Pre‐procedure

ActionRationale

1. 1.Show
   Remove any rings, bracelets and wristwatches, and roll up sleeves before entering the operating theatre suite or procedure area. Note: most organizations will require staff entering operating theatres to change into ‘scrubs’.
   To ensure good hand washing as jewellery inhibits this. Dirt and bacteria can remain beneath jewellery after hand washing. Long sleeves prevent washing of wrists and will easily become contaminated (NICE [85], C; WHO [124], C).
2. 2.Show
   If the skin is damaged with cuts or abrasions, advice should be sought from occupational health as it may not be advisable to proceed with surgical hand antisepsis.
   Cuts and abrasions can become contaminated with bacteria and cannot be easily cleaned. Repeated hand washing can worsen an injury. Breaks in the skin will allow the entry of potential pathogens (WHO [124], C).
3. 3.Show
   Remove nail varnish and artificial nails (most uniform policies and dress codes prohibit these). Nails must also be short and clean. Clean beneath the nails using a pick or brush if needed.
   Long and false nails and imperfections in nail polish harbour dirt and bacteria that are not effectively removed by hand washing (WHO [124], C). The area under the nails may harbour dirt and micro‐organisms not easily removed by the other stages of the procedure (WHO [124], C).

Procedure

1. 4.Show
   Turn on the taps and where possible direct the water flow away from the plughole. Run the water at a flow rate that prevents splashing.
   Plugholes are often contaminated with micro‐organisms, which could be transferred to the environment or the user if splashing occurs (Aranega‐Bou et al. [4], E; British Standards Institution [10], C).
2. 5.Show
   Run the water until warm.
   Warm water is more pleasant to wash with than cold so hand washing is more likely to be carried out effectively. E

   Water that is too hot could cause scalding. E
3. 6.Show
   Ensuring no part of the sink or taps is touched, wet the surface of the hands, wrists and forearms up to the elbow, working in one direction only from the fingertips to the elbow, keeping the hands higher than the elbows.
   Soap applied directly onto dry hands may damage the skin. The water will also quickly mix with the soap to speed up hand washing. E
4. 7.Show
   Wash the hands again from the hand to the middle of the forearm and then wash from the hand to the wrist area.
   As the hand moves up the arm, it may become contaminated. By washing after cleaning to the elbow, this risk of contamination is reduced. C
5. 8.Show
   Apply appropriate antiseptic soap to all surfaces of the hands in one downwards stroke. Work into the hands palm to palm and then all the areas of the hands and arms just below the elbows as outlined in the following steps.
   Liquid soap is very effective at removing dirt, organic material and any loosely adherent transient flora. The bactericidal additive contributes to the reduction in the number of bacteria. Chlorhexidine has a residual effect to prevent regrowth of bacteria for a period after hand decontamination (WHO [124], C).
6. 9.Show
   Wash the hands again from the hand to the middle of the forearm and then wash from the hand to the wrist area.
   As the hand moves up the arm, it may become contaminated. By washing after cleaning to the elbow, this risk of contamination is reduced. C
7. 10.Show
   Wash the hands following the steps below:

   • right palm over back of left and vice versa with fingers interlaced (Action figure 4.13, step two)
   • rub palm to palm with fingers interlaced (step three)
   • rotational rubbing backwards and forwards with clasped fingers of right hand into left palm and vice versa (step four)
   • rotational rubbing of right thumb clasped in left hand and vice versa (step five)
   • rub finger tips on palms of opposite hands (step six)
   • continue with rotating action down opposing arms, working to just below the elbows; do not move back to the wrist (step seven).

   All steps should be carried out thoroughly on both the left and right hands and arms. The scrub procedure should take a minimum of 2–5 minutes, depending on local guidelines (AfPP [2]).
   To cover all areas of the skin and prevent bacteria‐laden soap and water from contaminating the hands (WHO [124], C).

   To prevent recontaminating areas already covered (AfPP [2], C).
8. 11.Show
   Rinse hands and arms thoroughly from fingertips to elbows, keeping the hands above the elbows at all times. Avoid passing the hands back and forth through the water.
   To avoid recontaminating the hands with water that has been used to clean the arms (WHO [124], C).
9. 12.Show
   At all times take care not to splash water onto clothing.
   To avoid contamination. C

Post‐procedure

1. 13.Show
   Dry hands thoroughly with a sterile paper towel. Hands are dried first by placing the opposite hand behind the towel and blotting the skin, then using a corkscrew movement to dry from hand to elbow (do not move back towards the wrist). Discard the towel and use a second one to repeat the process on the other hand and forearm (Action figure 4.13, step nine).
   Damp hands encourage the multiplication of bacteria (DH [33], C). Drying from hands to elbows reduces the risk of contaminating hands with bacteria from parts of the arm that have not been washed. E
2. 14.Show
   Dispose of used paper towels in a black bag in an open or foot‐operated waste bin.
   Paper towels used to dry the hands are normally non‐hazardous and can be disposed of via the domestic waste stream (DH [25], C). Using an open or foot‐operated waste bin prevents contamination of the hands. E