Surgical Scrub, Gowning and Gloving - Standard Operating Procedure

Publication: 21/08/2014  --
Last review: 17/10/2017  
Next review: 01/10/2020  
Standard Operating Procedure
CURRENT 
ID: 3936 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2017  

 

This Standard Operating Procedure is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Please check the patients allergy status, as they may be allergic to Chlorhexidine, and alternative ( Providine iodine) solution will be required.
Be aware: Chlorhexidine is considered an environmental allergen.
Refer to the asepsis guidance.

Surgical Scrub, Gowning & Gloving

Background and indications for standard operating procedure/protocol

This SOP relates to any clinical area across the Trust where surgical procedures / asepsis are undertaken, e.g. operating theatres, intensive care units, accident and emergency department, radiology etc.

Objective:
Hospital-acquired infections have both a financial and a human cost. Hand hygiene is universally considered to be the most basic but vital infection prevention and control measure. However, when undertaking surgical procedures a more extended hand hygiene procedure – ‘surgical scrub’ - should be undertaken, along with the donning of sterile surgical gowns and gloves – to achieve and maintain a sterile procedure.

Key Principles and Definitions:

Surgical Procedure - where the skin is incised or a body cavity is examined and sterility is the required standard.

Surgical Asepsis - e.g. insertion of Central Venous Catheters, chest drain, tracheostomy. When undertaking any procedures within an operating theatre environment the appropriate theatre blues must be worn.  In other areas - a waterproof apron must be worn over clinical uniform /dress prior to surgical scrubbing to reduce water contamination of clothing prior to using a surgical gown.

Personal Protective Equipment:

Face masks & eye protection - if there is an anticipated risk of splash injuries from blood and body fluid, face and eye protection (that also covers the side of the face) must be used by scrub personnel.

  • Alternatively if spectacles or microscope glasses (loupes) are worn, these must also protect the sides of the face/eyes
  • Face masks should be positioned  and secured prior to hand antisepsis to cover the nose and mouth,  the user must not touch the mask once applied
  • Post procedure, facemasks should be removed and discarded and  handled only by the ties
  • Specific eye protection and facemasks are required when working with lasers and surgical smoke plume refer to: Laser and other Artificial Optical Radiation Safety Policy

Further Personal Protective Equipment - should be donned prior to surgical scrubbing if required e.g.

  • lead aprons
  • aspirators (for use within laminar flow enclosures)

Surgical Scrub Solutions:

Hands carry both transient and resident skin flora:

Transient skin flora comprises of microbes acquired on the surface of the skin through contact with other people, objects or the environment, e.g. MRSA. Whilst the antibacterial properties of the skin prevent their survival for more than a few hours, they are readily transferred to other people or objects within this time i.e. cross infection. They are easily removed during hand hygiene.

Resident (or normal) skin flora lives deep in the skin’s crevices, in hair and sebaceous glands. They are not easily removed by the mechanical action of hand washing – but their numbers can be reduced by the combination of a detergent and microbiocide.

The aim of surgical scrub is to remove debris and transient micro-organisms and reduce resident micro-organisms to a minimum and to inhibit their rapid rebound growth. Surgical scrub solutions therefore must be antiseptic or alcohol based, fast acting, have a broad spectrum of action and a residual effect. Different products have varying contact times; this Standard Operating Procedure has been written to ensure that whichever product is used, the contact time will be sufficient.

Available solutions in use include:

Antimicrobial solutions:
Chlorhexidine gluconate 4%
Providone-iodine 7.5%

Alcohol based formulations:
Hibi Liquid hand rub - Propan-2-ol 60 - 80% and Chlorhexidine digluconate
0.5 - 0.7% solution
Skinman soft protect - Ethanol and Myristyl solution

Please note:
Surgical scrub using antimicrobial solution: use either Chlorhexidine gluconate 4% or Providone-iodine 7.5% to complete the scrub; do not mix antimicrobial products during the scrub procedure.

Surgical scrub using alcohol based formulations: use an antimicrobial solution or a prescribed product for the pre scrub procedure, select one of the available alcohol based formulations for the scrub procedure; do not mix alcohol based products during the scrub procedure.

Soap and water alone are not acceptable as a scrub solution, as soap has no antiseptic properties. Individuals who are allergic to the scrub solutions must receive advice from Occupational Health, who may advise use of soap or an alternative hand wash product and water combined with an alcohol solution.

Surgical Gowns:
Surgical gowns are made from non-permeable material to provide an effective barrier to microorganisms and fluids and conform to Standard EN 13795 and are available in various styles and can be either single-use or reusable laundered gowns.

