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
   Before commencing the first scrub of the day, the hands should be washed thoroughly with soap and water and dried with a paper towel (see Procedure guideline 4.1: Hand washing). Note: WHO guidelines state that surgical procedures may be carried out one after the other without the need for further hand washing if hands are perfectly clean and dry, provided that the below hand‐preparation technique is followed with alcohol‐based handrub every time (WHO [124]).
   To ensure all physical dirt and soil is removed as alcohol is inactivated in the presence of dirt. E
2. 5.Show
   Wet the surface of the hands, wrists and forearms with a generous amount of alcohol‐based handrub as advised by the manufacturer.
   To ensure the correct amount is used and that skin coverage is appropriate. E
3. 6.Show
   Use steps 1–17 of the surgical hand preparation technique with an alcohol‐based rub (Action figure 4.14). The scrub procedure should take between 90 seconds and 3 minutes, depending on the manufacturer's guidelines.
   To ensure antimicrobial effectiveness (AfPP [2], C).
4. 7.Show
   Apply more alcohol to the hands and work this into the hands and wrists.
   As the hand moves up the arm, it may become contaminated. By applying more alcohol after cleaning to the elbow, this risk of contamination is reduced. C
5. 8.Show
   Allow the alcohol solution to dry on the hands before proceeding to don gown and gloves.
   Alcohol needs to be allowed to dry. E