Infection prevention and control

Health care-based infection prevention and control programs aim to reduce the spread of infections between patients and health care personnel (HCP). The most commonly used methods include standard precautions, which are a universal set of precautions that should be taken with all patients, and isolation precautions, which are designed to break the chain of infection for specific infectious diseases. Standard precautions include hand hygiene and routine cleaning and disinfection of devices and surfaces. Community-based precautions are utilized for notifiable diseases and during epidemic and pandemic disease outbreaks. HCP may be exposed to infectious pathogens, either through insufficient use of isolation precautions or a breach of personal protective equipment (e.g., a needlestick injury). Any HCP who have been exposed to an infectious pathogen should seek immediate advice from their occupational health department to prevent the development of infection and/or reduce the risk of further transmission. Specific protocols exist to reduce the risk of health care-associated infections (HAIs), which are often associated with the use of indwelling devices such as urinary catheters. Some of the recommendations outlined in this article to prevent specific HAIs may differ depending on local infection patterns and between institutions. Therefore, hospital-specific protocols should always be consulted.

• Definition: standard practices that should be used for all patients to minimize the spread of infectious material, whether an infection is suspected or not
• Includes the following: ^[1]
  • Hand and respiratory hygiene
  • Personal protective equipment (PPE): use of gloves, gowns, masks, and eye protection as needed
  • Aseptic and safe injection techniques
  • Routine cleaning, disinfection, and/or sterilization of devices, instruments, and surfaces

Hand hygiene ^[2][3][4][5]

• Definition: practices used to minimize pathogens on the hands of HCP
• Options
  • Antiseptic (most often alcohol based) hand rub: preferred method for unsoiled hands
  • Handwashing with soap and water: preferred method for soiled hands
• Basic precautions
  • Nails: cut short, no artificial nails
  • No jewelry on the hands or forearms
  • Avoid touching the face.
• General indications
  • If hands are not soiled, use alcohol-based hand rub before and after the following:
    • Work shifts and breaks
    • Contact with each patient and/or their immediate environment
    • Moving from contaminated to clean body sites on the same patient
    • Handling medication, syringes, invasive equipment, and infusions
    • Putting on and removing gloves
  • Wash hands with plain soap and water:
    • If hands are visibly soiled
    • Following exposure to spore-forming bacteria
    • Before eating and after using the restroom
    • If hand rub is not available
• Barriers to hand hygiene compliance
  • Work overload and time constraints
  • Poor situational awareness of the instances when hand hygiene should be performed
  • Intolerance or aversion to certain disinfectant formulations
  • Lack of a safety culture at the workplace
• Measures to increase hand hygiene compliance: The most effective measures to increase hand hygiene compliance are based on human factors engineering strategies.
  • Implement real-time feedback loops, in which designated hand hygiene observers or electronic hand hygiene systems monitor compliance and provide immediate feedback (e.g., verbal feedback on improper technique, real-time data visualization of each hospital floor's hand hygiene process measures).
  • Repeat training sessions on hand hygiene frequently to increase situational awareness.
  • Increase the number of hand hygiene stations and visual reminders (e.g., posters) and provide them at easily accessible locations.
  • Provide alcohol-based hand rubs at hand hygiene stations.
• Hand care: to prevent occupational irritant contact dermatitis
  • Use alcohol-based rubs when possible to minimize handwashing.
  • Avoid using hot water.
  • Use skin care products (e.g., moisturizers, emollients) regularly.

When using any hand hygiene method, pay particular attention to the fingertips, thumbs, and the spaces between the fingers.

Alcohol-based hand rubs are preferred unless hands are visibly soiled or if there has been contact with spore-forming pathogens. Hand rubs are quicker to use, more effective, and less irritating to the skin than handwashing. ^[2]

Respiratory hygiene ^[6]

• Definition: practices used to control the transmission of respiratory infections (e.g., influenza, COVID-19)
• Methods
  • Place a mask on coughing patients.
  • Cover the mouth when coughing or sneezing.
  • Maintain a distance of 3–6 feet from others while coughing or sneezing.
  • Dispose of tissues after use.
  • Perform hand hygiene after coughing or sneezing or coming into contact with respiratory secretions.
  • See also “COVID-19: Infection control.”

