as the 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 embedded in an approved antiseptic solution for use in the operating room.

Antiseptic solutions

Whether they are embedded in the surgical brush or taken from a dispenser (with foot pump), the washing of the surgical hands 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, soap solutions of iodine-povidone are usually 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 is allergic to iodine.

Knowledge of the technique

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

That is why so much emphasis is placed not only on learning the technique, but on practicing it to the point of exhaustion so that its execution is automatic and systematic, without skipping any step, in order to guarantee its correct execution.

Procedure for surgical hand washing

The washing of the surgical hands should take about 5 minutes. It is standardized and must always be done in the same way and following the same sequence. The procedure for surgical handwashing is described step by step:

- Open the surgical brush.

- Embed it in an antiseptic solution (if the brush is no longer embedded in it).

- Open the water.

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

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

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

- Even with the brush, clean the inside of all the 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 outer face of the fingers.

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

- Once the back of the fingers has been completed, brush the back of the hand for 30 seconds in a circular manner, always wiping one hand with the other.

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

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

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

- At all times the hands should remain in the initial position, fingers up, elbows down.

- Once the process is completed, open the water again and let the water drain from the tip of your fingers to your elbows. The antiseptic solution must be removed by water pressure and gravity. You should never squeeze your hands together.

- Once the antiseptic solution has been removed, close the water and go to the drying area. From this moment the hands are held with the fingers upwards, the elbows down, the arms semiflexed in front of the torso and the palms pointing towards the face of the surgeon.

- 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 compress, and the right side is dried with the other side.

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

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

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

References

1. 1. Bischoff, W.E., Reynolds, T.M., Sessler, C. N., Edmond, M.B., & Wenzel, R.P. (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, B.N., Stanley, G.L., Sheetz, C.T., Pfaller, M.A., Houston, A.K., Annis, L.,... & Wenzel, R. P. (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, T.V. (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, J. J., 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, E. L. (1995). APIC guidelines for handwashing and hand antisepsis in health care settings. American journal of infection control , 2. 3 (4), 251-269.
   8. Hingst, V., Juditzki, I., Heeg, P., & Sonntag, H. G. (1992). Evaluation of the efficacy of surgical hand disinfection following a reduced application time of 3 instead of 5 min. Journal of Hospital Infection , twenty (2), 79-86.