  • Sterile surgical gowns must be stored away from scrub sinks and hand wash basins to avoid contamination from splashing.
  • The specification and suitability for the surgical procedure should dictate the type of gown used e.g. standard gowns should be used for minor/low fluid risk procedures and reinforced gowns should be used for all other procedures.
  • Gowns must be tied properly and wrap around in style for most surgery.
  • Both reusable and single-use gowns must be supplied with two hand towels, to ensure effective and safe hand drying can be achieved.

Surgical Gloves:
There are numerous types of surgical gloves available, which must conform to Standard BS EN 455-1. Gloves act as a barrier for personal protection and help prevent transmission of infection.

  • Sterile surgical gloves must be stored away from scrub sinks and hand wash basins to avoid contamination from splashing.
  • The choice of surgical glove depends on the particular surgical procedure being undertaken and the needs of the wearer. Evidence supports the use of double gloving for all surgical procedures. The decision to ‘double glove’ should be influenced by the risk posed by the surgical procedure (i.e. exposure to sharps) and not the ‘risk’ posed by the patient or personal preference.
  • When a patient is sensitive or allergic to latex proteins all scrubbed personnel must wear latex free gloves.  Patients with known or suspected type 1 allergy are treated in an environment which is latex safe. Staff who are sensitive or allergic to latex proteins must receive advice from Occupational Health (refer to Procedure for prevention and management of latex allergy in staff and patients).

Gloving Procedure:

Closed Method of Gloving - the closed method of gloving prevents the bare hands coming into contact with the outside of the sterile surgical gown. The gloves are handled through the fabric of the gown sleeves. The hands are not extended from the sleeves until the gloves are pulled into place. The closed method of gloving is the preferred method.

Open Method of Gloving - the everted cuff of each surgical glove permits a gowned person to touch the glove’s inner side with bare hands and the outer side with gloved hands. Extreme caution is needed to prevent contamination of the sterile outer glove surface by the exposed hands.

Once ‘Scrubbed’:

  • Staff must only touch items that are sterile and be aware of the risks of contamination at all times.
  • When not involved in the sterile procedure - scrubbed staff should stand with their hands clasped in front of them at or above waist height or with their hands placed on the sterile field.
  • Scrubbed staff should not reach over unsterile areas to avoid contamination.
  • If a sharps or splash injury occurs during a surgical procedure – the individual must inform the other members of the scrubbed surgical team and the person in charge of the incident. If possible the injured person should leave the surgical procedure immediately and perform first aid, best practice would be for a substitute member of staff to complete the procedure, however this may not always be possible, if not, the injured person should rescrub, and on completion of the procedure continue to follow the LTHT Inoculation Incident Prevention and Management of an Inoculation Incident (needle stick injury) (including prophylaxis) policy

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Life threatening/emergency situations:

In life threatening emergency situations, scrub practitioners may not be able to complete a full scrub procedure as detailed. Compliance will be dictated by the balance of risk to the patient and the Consultant must be informed to assess the need for anti-microbial cover.

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Occupational Health

Staff who have skin problems or are allergic to scrub solutions must receive advice from Occupational Health regarding which products to use to perform a surgical scrub. If advised by Occupational Health to use an alcohol based solution to perform a surgical scrub: Follow the pre scrub/pre wash instructions below (1-9), dry hands using a sterile towel and follow the World Health Organisation instructions in appendix 1 ‘Surgical hand preparation technique with an alcohol-based hand rub formulation’.
A clock with a second hand must be available in each scrub area to allow timing of the procedure.

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Procedure for ‘Surgical Scrub, Gown and Gloving’

Preparation of Self:
Ensure:

  • Finger nails are short, clean and free of nail varnish and artificial nails.
  • Remove all jewellery (with the exception of a plain wedding ring) before commencing the ‘surgical scrub’ procedure.
  • The hands and forearms should be free from lesions or breaks in skin integrity as this could pose an infection risk to both patients and staff.  Minor lesions must be covered by a waterproof occlusive dressing, after completing the scrub procedure. If any wound is infected the individual must not scrub.

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Pre-scrub/pre-wash and 3 minute surgical scrub procedure with a surgical scrub solution and dry single use surgical scrub brush

 Step one: Pre-scrub/pre-wash

Perform this procedure before the first scrub of day or after returning to theatre to re scrub

Open the surgical scrub brush prior to wetting your hands and place on the side

Ensure the water runs at a comfortable hand hot temperature and steady flow to avoid undue splashing

 

Wash hands and arms to elbows with running water and antimicrobial solution or plain soap. Keep hands above elbows allowing water to drain away. Rinse hands and arms from finger tips to elbows

Use the following procedure:

Working from your fingertips down to your elbows use the seven-step method:

 