Overview

• Definition: a collection of physical barriers to protect against and/or prevent the transmission of microbiological, chemical, and/or radiological hazards
  • Prevents the spread of infection between patients and HCP
  • Examples include gloves, gowns, masks, face shields, and respirators
• General principles
  • Work from clean to dirty areas.
  • Change gloves and gowns:
    • When heavily soiled
    • Before using shared or portable equipment
    • Upon leaving a patient's room
  • Perform hand hygiene before and after PPE use.

Ensure all staff who enter a patient's rooms (including students and nonmedical staff, e.g., housekeeping) receive adequate training on how to use PPE properly.

Types of PPE and proper use

Standard precautions and isolation precautions require HCP to use PPE in the following situations.

Procedure-based PPE considerations

Some procedures, such as aerosol-generating procedures, clean technique procedures, and sterile technique procedures, require additional PPE.

• See “Isolation precautions” for PPE required during isolation precautions (e.g., contact, droplet, airborne).
• See “Presurgical infection prevention measures” for PPE required during surgical procedures.

Putting on PPE (donning) ^[8][9]

• Gather the required equipment, ensuring the correct size has been selected.
• Put on equipment in the following order:
  1. Long-sleeved isolation gown: Fully cover the torso, extending from the neck to knees and ends of the wrists, then close the back.
  2. N95 respirator or facemask: Secure and fit.
  3. Eye protection (e.g., goggles or disposable full face shield): Place and adjust.
  4. Clean, nonsterile gloves: Cover the cuffs of the isolation gown.
• For further information, see the example below.

Do not touch the front of the mask after entering the patient's room.

Safely removing PPE (doffing) ^[9]

• There are a variety of ways to remove PPE without contaminating the user; see examples.
• Do not touch any contaminated part of the PPE with ungloved hands during removal.
• Remove all PPE (except for a respirator) before leaving the contaminated space (e.g., the patient's room).
• Wash your hands or use an alcohol-based hand rub between steps any time they are contaminated.

Examples

Common disinfectants and antiseptics ^[10][11]

Disinfectants and antiseptics equally destroy microorganisms or inhibit their growth and the terms are often used interchangeably. The difference is that disinfectants are used on nonliving surfaces, whereas antiseptics are used on living tissue.

Skin and/or mucous membrane disinfection ^[10][11]

• Commonly used agents: alcohols (e.g., ethanol) , biguanides, phenols ^[3]
• Mechanism of action: protein denaturation
• Advantage: rapid onset of action and generally well-tolerated
• Disadvantages
  • Ineffective against bacterial spores and nonenveloped viruses
  • Antiseptic efficacy is reduced after it comes into contact with protein (e.g., blood).
• Alternative: iodine preparations

Surface disinfection ^[10][11]

• Commonly used agents: aldehyde, halogens, ammonium compounds, oxidants (e.g., hydrogen peroxide)
• Mechanism of action: denaturation of various structures (proteins, nucleic acids, cell nuclei)
• Advantage: high efficacy also against spores and nonenveloped viruses, minimal decrease in antiseptic/disinfecting efficacy after contact with proteins (e.g., blood)
• Disadvantage: poorly tolerated
• Alternative
  • Quaternary ammonium compounds
  • Disadvantage
    • Ineffective against gram-negative bacteria, mycobacteria, and mycoplasma
    • Decreased efficacy after contact with proteins

Sterilization (microbiology) ^[10][12]

• Definition: the process of destroying all microbial life, including spores, on a surface or in a fluid.
• Aim
  • Medical equipment that has come into contact with sterile tissue or fluids must also be sterilized.
  • Heat-stable equipment is sterilized mainly using steam (autoclave).
  • Heat- and moisture-sensitive equipment (plastics, electrical devices, and corrosion-susceptible metal alloys) require low-temperature sterilization using, e.g., ethylene oxide, hydrogen peroxide gas plasma, peracetic acid.

