Skin organisms are the most common cause of surgical site infections, making the elimination of bioburden from your hands with traditional, brushless or waterless scrubs infection control's most important practice. Each scrub type is effective, so how do you decide which product you'll use? The procedure you're scrubbing for, the efficacy of the prep's ingredients, your staff's preference — they're all factors. But more important than how you scrub is that you scrub properly before every case. Choose a method, commit to it and follow its protocols correctly each time you stand in front of the scrub sink.

Complete coverage
Sterile gloves offer an effective layer of protection between your hands and patients' skin, but that thin barrier isn't 100 percent impervious. The smallest of holes or tears, invisible to the naked eye, can put you or the patient at risk of exposure to harmful bacteria. So follow these guidelines, culled from AORN's, the CDC's and the World Health Organization's recommendations for performing a timed or brush-stroke scrub. Perform a traditional scrub before the first case of the day or if your hands are visibly soiled with blood or other bodily fluid.

• Remove jewelry. Rings, watches and bracelets can harbor harmful bacteria. Removing these personal adornments lets antimicrobial agents come in contact with all areas of your skin during scrubbing. AORN reports that the risk of infection from transient microorganisms increases in relation to the number of rings worn, but no increase in microbial count on caregivers' hands has been reported when rings are removed before work.
• Wash hands and forearms. Wet hands with lukewarm water and apply antimicrobial soap in accordance with its manufacturer's directions. Rub your hands together for about 15 seconds, covering all areas of the skin's surface. Failing to address the problem areas of the hand — back of the fingers, the thumb, webbing between fingers — where microbes can easily collect is one of the biggest mistakes I've seen while observing staff at scrub sinks. After washing, rinse hands with warm water and dry them with a disposable towel.
• Clean under nails. Use a disposable nail pick to clean underneath each nail while holding your hands under warm running water. Rinse your hands and forearms before proceeding further. Nails that extend past your fingertips are a no-no in surgical settings. Look at your hand, palm facing up — if you can see your nails, they need to be trimmed. Artificial nails look nice, but like jewelry, they harbor microbes. Nail polish, too, should be avoided. If you polish your nails, be sure to remove it and apply a new coat every 4 days.
• Apply the scrubbing solution. Follow manufacturers' directives when applying antimicrobial solution to wet hands and forearms. Some manufacturers may suggest the use of a standard or disposable brush or sponge for effective application. Sponges may be preferred here, as they protect the integrity of the skin's surface — the first and best line of defense between you and the patient. Brushless scrubs are also kinder to the skin, and might be preferred by staff with sensitive hands damaged by an abrasive scrub brush.
• Start timing or counting. Again, follow an individual scrub manufacturer's directions for determining how long to scrub for or how many brush strokes are needed. As a general rule, 2 to 6 minutes should suffice when performing a timed scrub. Clinical data has not demonstrated that longer scrubs are more effective in eliminating microorganisms from the hands.
• Hit all areas. Scrub the arms, keeping your hand higher than the elbow at all times. Wash each side of the arm to 3 inches above the elbow for 1 minute. Repeat the process on your other hand and arm. To reduce splashing and the spread of bacteria to already treated areas of the skin, do not move the arm back and forth through the water; rinse hands and arms by passing them through the water from fingertips to elbow only. Proceed to the operating room holding your hands above your elbows. There, dry your hands and arms with a sterile towel.

As when performing your pre-scrub wash, be sure to cover all areas of your hands and forearms, paying particular attention to often-overlooked areas such as each side of each finger, between the fingers, and the back and front of the hand. Try visualizing each area as 4 quadrants that must be addressed before a scrub is deemed successful. You'll perform countless scrubs throughout your career, so it's easy to overlook the basics by falling into a routine. Don't make that mistake: Truly concentrate for the few minutes it takes to perform an effective scrub.

Dry rubs
Brushless, waterless scrubs are growing in popularity and may soon be the scrubbing method of choice. The CDC and AORN recommend the use of waterless, alcohol-based scrubs over traditional methods. AORN also reports that randomized trials demonstrate better compliance with surgical hand antisepsis protocols when alcohol-based agents are used instead of traditional surgical scrub protocols. Alcohol-based scrubs have also proven to be just as effective in killing microbes than the tried-and-true method.

As is the case with traditional scrubbing, perform a routine pre-scrub wash before using a waterless product. Wash your hands and forearms with soap and running water. Use a nail pick to clean the subungual areas of both hands under running water. Apply the manufacturer-recommended amount of scrub solution to your hands and forearms and rub thoroughly into the skin until it's dry (typically that's a minute or less). Do not towel-dry your hands and forearms before donning gloves.

Alcohol-based scrubs are quick to dry but may leave behind a sticky residue, making glove donning slightly more difficult. But the quick-drying products let you scrub without counting seconds or brush strokes, which are clear advantages for efficiency-minded staff. They require no brushing and often contain emollients to counteract alcohol's drying nature, 2 pluses for staff with sensitive skin.

Widespread acceptance of waterless scrubs may depend on changing the preferences of practitioners who are accustomed to the familiar and proven traditional scrubbing methods. Involve your surgical teams in new scrub product trials. Develop scrubbing protocols based on manufacturers' directions, and review those protocols whenever you introduce a new product to the front line. The product you place around your scrub sinks will depend on your staff's feedback about its ease of application and its feel. Buy into their buy-in, because giving them a scrub they'll use is the best infection control measure you can make.