UNIT Two. Lesson 2B Hand Hygiene, Gowning, and Gloving Practices in the Perioperative Setting

_ UNIT Two Lesson 2B Hand Hygiene, Gowning, and Gloving Practices in the Perioperative Setting Introduction Aseptic technique includes those practices that protect the surgical team and the patient from acquiring an infection. Hand hygiene, gowning, and gloving principles prevent contamination of the surgical incision and help control infection. It is the responsibility of each surgical team member to practice according to outlined standards for his/her own safety and for the safety and protection of the surgical patient. The following lesson will focus on the principles of hand hygiene, gowning and gloving of all members of the surgical team. Learning Outcomes 1. Identify the appropriate surgical attire prior to beginning a surgical scrub/rub. 2. Identify the purpose of hand hygiene. 3. Differentiate between routine hand washing, traditional surgical scrub, and surgical rub. 4. Identify the purpose of the antiseptic solutions. 5. Distinguish between the three common antiseptic agents used in surgical hand scrub/rubs. 6. Identify the steps in the prewash process of hand hygiene. 7. Distinguish the steps in the surgical scrub using a brush between the countedstroke method and the anatomic timed scrub method. 8. List the steps in the surgical hand rub process using Manorapid Rub Method. 9. Describe the application of a sterile gown independently. 10. Describe the application of sterile gloves using the closed glove method. September 2014 RN Professional Development Centre & Nova Scotia DOH, Halifax, NS 1

_ 11. Describe the application of a sterile gown to another surgical team member. 12. Describe the assisted gloving technique for a surgical team member. 13. Explain the process of removing a soiled gown, gloves, and mask. 14. Discuss the appropriate correction of a break in aseptic technique (contamination) in relation to the following: contaminated glove and/or gown during initial setup for scrub nurse. contaminated glove and/or gown during the surgical procedure for any scrubbed team member. Required Readings Copeland, J.T. (2009). Do surgical personnel really need to double-glove? AORN Journal, 89(2), 322-328. Operating Room Nurses Association of Canada. (2013). The Standards for Perioperative Registered Nursing Practice. (11th ed.). Canada: Author, Dress Code, Scrub/Gown/Gloving, Section 2, pages 105-112. Rothrock, J.C. (Ed.). (2015). Alexander s care of the patient in surgery (15th ed.). Toronto: Mosby, Hand Hygiene, Gowning, Gloving, 108-116. Required Video AORN. (2011). Hand Hygiene, Gowning, and Gloving Practices in the Perioperative setting. [Video-40 mins]. September 2014 RN Professional Development Centre & Nova Scotia DOH, Halifax, NS 2

_ Hand Hygiene, Gowning, and Gloving Practices in the Perioperative Setting Before we discuss the role of hand hygiene in the perioperative setting, let s first review the necessary surgical attire that is required before any scrubbing, gowning, and gloving can occur. Surgical Attire Proper surgical attire consists of a two piece surgical scrubs, hair cap (head covering), mask, and shoe coverings, as required by each health care facility policy and procedure. Surgical attire should be clean and freshly laundered by facility; home laundering is not recommended Surgical attire should be changed daily or more frequently if soiled Unscrubbed personnel should wear long sleeve jackets to contain bacterial shedding from the arms (ORNAC, 2013) Surgical attire should completely cover other garments worn beneath them Scrub top should be tucked in at the waist (ORNAC, 2013) All hair and facial hair needs to be covered When masks are worn in the restricted areas of OR suite, the masks should cover nose and mouth and conform to facial contours to prevent venting (AORN, 2013). Jewelry Jewelry of any kind is a potential source of pathogens (Fuller, 2013). Microorganisms proliferate freely under rings and bracelets. Necklaces and earrings that are not confined under scrub attire pose a risk of falling onto the surgical field or even into the surgical incision. Exposed necklaces or earrings may become contaminated with blood or other aerosolized particles that can spread infection. The recommended standard issued by all health care agencies is to remove all jewelry or completely confine it inside scrub clothes or be removed before entering the semi-restricted or restricted areas (ORNAC, 2013). Protective Eyewear OR personnel should be protected from hazardous conditions in the OR suite. As stated in the ORNAC (2013) Standards, OR personnel must wear protective eyewear if a splash (e.g., blood or body substances) is anticipated in the OR setting. Protective eyewear includes side shields and face shields that reduce the incidence of contamination of mucous membranes of the eyes (ORNAC, 2013). September 2014 RN Professional Development Centre & Nova Scotia DOH, Halifax, NS 3