Sterilization techniques for heat-stable equipment

• Steam sterilization (autoclave)
  • Exposing equipment to direct steam at a certain temperature and pressure for a specified period of time
  • Mechanism of action: irreversible coagulation and denaturation of enzymes and structural proteins
  • Active against bacteria, fungi, viruses, and spores
  • Treated at > 121°C: typically uses 134°C for 3 minutes or 121°C for 15 min
  • Prions are not destroyed by standard autoclaving. They must be sterilized at 121–132°C for 60 min (not a standardized method).
• Dry air sterilization
  • Exposing equipment to dry heat, which gets absorbed by the external layer and transferred inward to the interior layer by a process called conduction
  • Denatures and oxidizes proteins and other cell components
  • Commonly uses 170°C (340°F) for 60 min, 160°C (320°F) for 120 min, and 150°C (300°F) for 150 min

Sterilization techniques for heat- and moisture-sensitive equipment

• Ethylene oxide gas sterilization
  • Ethylene oxide: flammable and explosive gas
  • The sterilization process includes preconditioning and humidification, gas introduction, exposure, evacuation, and air washes.
  • Mechanism of action: alkylation of protein, DNA, and RNA
  • Microbicidal against all microorganisms, with limited sporicidal effect due to spores resistance.
  • Disadvantages: lengthy cycle time, costly, and hazardous
• Hydrogen peroxide gas plasma sterilization
  • Hydrogen peroxide diffusion and gas plasma generation → formation of free radicals → damage enzymes, nucleic acid, and disrupt cellular metabolism
  • Active against bacteria (including mycobacteria), yeasts, fungi, viruses, and bacterial spores

Pasteurization ^[10][12]

• Aim: pathogen destruction through brief heating, especially of milk and other protein-containing products
• Procedure: treated with mild heat (< 100°C)
• Efficacy spectrum: destruction of a broad spectrum of bacteria but not heat-resistant spores

Isolation precautions (also known as transmission-based precautions) provide additional protection against the spread of suspected or confirmed highly contagious infections, and are used in addition to standard precautions.

General principles ^[6]

• Minimize interactions with the patient.
  • Coordinate tasks to minimize the number of patient encounters.
  • Perform tasks (e.g., imaging, procedures) inside the patient's room, if possible.
• Place patients in single-patient rooms, if possible.
  • Absolute indications: patients on airborne precautions and/or in protective environments
  • Consider for patients on droplet precautions and those with infectious gastrointestinal disorders.
• Utilize cohorts
  • Patient cohorts: grouping patients (e.g., by room or floor) with the same or similar medical condition
  • Provider cohorts: a single provider cares for patients with the same medical condition

Types of isolation precautions

• Contact precautions
  • Transmission method: direct contact with body fluids or fomites.
  • Commonly used in hospitals to prevent the transmission of:
    • Drug-resistant pathogens (e.g., MRSA, VRE)
    • Enteric infections (including Clostridioides difficile, Escherichia coli O157:H7)
    • Skin conditions, including scabies, impetigo, varicella, and draining abscesses
  • Required HCP PPE: gloves and gowns, even when direct contact with the patient or infected material is not expected
  • Medical equipment should be dedicated to a single patient; if this is not possible, disinfect before reuse.
• Droplet precautions
  • Transmission method: large respiratory droplet spread (typically droplets > 5 micrometers in size) via coughing, sneezing, or talking
    • E.g., Neisseria meningitidis, Bordetella pertussis, Influenza, Parainfluenza, Adenovirus, Haemophilus influenzae type B, Mycoplasma pneumoniae, and Rubella
  • Required HCP PPE: a mask when within 6 feet of the patient. The patient should also wear a mask during transport.
• Airborne precautions
  • Transmission method: aerosolized particles (particulates and aerosols < 5 micrometers in size) that remain suspended in the air (e.g., tuberculosis, varicella)
  • Goal: Prevent contaminated air from escaping the patient's room.
  • Airborne infection isolation rooms (AIIRs) can provide the following:
    • Constant negative air pressure compared to the hallway
    • Frequent air changes (6–12 air cycles/hour)
    • HEPA filtration of outgoing air
  • Required HCP PPE: a fitted N95 respirator or PAPR when entering the patient's room
  • If patient transport is necessary, the patient should wear a surgical mask.

