A surgeon disinfects her hands before an operation.
Rub vs. Scrub

The evolution of surgical hand hygiene

It comes up all the time in TV series like Grey's Anatomy or Scrubs – the elaborate hygiene procedures that surgeons go through right before surgery. The sequence is always the same. They enter the preparation room, turn on the water tap and soap dispenser with their elbows and then scrub their hands and forearms for minutes under running water. In recent years, however, more and more hospitals have replaced this technique with a new form of surgical hand hygiene using disinfectant instead of medical soap. In this article, we look at how this development came about and explain what the differences are between rub and scrub.
For more than a hundred years, it has been common practice for surgeons and their assisting teams to thoroughly clean their hands before operating to facilitate the most sterile working environment possible. Along with face masks, surgical caps, gowns and gloves, this procedure is one of the most important measures to prevent infection during surgery. But how did surgical hand hygiene become such an indispensable aspect of preparing for surgery?

A brief history of surgical hand hygiene

Illustration of a nurse wearing an historical 19th century surgical gown.
The fact that microorganisms can cause infectious diseases was not known until the late 19th century.

Let's take a trip back in time to the mid-19th century. At that time, research on germs and bacteria was still in its infancy. Although scientists of the time were aware of the existence of microorganisms, there was still a lack of understanding of how the "little creatures" were linked to infectious diseases [1].

This didn't change until 1847, when German physician Ignaz Semmelweis, who worked at the Vienna General Hospital, noticed something of great significance. His hospital had two separate maternity wards – one staffed exclusively by male doctors and the other by female midwives. Inexplicably, the mortality rate among women giving birth in the ward staffed by male doctors was about twice as high as in the ward with the midwives [2].

On the trail of infectious diseases

Semmelweis wondered why. After testing various hypotheses, he quickly came up with the right explanation. Unlike the midwives, the male doctors often performed autopsies before deliveries. And since they were not obliged to disinfect their hands before procedures, they often transmitted dangerous pathogens from contact with corpses to the women they treated. The result: childbed fever and death.

Semmelweis proposed a solution that was as simple as it was effective: he introduced new hygiene rules at the hospital. Attending physicians were now required to disinfect their hands and instruments with a special chlorine solution before examinations and procedures. Previously, doctors only cleaned themselves with soap, if at all. In just a few months, the new rules significantly reduced the mortality rate on the ward [3].

Despite the success of this hygiene measure, it still took about two decades and further research, for example by Joseph Lister, Louis Pasteur, and Robert Koch, to fully prove that microorganisms can cause infectious diseases. It was not until the 1870s that doctors began to disinfect their hands and instruments routinely and thoroughly before operating on patients. Although his findings did not spread in medical circles until after his death, Semmelweis laid the foundation for the hygiene measures that are now taken for granted before surgery.

Illustration of a doctor wearing a medical mask and surgical gloves.

Surgical hand hygiene today

What do things look like today? What steps are involved in preparing for surgery in modern healthcare and what do the terms "rub" and "scrub" mean? To better understand surgical hand disinfection, let's first look at the differences in hygienic hand disinfection methods.

The difference between surgical and hygienic hand disinfection

More than 150 years after Semmelweis's groundbreaking findings at Vienna General Hospital, we know that pathogens can be transmitted from doctors and nursing staff to patients – especially via the hands. This can occur both during treatment and contact in the immediate patient environment. One of the most important methods of interrupting infection chains in health and care facilities and preventing nosocomial infections is hand disinfection by doctors and nursing staff.

There are two types of hand disinfection, surgical and hygienic. While the former, as the name already suggests, takes place exclusively before a surgical operation, hygienic hand disinfection is now part of everyday life in almost all areas of hospitals and care facilities. According to the WHO, this measure is always necessary in the following five scenarios:

Infographic showing the five moments of hand hygiene.
Illustration of the different exposure times of disinfectants for hygienic hand disinfection (30 seconds) and surgical hand disinfection (1.5 minutes).
Surgical hand disinfection is significantly more complex than hygienic hand disinfection.

Hygienic hand disinfection thus takes place far more often in the daily hospital routine than surgical hand disinfection. Its main aim is to inactivate all the germs that get onto the skin from outside and do not belong to the natural skin flora, such as harmful viruses or bacteria. In technical jargon, this is called the reduction of the so-called transient flora. Rubbing the hands for 30 seconds is sufficient for this [4].

In contrast, the surgical hand disinfection procedure is much more complex. Since its goal is to prepare to operate on the open body, in addition to the transient flora, surgical hand disinfection must also reduce the so-called resident flora as much as possible. This layer harbours germs that occur naturally on the skin and do not normally harm the organism but that can trigger infections in the patient during surgery. To eliminate this risk, disinfection must be much more thorough and last at least 1.5 minutes [5]. How is this done?

The 4 steps of surgical hand disinfection

Illustration of the four steps of surgical hand disinfection.
The individual steps of surgical hand desifnection are precisely prescribed.

To ensure that all germs are effectively inactivated, the procedure for surgical hand disinfection is precisely prescribed. Surgeons, doctors, and assisting staff must adhere to the following steps.