_ Case Study Let s now return to our case study with Mrs. Black. To review, Mrs. Black is a 49 year patient with a mild chest infection requiring an emergency open appendectomy for a ruptured appendix. Lucy, RN, is the circulating nurse and Matt, LPN, is the scrub nurse. After the patient was intubated, the surgeon and the surgical resident assisted with positioning. The surgical skin prep was completed by the surgical resident. Matt was ready for the surgeon and the surgical resident as they entered the OR from the scrub sink where they performed their surgical hand scrub/rub. Matt proceeded to assist gown and assist glove the surgeon and resident without incident. Just then a 4 th year medical student arrived and was asked to scrub in. The 4 th year resident returned to the OR from the scrub sink. Matt had an extra gown on his back table and Lucy opened gloves for the medical student. Matt then passed an unfolded sterile disposable white towel to the medical student. The medical student was able to dry his hands completely. Matt then assisted gowned and gloved the student and Lucy proceeded to tie the back of the gown. The medical student then turned to Lucy to finishing tying the front tie of the gown. As the student was passing Lucy the gown s front tie tab, the surgeon asked the medical student a question. The student turned quickly, brushing his gloved right hand against Lucy s hand. Case Analysis Perioperative LPNs use their specialized knowledge of sterile technique and perioperative professional standards to speak up and report when either care or the environment falls short and places patients at risk of harm, or potential contamination. Thus, they must advocate for their patients at all times throughout the surgical continuum. The following will outline the specific hand hygiene and gowning and gloving practices used in the perioperative setting. These practices are interventions used to prevent the transmission of microorganisms from surgical team members to vulnerable surgical patients and the surgical environment. Hand Hygiene Hand hygiene is the most important tool for preventing infection in the health care setting (Phillips, 2013). Skin contains both transient and resident flora. Hand hygiene removes transient and some resident microorganisms commonly found on human hands. Resident floras remain in the deeper skin tissues and are more resistant to removal, whereas transient microbes accumulate on the surface of the skin. September 2014 RN Professional Development Centre & Nova Scotia DOH, Halifax, NS 4

_ Handwashing can reduce the number of these microorganisms, and when combined with antiseptic agents, can inactivate or inhibit microbial growth (AORN, 2013). Routine hand washing: Event-related practice which is performed before and after a specific event/task (e.g., before and after patient care, after toileting, visible soiling of hands, etc.). Hand washing uses soap and water, antiseptic soap and water, or antiseptic hand rubs. Antiseptic liquid soap or antiseptic hand rubs are used in health care settings. Traditional surgical scrub: Uses a sponge brush, antiseptic solution, and water to remove and/or inhibit growth of harmful microbes on skin. Surgical handrub: Alcohol based handrub to remove and/or inhibit growth of harmful microbes on skin. Effective hand hygiene (e.g., surgical scrub/rub) must be performed before donning a sterile gown and gloves. This creates a level of protection (in addition to the gown and gloves) in the event of a break in the integrity of the gowns and gloves (AORN, 2013). Note: The hands cannot be sterilized. Hand hygiene, hand washing, and surgical hand scrubs/rubs are the most effective way to prevent and control infection by making the skin surgically clean (AORN, 2013; Rothrock, 2015). Initial Preparation Before beginning the surgical hand scrub/rub, surgical personnel must make sure they are prepared by: inspecting his/her hands and arms to ensure that the skin is intact and free of rashes, burns, lesions, cuts, etc. removing all jewelry donning a hair cap/hood that is adjusted to cover all hair including side burns and beards (where applicable) ensuring fingernails are short, clean, and healthy (Gruendenmann & Mangum, 2001) ensuring acrylic or artificial nails are removed as they are prohibited ensuring nail polish (if permitted by institutional policy) is fresh and not older than 4 days old, and free of chips (ORNAC, 2013). wearing a mask with a face shield or a mask and eye shield to protect the eyes from any splash, spray, or aerosol of blood or other infectious material. wearing fluid resistant shoe covers if indicated (e.g., when there are copious irrigations such as in urologic or orthopedic procedures, etc.). September 2014 RN Professional Development Centre & Nova Scotia DOH, Halifax, NS 5

_ wearing appropriate surgical attire with scrub shirt tucked into the pants to prevent possible contamination of scrubbed hands from brushing against the shirt (Rothrock, 2015). Antiseptic Solutions Antiseptics are agents/solutions that are applied to living tissue/skin to reduce the number of microorganisms. Antiseptic agents (e.g., hand scrub/rub) work by altering the physical or chemical properties of the cell wall. Antiseptics are designed to reduce or destroy microorganisms on the skin or mucous membranes without damaging these tissues. They bind to the stratum corneum, resulting in a persistent activity on skin. Antiseptic agents vary, but all are based on the same principles and share the same objectives: To remove dirt and transient microbes from the skin To reduce the resident microbial count as much as possible in the shortest time Provides a broad spectrum (e.g., gram positive and gram negative organisms, viruses) against a variety of microbes To provide the least amount of irritation to the skin (nonirritating and non toxic) To prevent rapid rebound growth (persistent effect) of microbes on the skin (Rothrock, 2015; AORN, 2013). The choice of antiseptic agent depends on the OR personnel s allergies/sensitivities/preferences, and the availability of antiseptic agent at health care facility. Manufacturer s recommendations for application should always be followed (AORN, 2013). There are a variety of antiseptic agents available in various concentrations and combinations; however we will only concentrate on the three most commonly found: Alcohol Available in 60-90% concentrations (usually contains emollients to prevent drying) Denatures proteins Broad range of activity Excellent rapidity of action No persistent/residual activity Do not use on eye or ear Do not use on mucous membranes Can be flammable/volatile if not dried completely CHG (Chlorhexidine Gluconate) 4% concentration in a soap base and/or 0.5% mixed with alcohol Disrupts cell membranes September 2014 RN Professional Development Centre & Nova Scotia DOH, Halifax, NS 6