Isolation precautions, when indicated, are used in addition to standard precautions. A combination of isolation precautions may be indicated for patients with particular infections (e.g., varicella) and those with certain conditions.

Protective environment for immunosuppressed patients ^[6]

• Indication: allogeneic hematopoietic stem cell transplantation (HSCT) recipients
• Goals: Keep potentially infectious air out of the patient's room and prevent exposure to fungal spores (reverse isolation).
• Precautions
  • Positive pressure rooms
    • Constant positive air pressure compared to the hallway
    • Frequent air changes
    • HEPA filtration of incoming air
  • Keep no carpet or upholstery, flowers, or potted plants in the patient's room.
  • Special room cleaning
    • Daily surface disinfection
    • Avoid dispersal of dust (e.g., damp dusting cloth, HEPA filtered vacuum).
  • Patients should only leave their room for diagnostic and therapeutic procedures.
  • Required HCP PPE: Only wear PPE as indicated by standard precautions or isolation precautions.
  • During periods of hospital construction work, patients should wear N95 respirators when outside their room.

General measures

Certain communicable diseases have the potential to spread in the local community and must be reported to the local health department (notifiable diseases). Controlling local outbreaks may involve the following methods.

• Isolation: separation of a person or group of people with a confirmed or suspected infection caused by a highly infectious pathogen, e.g., SARS-CoV-2
• Quarantine: separation of asymptomatic individuals who have been exposed to a virus
• Contact tracing: Trained health workers contact patients who test positive for certain infections in order to identify the source of infection and prevent further spread.
  • They identify and notify individuals who came into close contact with the patient while they were infectious.
  • This allows the application of quarantine and isolation to prevent further spread.
• Postexposure prophylaxis (PEP): a form of secondary prevention in which treatment is administered following exposure to a highly infectious pathogen
  • Types of PEP include immunizations, antibiotics, antivirals, and immunoglobulins.
  • Conditions that may require PEP include HIV, bacterial meningitis, tuberculosis, hepatitis B, tetanus, rabies, varicella, measles, and anthrax.

Epidemic control

During widespread epidemics and pandemics, government-mandated public health measures may be enacted. ^[13]

• Social distancing :
  • Maintain a distance of ∼ 6 feet (2 meters) from others.
  • Avoid congregate settings (e.g., shopping centers) and mass gatherings (e.g., concerts, rallies).
• Lockdown: Local or national governments encourage and/or mandate individuals not to leave their homes unless absolutely necessary.

Healthcare-associated infections (HAIs) or nosocomial infections are avoidable infections acquired within a medical setting. A number of health care quality improvement initiatives focus on reducing the number of HAIs. ^[14][15]

General infection control measures

• Follow standard precautions.
• Ensure patients are screened for common causes of HAIs, e.g., MRSA, and isolated appropriately.
• Use antibiotics judiciously to prevent the spread of antimicrobial resistance and antibiotic-associated infections, e.g., C. difficile.
• Ensure health care staff do not work if they are ill and that they are up to date on their vaccinations (see “Preventing health care personnel infections”).

General precautions for indwelling devices

• Only insert medical devices and perform medical procedures when clearly indicated.
• Consider alternative, less invasive options.
• Inspect devices daily and provide proper care.
• Assess daily whether the device is still needed and remove it as soon as it is no longer required.
• Consider using hospital bundles to automate prevention steps.
• Do not routinely use systemic prophylactic antibiotics.

Prevention of common healthcare-associated infections

• The following prevention steps should be used in addition to the general precautions listed above.
• For further information on definitions, risk factors, and management steps for each condition, see “Overview of nosocomial infections” in “Nosocomial infections.”