  1. Wash hands: 10 minutes before the first hand disinfection procedure on operation day, thoroughly and carefully wash and dry the hands and forearms (if several operations are performed in a day, this step must only be done once as long as the hands do not get dirty).
  2. Wet hands and forearms with disinfectant: Operate the dispenser lever with the elbow and wet both hands and forearms with sufficient hand disinfectant.
  3. Rub hands and forearms with disinfectant: Then rub the hands and forearms and keep them moist for the entire exposure time of 1.5 minutes. If necessary, add more hand disinfectant.
  4. Drying: Allow the hands and forearms to air dry before putting on the surgical gloves.

“Rub” vs. “Scrub”

Better skin tolerance, more efficient inactivation of germs and time saving: The advantages of "Rub" over "Scrub" are obvious.
Better skin tolerance, more efficient inactivation of germs and time saving: The advantages of "Rub" over "Scrub" are obvious.

Steps two and three of the instructions described above have only become common in recent years and reflect the transition from "scrub" to "rub". In the past, people did not use disinfectants to prepare for surgery, but washed their hands with water and antimicrobial soap ("surgical scrub"), mainly with chlorhexidine or iodine. Special sponges were used for this purpose, with which surgeons and their team scrubbed their hands for several minutes under running water [6].

The disadvantage of this technique is that frequent washing with soap and water, combined with intensive scrubbing for several minutes, can cause skin irritation and even inflammation. Frequent washing with soap and water also makes the hands brittle and cracked, making viruses and bacteria harder to inactivate. In recent years, more and more hospitals have introduced alcohol-based hand disinfectants ("rub"), which irritate the skin less. The refatting substances in products such as Sterillium®* [7] help the skin maintain or even rebuild its natural protective film [8].

But it is not only the better skin tolerance that speaks in favour of "rub" instead of "scrub" – various studies have shown that alcohol-based hand disinfectants also inactivate the viruses and bacteria found on the skin more effectively than traditional antimicrobial soap. Especially when it comes to the long-term reduction of pathogens on the skin, disinfectants show a greater effect [9, 10]. Another important point is that the modern "rub" technique takes much less time than scrubbing hands with soap and water for minutes on end.

Hand disinfection is indispensable even when wearing gloves

Illustration of a surgical glove that has a small tear.
Surgical gloves can perforate, which is why hand disinfection before procedures remains indispensable.

But why disinfect at all if surgeons and staff wear gloves anyway? The question is justified, as modern surgical gloves are very effective at preventing the transmission of potentially dangerous pathogens. They thus offer good protection against post-operative infections.

Various studies, however, have shown that surgical gloves perforate in up to 40 per cent of procedures, allowing pathogens to enter the patient's body via the wound [11]. Thorough surgical hand disinfection, even in combination with gloves, is thus indispensable when preparing for an operation.

Sources:

[1] National Geographic / “Wash your hands” was once controversial medical advice
https://www.nationalgeographic.com/history/article/handwashing-once-controversial-medical-advice

[2] Ibd.

[3] Ibd.

[4] KRINKO (2016) Händehygiene in Einrichtungen des Gesundheitswesens, Bundesgesundheitsbl. 59: 1189-1220
https://www.rki.de/DE/Content/Infekt/Krankenhaushygiene/Kommission/Downloads/Haendehyg_Rili.pdf%3F__blob%3DpublicationFile

[5] Ibd.

[6] A.F. Widmer / Surgical hand hygiene: scrub or rub?
https://pubmed.ncbi.nlm.nih.gov/23453175/#:~:text=In%20the%20past%2C%20washing%20hands,less%20time%20than%20washing%20hands.

[7] Please amend in accordance with local requirements (e. g. law of advertising, product status, CLP labelling).
Biocide mandatory texts
Art. 72 pursuant to EU/528/2012: Use disinfectants safely.
Always read the label and product information before use.

[8] IHO.de / Händehygiene – So wird's richtig gemacht!
https://www.iho.de/aktuell/haendehygiene-so-wirds-richtig-gemacht/

[9] Carlos Martin-Villa et al. / Comparing rubbing and scrubbing surgical hand antisepsis with propan-1-ol 60% in accordance with European regulation UNE-EN 12791:2016+A1:2018
https://www.cambridge.org/core/journals/infection-control-and-hospital-epidemiology/article/abs/comparing-rubbing-and-scrubbing-surgical-hand-antisepsis-with-propan1ol-60-in-accordance-with-european-regulation-uneen-127912016a12018/217EEE0AB494140497D918B4F93D54E0

[10] Suzan AMA Kareeem / Alcohol Based Handrub versus Traditional Hand Scrub as Surgical Hand Disinfection in a Tertiary Eye Teaching Hospital in Iraq
https://www.longdom.org/open-access-pdfs/alcohol-based-handrub-versus-traditional-hand-scrub-as-surgical-hand-disinfection-2155-9570.1000340.pdf

[11] KRINKO (2016) Händehygiene in Einrichtungen des Gesundheitswesens, Bundesgesundheitsbl. 59: 1189-1220
https://www.rki.de/DE/Content/Infekt/Krankenhaushygiene/Kommission/Downloads/Haendehyg_Rili.pdf%3F__blob%3DpublicationFile

*Please amend in accordance with local requirements (e. g. law of advertising, product status, CLP labelling).

Biocide mandatory texts

Art. 72 pursuant to EU/528/2012: Use disinfectants safely.
Always read the label and product information before use.

„HWG“-Pflichttexte, alternativ auch im Website-Footer.

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