_ Wide range of activity (e.g., gram positive and gram negative organisms) Moderate rapidity of action Excellent persistence- remains chemically active for six hours (Phillips, 2013) Do not use on eye or ear-toxic/irritating Use with caution on the mucus membranes (AORN, 2013) Skin irritation possible with prolonged contact Do not use for lumbar puncture and meninges. Iodophors Available in 10%, 7.5%, 2% and 0.5% concentrations Wide range of activity Moderate rapidity of action Minimal persistence or residual effect (Phillips, 2013) Can use in or around eyes and ears Can use on mucous membranes Avoid use in neonates Skin irritation possible with prolonged contact Surgical Scrub/Rub There are a variety of methods for the actual surgical scrub/rub. Each health care facility should have a written policy that stipulates the health care facility s policy and procedure. The following will focus on the surgical hand scrub with a brush, and a surgical hand rub (brushless surgical scrub). Although surgical team members wear sterile gloves during the surgical procedure, the skin of their hands and forearms should be prepared to reduce the number of microorganisms in the event of glove tears. This is accomplished with a surgical hand scrub/rub using a: mechanical process - removes soil and transient microorganisms with friction of scrubbing/rubbing. chemical process - reduces resident flora and inactivate microorganisms with an solution Prewash A prewash is necessary no matter which surgical scrub/rub is selected. A prewash is usually done prior to the surgical hand scrub/rub with neutral/plain soap. The primary action of a neutral soap (e.g., Dermotan) is the mechanical removal of transient bacteria from the skin (Gruendenmann & Mangum, 2001). In comparison, antiseptic September 2014 RN Professional Development Centre & Nova Scotia DOH, Halifax, NS 7

_ agents (e.g., chlorhexidine gluconate) work by altering the physical or chemical properties of the cell wall. Antiseptic solutions are designed to reduce or destroy microorganisms on the skin or mucous membranes without damaging these tissues. This is also the time when special attention is given to the fingernails or subungal areas. Fingernails harbor the majority of flora on the hands (ORNAC, 2013). Therefore, cleaning under each fingernail must be done before performing the first surgical scrub of the day or if hands are visibly soiled (ORNAC, 2013). The hands are prewashed with a neutral soap and warm water to remove gross dirt and skin oils. This wash should encompass the hands (nails, fingers, webspaces, palms, back of hands), wrists and forearms, and should also extend 2 inches above the elbows. Friction should be applied while washing. After the prewash of the hands and forearms, the undersides of the fingernails are cleaned using a nail stick under running water to remove any debris. Once the prewash and fingernails are cleansed, the perioperative nurse will begin the surgical hand scrub/rub. There are a variety of methods used for the surgical hand scrub depending on personal preferences and the availability of the antiseptic solutions at the health care facility. Typically the surgical nurse will either choose a surgical hand scrub with a brush or a surgical hand rub (brushless surgical scrub). Surgical Hand Scrub with Brush Secures all head and facial hair and clothing. All jewelry should be removed. Ensures fingernails are short, clean. Only clear, freshly applied polish may be worn. No artificial nails may be worn. Open wrapper containing disposable brush and nail stick. Dampens the hands and forearms under running water to 2 above elbow, then applies the neutral soap for the prewash. Washes hands and forearms (to 2 inches above elbow) and rinse. Use nail stick to clean under nails, under the running water. Discard nail stick. Remove surgical brush from package and discard package in appropriate receptacle. Holding the brush and squeezing to release solution, place all fingers and thumb together to scrub nail tips using the bristle side of the brush. Next scrub all sides of each digit (including web spaces) with the softer sponge side of the brush. Wash all four sides making sure to keep hands elevated at all times. Then scrub the palm and the back of the hand in a circular motion, making sure to include the wrist. Scrubs, in a circular motion, each forearm to the elbow. Repeat for opposite hand and arm. September 2014 RN Professional Development Centre & Nova Scotia DOH, Halifax, NS 8