Prevention of catheter-associated urinary tract infections (CAUTIs) ^{[14][15][16][17]}

• Procedural
  • Consider whether routine catheterization is necessary.
  • Consider alternative options
    • Clean intermittent catheterization (CIC)
    • Condom catheters
  • Select the smallest catheter necessary.
  • Use sterile technique during insertion.
  • The use of antimicrobial catheters is not routinely recommended. ^[16][18]
• Postprocedural
  • Perform daily maintenance for indwelling catheters.
    • Clean the genital area, including the meatal area, with soap and water. ^[16]
    • Ensure unobstructed urine flow.
    • Maintain a sterile closed system.
  • Systemic prophylactic antibiotics are not recommended. ^[16]

Prevention of intravascular catheter-related infections (CLABSIs and CRBSIs) ^[14][15][19]

• Procedural
  • Consider a peripherally inserted central line (PICC).
  • Choose a catheter with:
    • The fewest ports or lumens required.
    • Antiseptic or antimicrobial properties ^[14]
  • Avoid femoral lines in adults if possible.
  • For the procedure:
    • Perform skin preparation with chlorhexidine and alcohol.
    • Follow hand hygiene and strict aseptic technique.
    • Place the line under ultrasound guidance.
• Postprocedural
  • Replace lines that were inserted emergently within 2 days.
  • Perform regular maintenance.
    • Inspect the catheter daily.
    • Daily chlorhexidine bath for patients in the ICU
    • Change dressings regularly. ^[14]
    • Use antimicrobial lumen locks and antiseptic covers. ^[14]

Prevention of ventilator-associated infections ^[14][15][20]

• Procedural
  • Consider alternatives, e.g., NIPPV
  • Oral rather than nasal intubation, if possible
• Postprocedural
  • Oral care with sterile water
  • Use a ventilator bundle protocol that includes:
    • The lowest level of sedation possible
    • Early exercise and mobilization
    • Minimizing secretion pooling
    • Elevation of the head of the bed to 30–45°
  • Maintain the ventilator circuit.
  • Further measures may be utilized in high-risk groups.

Prevention of surgical site infections (SSIs) ^[15][21]

• Procedural
  • Use alcohol-based surgical skin preparation.
  • Follow local or national guidelines for IV antimicrobial prophylaxis. ^[22]
  • Prior to elective operations:
    • Advise smoking cessation one month prior to surgery.
    • Treat all infections.
    • Advise patients to bathe or shower the night before surgery.
  • Perioperatively, maintain: ^[21]
    • Blood glucose levels < 200 mg/dL
    • Normothermia
    • ↑ FiO₂ when under general anesthesia and immediately post extubation
• Postprocedural
  • Do not apply antimicrobial agents to the incision.
  • Inspect dressings regularly and change as needed.
  • Minimize blood loss to avoid the need for transfusion, however, do not withhold necessary blood transfusions to prevent SSIs. ^[21][23][24]

HCP have an increased risk of acquiring infections from work, including those caused by multidrug-resistant organisms and highly communicable diseases, compared with the general population. HCP can also potentially transfer infectious pathogens to vulnerable patients. ^[25]

• Follow standard precautions and isolation precautions.
• Advise HCP not to attend work if they are unwell. ^[26]
• Immunizations
  • Ensure HCP are up to date on immunizations for health care personnel. ^[27]
  • Consider preexisting health conditions; see “Immunization schedule by medical indication.”
• Ensure protocols are in place to deal with exposures in the workplace.

Exposures occur when potentially infectious body fluids penetrate protective barriers.

Types of exposure ^[25]

• Percutaneous injuries, e.g., needlestick and sharps injuries: piercing of the skin by an object (e.g., scalpel, wires, pins, needles, glass shards) contaminated with body fluids
• Bites
• Through nonintact skin
• Splashes onto mucous membranes

Prevention ^[28]

• General: Follow standard and isolation precautions and use PPE.
• Percutaneous injury prevention
  • Avoid using needles if possible (e.g., needle-free IV systems).
  • Use medical devices with built-in safety features (e.g., blunt-tip suture needles, safety syringes, safety scalpels).
  • Do not remove a contaminated needle from the syringe.
  • Do not recap or bend needles.
  • Use a neutral zone rather than directly handing sharps to other members of staff.
  • Dispose of used needles and sharps in appropriate sharps disposal containers.
  • Consider double gloving. ^[29]

Percutaneous injuries pose the highest risk for transmission of bloodborne viruses. Despite precautions, ∼ 385,000 exposures occur every year in the US, resulting in significant health care costs and anxiety. ^[30]

Approach ^[25]

The following steps may help prevent an infection from developing.

• Exposed HCP
  • Perform first aid.
  • Notify the supervisor and occupational health department.
  • Immediately seek medical care (e.g., through occupational health or the emergency department).
• Treating clinician
  • Obtain further history about the exposure.
  • Order laboratory studies for both the exposed HCP and source patient, if possible.
  • Arrange follow-up and provide PEP, if indicated.
  • Counsel on additional recommended precautions to take during the follow-up period.

First aid ^[25]

• Percutaneous injuries
  • Wash gently with soap and water.
  • Allow the wound to bleed for > 1 minute under running water.
• Nonintact skin exposures: Rinse under running water.
• Splashes to the eyes, nose, or mouth: Flush or irrigate with water or normal saline.
• Eye exposures: Irrigate the eyes with clean water, saline, or sterile irrigants. ^[31]

History ^[25]

• Verify that an exposure occurred.
• Document how the injury occurred.
• Confirm if the source patient is known.
• Determine if the exposure was high risk for transmission of bloodborne viruses, e.g.,:
  • Percutaneous injuries ^[32]
  • Source patient with a high viral load
• Confirm that the HCP is up to date with hepatitis B and tetanus vaccinations.

Baseline laboratory studies ^[32][33][34]

Health care exposures require laboratory studies for both the source patient, if identified, and the exposed HCP. These studies focus on bloodborne pathogens, e.g., HIV, hepatitis B, and hepatitis C.

Postexposure prophylaxis (PEP) ^[32][33][34]

• Indications
  • Source patient is positive or high risk for a bloodborne pathogen
  • Source patient unknown
• Depending on risk factors, exposed HCP may require:
  • HIV postexposure prophylaxis (e.g., PEP antiretroviral therapy)
  • Hepatitis B postexposure prophylaxis (e.g., HBIG and/or hepatitis B vaccine): only in HCP without documented immunity ^[34]
  • Tetanus prophylaxis (e.g., tetanus booster and/or immunoglobulin)
• There is no postexposure prophylaxis for hepatitis C.
• Additional precautions during the follow-up period depend on the suspected pathogen ^[25][32][34]
  • Any bloodborne pathogen: Avoid donations of blood, plasma, organs, tissue, and semen.
  • HIV
    • Use barrier contraception (e.g., condoms).
    • Avoid breastfeeding and becoming pregnant.

Follow-up for exposure to bloodborne viruses ^[32][33][34]

In the United States, the Clinician's Post-Exposure Prophylaxis Hotline (1-888-448-4911) and website (https://nccc.ucsf.edu/clinician-consultation/pep-post-exposure-prophylaxis) are available to provide further assistance regarding the initiation and management of PEP therapy after a workplace exposure.

Other infectious exposures ^[6][27]

• Always contact the occupational health department for instructions on how to respond to health care exposures.
• Exposures to the following pathogens may require PEP and/or other interventions: ^[6][27]
  • Varicella: See “Postexposure prophylaxis of chickenpox” in “Chickenpox” regarding vaccination and immunoglobulin.
  • Measles: See “Postexposure prophylaxis” in “Measles” regarding vaccination and immunoglobulin.
  • Mumps: Exposed HCP with no immunity should remain at home. ^[35]
  • Rubella (nonimmune individuals only) ^[6]
    • MMR vaccine within 3 days of exposure (excluding pregnant individuals)
    • Consider immunoglobulins for exposed individuals in early pregnancy. ^[36]
    • Exposed HCP should remain at home for the duration of the potential incubation period.
  • Pertussis: See “Postexposure prophylaxis” in “Pertussis” regarding antimicrobial PEP.
  • Bacterial meningitis: See “Postexposure chemoprophylaxis for bacterial meningitis.”

Always notify the occupational health department about an exposure in the workplace to receive further recommendations and hospital-specific protocols.