_ Discards the brush. Rinses the hands and forearms in one direction only from fingertips to elbows as often as needed to remove antiseptic solution. Holds the hands above elbows at all times and away from surgical attire. Hands and arms are held in front of body with elbows flexed while proceeding to the operating room. Ensures that scrub attire is kept dry and avoid any splashing and potential strikethrough. Strike-through is a contamination of a sterile item/surface (e.g., drape, cover, gown, etc.) by moisture that has originated from a non-sterile surface and penetrated the protective covering of the sterile item (AORN, 2013). Question: Why should the perioperative nurse use the softer side of the scrub brush for their hands and arms (not fingernails)? Answer: The softer side of the brush is used on the hands and arms to reduce damage to the epidermis layer of the skin (Rothrock, 2015). Typically, there are two different surgical hand scrubs with a brush that the surgical nurse can chose from: a counted-stroke scrub with a brush, or an anatomic timed scrub with a brush. A. Counted-Stroke Surgical Scrub The counted-stroke method may vary between health care facilities, so be sure to follow the method outlined in your institution s policy and procedure manual. The counted-stroke method begins by scrubbing the: nails of first hand are scrubbed with 20 strokes fingers (including web spaces) with 10 strokes to each side of the finger back of the hand with 10 strokes palm surface of the hand with 10 strokes each half of the arm with 40 strokes, 10 strokes to each side same method is repeated for the other hand and arm (AORN, 2013). During the entire procedure and during rinsing, the hands should always remain higher than the elbows so that contamination will be rinsed away from the hand area. If the hands or arms come in contact with faucet head, sink, scrub attire or other surface, the process should start again with a new scrub brush (Gruendemann & Mangum, 2001). Upon completion of the surgical scrub, the September 2014 RN Professional Development Centre & Nova Scotia DOH, Halifax, NS 9

_ nail cleaner, brush, or sponge should be discarded in the proper receptacle without lowering the arms or hands. The total time for both extremities is ~ 5 minutes. B. Anatomic-Timed Surgical Scrub The anatomic timed scrub method begins by scrubbing the: nails for 30 seconds with the bristle side (if preferred) of the scrub brush fingers and web spaces for 1 minute with the sponge side of the scrub brush palm for 15 seconds with sponge back of the hand for 15 seconds with sponge wrist and forearm for 30 seconds with sponge upper arm (2 inches above elbow) for 30 seconds with sponge same method is repeated for the other hand and arm (AORN, 2013). The total time for both extremities is ~ 5-6 minutes. If you are using the timed method make sure all surface areas have been scrubbed. Although the timed scrub method has been around for many years, it is used less commonly than other methods. Surgical Hand Rub (Brushless Surgical Scrub) The surgical hand scrub is the foundation of aseptic technique in the operating room. In the past decade, the technique of scrubbing has come into a new focus, as the idea of removing the surgical brush from the surgical scrub has received a lot of attention. There are a variety of antiseptic agents used as brushless surgical scrubs/rubs, however most are alcohol-based scrubs/rubs with the addition of moisturizing emollients and surfactants. Alcohol-based hand rub: An alcohol-containing preparation designed for application to the hands/arms for reducing the number of viable microorganisms on the skin. Such preparations usually contain 60%-95% alcohol. The actual procedure and timing for the scrub/rub varies and should be based on the manufacturer s recommendations for their particular product. In general, the brushless scrub/rub has been shown to decrease surgical scrub time, therefore the surgical team can commence the surgical procedure sooner and compliance increases. Each health care facility will chose their preference of which brand of brushless surgical scrub/rub they will use, depending on their preferences and vendor contracts. A pre-wash with an approved neutral soap (e.g., Dermotan), running water, and a nail pick to clean subungal (fingernails) spaces is usually recommended by most manufacturers. September 2014 RN Professional Development Centre & Nova Scotia DOH, Halifax, NS 10

_ Example Surgical Hand Rub 1. Pre-wash a. Wash hands with neutral soap (e.g., Dermotan) and warm water. b. Clean under the nails (subungual area) of both hands under running water using a disposable nail cleaner/stick. c. Rinse hands and forearms under running water. d. Dry hands and forearms thoroughly with a disposable paper towel so that there is no remaining water that could dilute alcohol-based product (Phillips, 2013). 2. Dispense the manufacturer s recommended amount of surgical hand rub product, using a hands free dispenser. a. Apply the product to the hands and forearms according to the manufacturer s written instructions. Pay particular attention to the areas between the fingers. The alcohol-based product must come in contact with ALL surfaces. b. Repeat the product application process as directed. c. Continue to rub the solution until it is evaporated and the hands are dry (10-15 seconds). 3. Don sterile surgical gown and gloves. Examples of surgical hand rubs are Manorapid, Sterillium, Avagard, Triseptin, and many others. Drying Scrubbed Hands (only if using a surgical scrub with a brush) Scrubbed personnel must thoroughly dry the hands and arms before donning the gown to prevent microorganisms on the wet skin from soaking through and contaminating the sterile gown (ORNAC, 2013). To dry hands after using a surgical scrub brush, the scrub nurse: Removes the towel from the sterile field with one hand. Step away from the gown table. This is done to prevent contamination of the gown by not allowing water to drip from wet hands on the sterile gown. Leaning slightly forward, holding the towel and hands away from the body and clothing. Allow towel to unfold to full length with one hand. Use one half of the towel for drying one hand and between your fingers first. First dries one hand, then with a rotating motion continue advancing up the forearm to 2 inches above your elbow. Be careful that the sterile towel does not touch scrub top which is unsterile. September 2014 RN Professional Development Centre & Nova Scotia DOH, Halifax, NS 11

_ With your dried hand, grasp the unused bottom portion of the towel and dry the other hand and arm with the unused half as outlined above. Discard the towel without any excess manipulation into the appropriate receptacle, keeping your hands above waist level. Gowning Gowning and gloving should be done from a separate table or surface that is waist height, away from the sterile field using the closed gloving method (AORN, 2013). This avoids any chance of contamination of the sterile field. As noted earlier, scrubbed personnel don sterile gowns and sterile surgical gloves over surgical attire to prevent microorganisms on their hands and clothing from being transferred to patients undergoing invasive procedures (AORN, 2013). The sterile gown and gloves also serve to protect the hands and clothing of the surgical personnel from microorganisms that are present in their patients or the environment (AORN, 2013). To don a sterile gown after drying hands (or hands were dry from brushless scrub/rub), the scrub nurse: Removes the gown below the neck edge, lifts it directly upward, and steps away from the sterile gown table to avoid touching the edge of the gown wrapper. See AORN (2011) Hand Hygiene video for a video on how to gown sterile gown properly. A trick is to think of the folded gown like a book-grab it by its binding (aka below the neck) so it is more secure when handling and step away from table. Grasps gown at the neckline with both hands. Inside of the gown is facing the wearer. Holds the gown at the shoulders and away from body, allowing the gown to unfold. Do not allow the outside of the sterile exterior to touch your clothing or body. Find the armholes on the gown. Slips both hands into the armholes at the same time, keeping hands at shoulder level and away from body. Advance hands and arms into the sleeves of the gown until hands reach the proximal end of the cuff. Do not advance hands to the distal end of the cuff as this will cause contamination of the gown (ORNAC, 2013 page 109). The circulating nurse will pull the gown over the scrubbed person's shoulders and ties the strings of the gown. After gloving (will be explained below), the scrub nurse passes the tab attached to the tie of the gown (which is located at the waist level) to the circulating nurse. The scrub nurse retrieves the back tie from the circulating nurse and completes tying the ends together. Please see Rothrock page 111-112 for pictures demonstrating this. September 2014 RN Professional Development Centre & Nova Scotia DOH, Halifax, NS 12

_ Gloving Closed gloving is the preferred method for establishing the initial sterile field by the scrub person (Phillips, 2013). Closed gloving is a technique that allows a nurse to glove without contaminating the sterile part of a surgical gown or gloves. Closed gloving keeps the hands inside the cuffs of the sterile gown (Phillips, 2013). This is necessary in situations (e.g., initial setup) where there are no other sterile personnel to assist with the gloving process. According to the research, health care practitioners should wear two pairs of gloves, one over the other (double gloving), during invasive procedures. This practice is also supported by AORN (2013). Please refer to required reading for rationale. Double gloving will be discussed in more detail further in the lesson. Open gloving is the method used when donning sterile gloves for procedures which do not require sterile gowns (e.g., dressing change, foley catheter insertion, etc.) (Phillips, 2013). Open gloving uses a skin to skin and glove to glove technique, where the hand must not touch the exterior of the sterile glove (Phillips, 2013). Please refer to Rothrock (2015), for more details on open gloving. Closed Gloving Procedure During the closed gloving procedure, the scrub person keeps the hands inside the cuffs of the sterile gown (Phillips, 2013; ORNAC, 2013). Ungloved fingers outside the cuff of the sterile gown constitute contamination. Please refer to Rothrock, 2015 page 115 to review closed gloving. Keep hands inside the sterile gown cuffs and use cuff-covered hands (e.g., lobster claw) to grasp the sterile gloves from the circulating nurse. Open the glove wrapper on the sterile field created from the gown s outer wrapper on the gown table. If right handed, it may be best to don the left glove first, using the dominant right hand to begin the procedure; however, this is your choice of which hand to start with (Gruendenmann & Mangum, 2001). Pick up the chosen glove using the thumb and index finger (lobster claw) of your hand which is still inside the sleeve of the gown. Place the glove on the forearm of the hand to be gloved. The glove should be palm down with the thumb aligned with your thumb and the fingers pointing toward the elbow. The inside cuff of the glove should be parallel to the cuff of the gown. Secure the glove by grasping the ridged edge of the inner side of the cuff with the thumb and forefinger of the hand to be gloved. Grasp the ridged edge of the September 2014 RN Professional Development Centre & Nova Scotia DOH, Halifax, NS 13