General

• Aim: reduce the risk of an intraoperative surgical site infection through contamination with bacteria from the skin
• Who: all sterile staff members of a surgical team in the operating room (e.g., surgeons, scrub technicians, medical students assisting in a procedure)

Preparation

• Appropriate surgical attire ^[37]
  • The fingernails should be short. No artificial nails and/or nail polish should be worn.
  • All jewelry (e.g., bracelets, rings, watches) should be taken off.
  • The surgical staff member should wear:
    • Surgical scrubs
    • Surgical footwear (e.g., closed rubber clogs, shoe covers)
    • Surgical cap
    • Surgical mask
    • Protective eyewear
• Material: Gowns and gloves have to be prepared before scrubbing.
  1. Gowns: Place the gown package on a clean surface. Pull on the outer edges of the wrapping to expose the gown without touching the sterile content that is inside.
  2. Gloves: Open the plastic packaging and let the inner sterile glove packet drop onto the gown.

Prescrub wash

• Indication: only required before the first case of the day or when the hands are visibly soiled
• Instructions
  1. Adjust the water temperature to a comfortable, lukewarm level.
  2. Open the scrub sponge package and set it on the side. The sponge is not used during the prescrub wash.
  3. Wet the hands and arms and apply antimicrobial soap.
  4. Start by washing the hands, followed by the arms, and lastly the elbows.
  5. Use the nail pick from the scrub sponge package to clean the subungual spaces under running water.
  6. Thoroughly rinse off the soap from the hands and arms.

Surgical hand disinfection

Scrubbing in (surgical scrub)

• Indication: before each operation, before gowning and gloving
• Methods: Every institution has its own protocol for scrubbing in. The two most common are the brush stroke method and the timed method.
  • Brush-stroke method: A specific number of brush strokes is applied to each surface of the fingers, hands, and forearms. (see instructions below)
  • Timed method: The scrub is performed for a specific amount of time (typically 3–5 minutes).
• Substances
  • The most common scrub solutions contain one of the following agents:
    • Chlorhexidine gluconate
    • Povidone-iodine
  • Mechanism of antimicrobial action
    • Elimination of transient bacterial flora, reduction of resident bacterial flora
    • Inhibition of bacterial growth under the glove
• General rules
  • Always hold the hands at a higher level than the elbows.
  • Start with the fingertips and work towards the elbows.
  • Every area is only scrubbed once. Do not return to a previously scrubbed area.
  • To ensure thorough cleaning, the fingers, hands, and arms should be seen as having four sides , each of which has to be brushed individually.
  • Completely finish one side (left/right) before moving to the other hand and arm.
  • The abrasive side of the scrub sponge (nail brush) is only used to clean the fingernails. ^[2]
  • Neither the hands nor forearms should come in contact with any nonsterile object or surface (e.g., scrubs, tap). Otherwise, the entire scrubbing procedure needs to be repeated.
  • After scrubbing, the hands should stay at a level between the waist and the neck at all times.
• Instructions for the brush-stroke method ^[38]
  1. Remove the scrub sponge from the wrapper and moisten it under running water until you work up a sufficient lather.
  2. Put the fingertips of one hand together and brush the fingernails with the abrasive side of the scrub sponge for 30 strokes.
  3. Use the nonabrasive side of the scrub sponge to apply 10 strokes to all four sides of each finger, starting with the thumb. Do not forget the interdigital folds.
  4. Apply 30 strokes to the palm and 30 strokes to the back of the hand.
  5. Move on to the forearm. Mentally divide the arm into three equal increments, the most proximal of which ends two inches above the elbow. Scrub all four sides of each increment with 10 strokes, moving from distal to proximal.
  6. Switch sides and repeat steps 2–6.
  7. Discard the scrub sponge into the bin.
  8. Rinse off the foam.
     • Start at the fingertips and move forward under the water in a single fluid motion.
     • Do not move back and forth under the water.
     • Completely rinse off one side before moving to the other.
  9. Wait and let the water drip from the elbows. Do not shake the arms.
  10. Dry off the hands with the sterile towel from the already opened gown package. (See “Preparation” above.)
      • Take the towel without touching anything else.
      • Dry off one side completely (hand before arm), then continue with the opposite side.
      • Dab with the towel, rather than rub.