_ outer side of the cuff of the glove with the thumb and fingers of your other hand, which is still inside the sleeve of the gown. Stretch the cuff away from your forearm to create a pocket to push your hand into. As the glove is pulled over your hand, move your hand up through the gown cuff and into the glove. If your hand has not completely entered the glove, use your non-gloved hand (still in the gown cuff) to push your hand through into the glove by pulling on the cuff. Now repeat the procedure for the other hand. Use the gloved hand to grasp the second glove and lay it onto the forearm with thumb facing the floor and fingers pointed to the elbow. Secure the glove by grasping the ridged edge of the inner side of the cuff with the thumb and forefinger of the hand to be gloved (still inside gown). Grasp the ridged edge of the outer side of the cuff of the glove with the thumb and fingers of the hand which is already gloved. Stretch the cuff away from your forearm to create a pocket to push your hand into. As the glove is pulled over your hand move your hand up through the gown cuff and into the glove. Adjust the fingers after both gloves are on for comfort and fit. Don a second pair of gloves if double gloving (using any sterile method), as your initial pair of sterile gloves would already be on (Phillips, 2013). This skill will be tricky to master at first! Get a pair of surgical gloves and practice. Draw the sleeves of your gown/sweater up over your hands, and follow the procedure outlined above! The more you practice the easier it becomes. Double Gloving Scrubbed team members should wear two pairs of gloves, one over the other, during invasive procedures. In a review of 31 randomized controlled trials by Childs (2013), glove perforations showed that the addition of a second pair of surgical gloves significantly reduced perforations to the inner glove. To obtain a comfortable fit when you double gloving, experiment with different combinations and sizes of gloves to find a comfortable fit. One method does not work for everyone. Possible double gloving combinations are wearing a half-size larger glove as the under glove and the user s usual size as the outer glove, wearing two similarly sized gloves, or wearing an outer glove that is a half size larger. September 2014 RN Professional Development Centre & Nova Scotia DOH, Halifax, NS 14

_ For example when double gloving, here is an example for OR personnel who have a glove size of 7.5: Size 7.5 + 7.5 wearing two gloves with similar sizing Size 7.5 + 8.0 outermost glove half a size larger (e.g. 8.0) Size 8.0 + 7.5 outermost glove is 7.5 with under glove half a size larger 8.0 If your fingers are falling asleep/have numbness, this may be happening because you are wearing an underglove that is too tight. Try varying combinations of under and outer glove sizes such as wearing a larger size as the underglove and a glove that is your actual glove size as the outer glove (Phillips, 2013). The main thing with double gloving is to wear two sets of surgical gloves that are comfortable for you and allow the extra layer of protection from perforations. Gowning & Assisted Gloving of Other Surgical Team Members It is the responsibility of the scrub nurse to assist the surgical team with drying their hands (if required) and donning sterile gowns and gloves. If the surgical team member s hands are wet, pass the team member a sterile towel (unfolded) to dry their scrubbed hands. This is done by laying an open towel over their outstretched hand. Pick up the gown, step away from the sterile table and let the gown unfold. Grasp the gown so that your gloved hands are covered by the sterile gown (e.g., hold it by the shoulders not the neckline and make a cuff).this cuff made from the shoulders protects the scrub nurse s hands from being contaminated when assist gowning the unsterile team member. Remember to keep your hands above waist level. Offer the inside of the gown to the team member by aligning the armholes of the gown towards the arms of the person. Assist the person putting on the gown by holding the gown until they have forearms in the gown sleeves. The circulating nurse will then assist with pulling the gown over the shoulders of the surgical team member. The circulator may also need to pull the upper sleeves from the inside of the gown so that the person s hands can pass through the cuffs of the gown in preparation for assist gloving. September 2014 RN Professional Development Centre & Nova Scotia DOH, Halifax, NS 15

_ The circulator secures the back of the gown at the neck and waist. The circulator may also need to grasp the bottom of the gown and pull down gently to help eliminate any wrinkles/folds in the gown. Grasp a glove and stretch it out to release any areas that may cling together. The right glove is usually donned first (Gruendenmann & Mangum, 2001). The palm of the sterile glove is turned toward the ungloved person s hand with the glove directly opposed to the thumb of the person s hand (Rothrock, 2015). Or in other words, the palm of the sterile glove is turned toward the person being gloved (Phillips, 2013). Place the fingers of each of your hands under the cuffs, with your thumbs everted, stretch the cuff of the glove as the gowned person slips their hand into the glove. Be sure to keep your thumbs pointing outward to avoid touching the other team members bare hands. Exert a slight upward pressure as the gowned person is advancing their hand into the glove downward. Do not let your hands go below waist level. The gowned person can assist with the second glove by grasping the glove under the cuff on the palm side as it is presented to them. The person then slides their left hand into the glove in the same manner as the right hand. Ensure the glove covers their gown cuff entirely. Removing Soiled Gown and Gloves Soiled gown and gloves are removed in a manner, which minimizes cross contamination to the wearer s scrub attire and hands. The gown is always removed before the gloves to prevent the bare hands from contamination that would occur from handling a soiled gown. Wipe your gloves, to remove most of the contamination (e.g., blood, fluids, etc.), with a wet towel or sponge. Untie the external waist tie on the front of gown. The circulating nurse or other team member will untie the back ties of the gown, if it is not a disposable gown. If you are wearing a disposable gown, you can either tear September 2014 RN Professional Development Centre & Nova Scotia DOH, Halifax, NS 16

_ the ties by pulling at the waist (if no gross contaminants exist) or get another team member to untie. Grasp your soiled gown by the shoulders, pull it forward and off over your gloved hands. The cuffs of the gloves usually turn down as the gown is pulled off the arms (Gruendenmann & Mangum, 2001). Keep your arms and soiled gown away from your body as the gown is folded inside out and discarded in the laundry hamper/garbage. A glove-to-glove skin-to-skin technique is used to protect clean hands from the outside of soiled gloves. Grasp the cuff of one glove with the gloved fingers of the other hand pulling it off inside out and discard. Then slip the thumb or fingers of the ungloved hand under the cuff of the gloved hand forming a skin-to-skin contact as it is pulled off inside out and discarded. See Figure 4-23 page 116 in Rothrock, 2015. Remove your mask by untying the strings. Do not touch the mask itself. Discard mask in receptacle. Wash your hands immediately to reduce contamination and the risk of a latex allergy. Contamination Contamination of a sterile gown or glove can occur from a variety of sources. The goal is to contain and correct the contamination, thus recreating a sterile field. Correction of the contamination will be influenced by the source and timing of the contamination. Important aspects to consider in glove contamination are: The knitted cuff of the gown is porous and does not provide a microbial barrier (Gruendemann & Mangum, 2001). The cuffs of the sterile gown collect moisture and become damp during wearing, and they are considered unsterile. Hence, only closed gloving can be used during the initial gloving (Rothrock, 2015). Cuffs may not be pulled down over the wearer s hand for subsequent gloving (ORNAC, 2013). For subsequent gloving, an alternative technique must be use such as assisted gloving or open gloving for more experienced nurses (Rothrock, 2015). Hence, the cuffs of surgical gowns become contaminated when the scrubbed person s hands pass through the cuff during closed gloving (ORNAC, 2013). September 2014 RN Professional Development Centre & Nova Scotia DOH, Halifax, NS 17

_ Thus, it is important to note this principle when correcting a break in asepsis such as contaminated glove(s). During double gloving, both the inner and outer gloves should be changed as soon as possible when a perforation is noted. Perforations in the outer gloves are an indication that the inner glove may be compromised as well (Copeland, 2009). 1. Initial Set-Up of Case (scrub nurse is the only scrubbed member of team during initial setup) a. Sterile gown is donned, but sterile gloves are not on at this point in time. If the sterile gown is donned and becomes contaminated before the sterile gloves are donned, then the scrub nurse must complete the closed gloving technique. The scrubbed hands must be protected at all times. The scrub nurse completes the closed gloving technique for both hands. Once the sterile gloves are donned, the scrub nurse should then remove their gown by grasping the front, below the neckline and pull it off inside out, rolling it away from the body (Phillips, 2013). The gloves are then removed by the circulator (wearing disposable gloves) who will grasp the outside surface of the gloves, taking care not to touch the scrubbed person s arms or hands. Scrub nurses may also remove their own gloves using the glove to glove - skin to skin technique. If any contamination of the arms or hands occurs then the entire scrubbing procedure should be repeated. The circulator will open a new gown and gloves away from the sterile field (on a gown table) and the scrubbed person will re- gown and close glove to re-establish sterility. Note: The scrub nurse s gown cannot be removed without finishing the closed gloving technique as the scrubbed hands need to be protected from contamination from the gown s armholes (which have already touch the scrubbed person s scrub top). b. Sterile gown and gloves are already donned. If glove(s) or gown become contaminated (e.g., pin hole, tear, etc) during the initial set-up, the scrub nurse must stop what he/she is doing September 2014 RN Professional Development Centre & Nova Scotia DOH, Halifax, NS 18

_ (Gruendenmann & Mangum, 2001). The circulator will then remove the scrubbed person s gown and then their gloves without touching the scrubbed person s hands. Removing the gown first allows the surgical gloves to protect the hands as they are removed from the gown. The gloves are then removed by the circulator by grasping the outside surface taking care not to touch the scrubbed person s arms or hands. Scrub nurses may also remove their own gloves using the glove to glove- skin to skin technique. If any contamination of the arms or hands occurs then the entire surgical hand scrub/rub should be repeated. The circulator will open a new gown and gloves and the scrubbed person will re-gown and close glove to re-establish sterility. 2. During Surgical Procedure (other surgical team member(s) are scrubbed in) a. Assisted-gloving (Preferred Method) If glove(s) become contaminated (e.g., pin hole, tear, etc.) during the surgical procedure, the scrubbed person must stop what they are doing as patient safety permits (Gruendenmann & Mangum, 2001). The circulator (wearing disposable gloves) should remove the scrubbed person s gloves, making sure the cuff of the gown remains at the wrist level (ORNAC, 2013 page 111). The circulator will open a new pair of gloves and present them to the sterile field. When possible, another scrubbed team member (e.g., scrub nurse, surgeon) should assist glove the contaminated team member. According to Phillips (2013), the closed glove method is not appropriate for a glove change during the surgical case, as there is no way that the new glove can be used with the knitted cuff of the gown, in which the hand has already passed through. As stated at the beginning of this section, the knitted cuff of the gown is porous and does not provide a microbial barrier (Gruendemann & Mangum, 2001). Hence, the cuffs of surgical gowns become contaminated when the scrubbed person s hands pass through the cuff during closed gloving (ORNAC, 2013). September 2014 RN Professional Development Centre & Nova Scotia DOH, Halifax, NS 19