Alcohol-based disinfection (surgical hand rub)

• Indication: This method is an alternative to scrubbing with a sponge.
• Substances: disinfectants containing alcohol and phenol mixtures
• Instructions
  1. Wash hands and forearms with nonantimicrobial soap. Thoroughly rinse off all foam.
  2. Completely dry off the hands and forearms with disposable paper towels.
  3. Use the elbow to dispense the disinfectant into the opposite hand.
  4. Set a timer and use the hands to thoroughly rub disinfectant on the hands and forearms for ≥ 3 minutes.
  5. During the set time, reapply disinfectant if necessary. All areas should have constant contact with the disinfectant.

Do not touch nonsterile objects and/or surfaces during the disinfection process. Otherwise, the entire routine needs to be repeated.

The hands should always be held at a higher level than the elbows.

Gowning

• Indication: A sterile gown has to be donned for all surgical procedures. Often, surgeons are being gowned by an assistant that is already wearing sterile attire. However, every sterile member of the surgical team should be able to perform self-gowning.
• Instructions: The gown needs to be prepared before scrubbing (see “Preparation” above).
  1. Pick up the folded gown, only touching the inner side.
  2. Identify the sleeve openings and slide the hands into it on both sides.
  3. Take a step back to ensure that the gown can not touch any nonsterile objects while unfolding.
  4. Let the gown unfold while simultaneously sliding the arms into the sleeves. At no point should the hands exit the sleeve cuffs. Keep the hands above waist level.
  5. An assistant will fasten the gown and secure it with a velcro tab at the neck and upper back.
  6. Proceed with gloving (see “Closed glove method“ below).
  7. Pull only the left (shorter) tie out of the gown pass card.
  8. Pass the card to an assistant without letting the remaining tie slip from the card.
  9. Make a 360° turn so that the tie that is held by the assistant wraps around your waist.
  10. Pull the tie out of the card and secure both ties with a bow at your waist.

The gown is not considered sterile on the back, below the waist, or above the neck, because these areas are more likely to come in contact with unsterile objects.

Gloving

Closed glove method

• Indication: preferred method when preparing for a surgical procedure
• Instructions: Before starting closed gloving, a sterile gown must be donned.
  1. Open the sterile wrapper containing the gloves while the hands remain in the gown sleeves.
  2. Pick up the right glove by grabbing the folded cuff edge with the left sleeve-covered hand.
  3. Make sure the palm of the right hand faces the ceiling in the gown sleeve.
  4. Place the right glove on the right hand with the fingers of the glove pointing towards the shoulder. The palm of the glove should face the palm of the hand.
  5. Grab the palm-facing side of the folded cuff of the glove with the right sleeve-covered hand and hold onto it.
  6. Pull the ceiling-facing side of the folded cuff with the left sleeve-covered hand.
  7. Pull the glove up with the left hand and over the right hand.
  8. Pull the gown and glove up the arm to position your fingers inside the glove.
  9. Remove excessive gown sleeve from underneath the glove by pulling only on the gown. Make sure that the gown cuff stays fully covered by the glove cuff.
  10. Using the gloved hand, repeat the procedure for the other glove.

The gown cuff has to be fully covered by the glove cuff.

Open glove method

• Indication: predominantly used for smaller procedures that only require the hands to be sterile
  • Placing a urinary catheter
  • Performing a bone marrow biopsy or lumbar puncture
  • When gloves have to be changed during an operation
• Instructions
  1. Ask an assistant to help you in retrieving the sterile wrapper containing the gloves from the plastic packaging.
  2. Place the sterile wrapper on a clean surface.
  3. Unfold the wrapper by grabbing the outer edges without touching the inner surface. The gloves should now be exposed.
  4. Take the folded edge of the right glove with the left hand and hold onto it. Insert the right hand into the glove and pull the cuff over the hand.
  5. Slide the fingers of the gloved hand underneath the rolled cuff of the left glove.
  6. Lift the glove so that the opening is facing upwards.
  7. Widen the opening with the fingers of the gloved hand that are underneath the cuff.
  8. Insert the fingers of the left hand and pull the cuff over the hand.

• One-Minute Telegram 36-2021-1/3: Can probiotics prevent pneumonia in mechanically ventilated patients?
• One-Minute Telegram 36-2021-3/3: Replacement of peripheral IV catheters and incidence of bloodstream infections

Interested in the newest medical research, distilled down to just one minute? Sign up for the One-Minute Telegram in “Tips and links” below.