_ b. Other options when assisted-gloving not possible If it is not possible for another scrubbed team member to assist glove the contaminated team member, then the scrub nurse has two other options, depending on the situation and patient safety: 1. To have the circulator remove the scrubbed person s gown and then both gloves. The circulator will open a new gown and gloves to another table (other than the back table). The scrubbed person can then re-gown and close glove. 2. The contaminated glove remains on the hand of the scrubbed person. The circulator will open a new pair of gloves to the sterile field. The scrub person will carefully add the new glove over the existing glove using the open-gloving technique (Gruendemann & Mangum, 2001) until it can be changed (ORNAC, 2013). 3. Contamination when Double Gloving The contaminated outer glove can be removed, leaving the sterile under glove in place, if under glove not contaminated (e.g., punctured, needle stick, etc.). A new second pair of sterile gloves can be added to the sterile field and applied over the under glove. However, if the nature of the contamination is perforation/puncture, both sets of gloves must be considered contaminated and must be removed. If this is the case, then re-gloving would use the above outlined assisted-gloving method from another scrubbed team member would be appropriate (Phillips, 2013). Case Analysis Let s now return to our case study with Mrs. Black. The 4 th year student has contaminated his right glove by brushing his gloved right hand against Lucy s hand. Lucy, the circulating nurse, must speak up and identify the contamination. Lucy must communicate with the medical student (and the rest of the surgical team if appropriate) the area of contamination and the necessary actions to correct the contamination. The medical student s sterile right glove is now contaminated as it touched Lucy s unsterile hand. One option to correct the contamination would be for Lucy to open a new pair of sterile gloves to Matt, the scrub nurse, for the resident. She also needs to safely remove the medical student s contaminated right glove by gently pulling on the palm side of the glove (in the centre), making sure not to touch the sterile gown, which leave the sterile gown cuff at wrist level. Then Matt can take the new right glove and assist glove the medical student s hand. September 2014 RN Professional Development Centre & Nova Scotia DOH, Halifax, NS 20

_ Another option for correcting the contamination would be to open a new gown and gloves, especially if the nurses were not sure if the gown was contaminated as well. Lucy would open a new gown to Matt or Matt can use one from the sterile back table if he has an extra gown. She must also open a new pair of sterile gloves. Lucy must then assist the medical student in the removal of the surgical gown first and then the surgical gloves. Matt will then assist gown and assist glove, as done previously. Either method corrects the contamination and advocates for a competent and safe surgical experience. Summary As you begin to practice scrub, gowning, and gloving in the clinical setting, you will become aware of some of the conflicting practices that are being carried out, as far as surgical hand antisepsis practices and correction in contamination practices are concerned. This lesson provides you with the building blocks of aseptic technique so you can critically think about current operating room practices and recognizes that some of the information has been based on past practice - "we ve always done it this way" and not evidence based practice. New information that is evidenced based regarding these practices is emerging everyday and you need to be prepared to adapt to it in the clinical setting in which you will be learning and working. September 2014 RN Professional Development Centre & Nova Scotia DOH, Halifax, NS 21

_ References AORN (2013). Perioperative standards and recommended practices. Denver: AORN, Inc. Childs, T. (2013). Use of double gloving to reduce surgical personnel s risk of exposure to bloodborne pathogens. AORN Journal, 98(6), 586-596. Copeland, J.T. (2009). Do surgical personnel really need to double-glove? AORN Journal, 89(2), 322-328. Fuller, J. (2013). Surgical technology. (6th ed.). Toronto: Mosby. Gruendenmann, B.J. & Mangum, S. (2001). Infection prevention in surgical settings. Toronto: W.B. Saunders. Operating Room Nurses Association of Canada. (2013). The Standards for Perioperative Registered Nursing Practice. (11th ed.). Canada: Author. Phillips, N. (2013). Berry & Kohn s operating room technique (12 th ed.). Toronto: Mosby. Rothrock, J.C. (Ed.). (2015). Alexander s care of the patient in surgery (15th ed.). Toronto: Mosby. Tanner, J., Blunsden, C., & Fakis, A., (2007). National survey of hand antisepsis practices. Journal of Perioperative Practice, 17(1), 27-37. September 2014 RN Professional Development Centre & Nova Scotia DOH, Halifax, NS 22