1. Rub palm to palm

2. Rub the back of each hand with the palm of the other hand with fingers interlaced

3. Rub palm to palm with fingers interlaced

4. Rub with backs of fingers to opposing palms with fingers interlaced

5. Rub each thumb clasped in opposite hand using rotational movement

6. Rub tips of finger in opposite palm in a circular motion

7. Using a rotational movement rub from the wrist to the elbow of each arm, rinse from fingertips to elbow. Once the elbow has been reached the hand must not go back to the other hand or wrist until after rinsing

8. Remove debris from under nails using a nail pick, under running water

Wash for 1 minute

 

NB: If advised by Occupational Health to use an alcohol based solution to scrub, dry hands with a sterile towel and follow instructions in appendix 1

 

Step two: Scrub Procedure (3 minutes)

 

Wet your hands and forearms and apply approximately 5mls of antimicrobial solution (approximately 3 applications) to your hands

 

Working from your fingertips down to just below your elbows use the seven-step method:

  1. Rub palm to palm
  2. Rub the back of each hand with the palm of the other hand with fingers interlaced
  3. Rub palm to palm with fingers interlaced
  4. Rub with backs of fingers to opposing palms with fingers interlaced
  5. Rub each thumb clasped in opposite hand using rotational movement
  6. Rub tips of finger in opposite palm in a circular motion
  7. Using a rotational movement rub from the wrist to the elbow of each arm, rinse from fingertips to elbow. Once the elbow has been reached the hand must not go back to the other hand or wrist until after rinsing

See Above steps 1-7

Wash for 1 minute

 

Rinse your hands and arms from the fingertips to the elbows - allowing the water flow to remove the scrub solution

Pick the scrub brush up, wet and apply 5mls of solution to the brush side and use to scrub your nails only for 30 seconds per hand

Do not scrub your hands or arms with the brush - as this can cause abrasions to the skin

Rinse your finger tips

 

Apply another 5mls of solution; wash your hands and arms using the seven step method as above, paying particular attention to palms, finger webs and dorsum of the hands. Only wash the first two thirds of the forearms and do not touch the elbows to avoid contamination

Wash for a further 1 minute

 

Rinse your hands and arms from the fingertips to the elbows - allowing the water flow to remove the scrub solution

Turn the taps off using your elbows

        

Allow excess water to drain from your elbows into the sink

Total time taken 3 minutes

 

 

 

Gowning Procedure:

 

The outer gown wrap is opened by the circulator, checking the sterility and expiry

Once scrubbed open the inner wrap touching the edges of the wrap only

When drying your hands adhere to the principle of working from the fingertips to the elbows

 

Using two towels: use one towel per hand. Open the towel, place one hand behind it and dry the opposite hand thoroughly by blotting the skin and then use a corkscrew movement to dry from your hand to your elbow.

 

Do not return the towel to your dried hand and discard into a waste bin

 

Repeat with the second towel for your opposite hand

 

Once your hands are dry and keeping them away from your clothing, pick the sterile gown up by the inside surface only

 

Step away from the trolley / shelf to avoid contamination of the gown.

Locate the neck of the gown, hold firmly in your hands and release the rest of the gown, ensuring the inside is towards you

Locate the armholes and insert both arms, letting the gown fall towards you, ensuring the gown does not touch any unsterile surfaces

Keep your arms above your waist and in front of you - keeping your hands within the sleeves of the gown

The circulator secures the gown’s back ties or Velcro by grasping the inside of the gown at the shoulders to adjust the fit

The circulator will open the sterile gloves onto the open gown pack

0495

Gloving Procedure:

 

Closed Method:
Keep your hands within the sleeves of the sterile gown - and draw the sterile glove pack towards you

Open the pack so that the gloves are facing fingertips towards you

With one (sleeve covered) hand grasp with the thumb and forefinger of the corresponding glove by the folded cuff edge (i.e. crossover hands) ensuring your thumb is aligned with the thumb of the glove

 

Lift and turn your hand over so that the glove lies on your wrist with the fingertips lying towards the elbows

Using your other (sleeve covered) hand to grasp the uppermost edge of the glove’s cuff and stretch this cuff over the back of your hand, and straighten your fingers into the glove

Grasp both the glove cuff and the sleeve to pull the glove onto your hand

Repeat with the opposite hand

When both gloves have been donned check to make sure the gown cuffs are covered and adjust the fingers as necessary to ensure a good fit.

Don your second pair of gloves

Open Method:
The circulator will open the sterile gloves onto the open gown pack

0495

Open the glove packet so that the glove cuffs are towards you

Hold the first glove by the inside surface and pull onto the hand - leaving the folded back cuff in place

Place the gloves hand under the cuff of the second glove and insert the second hand into the glove

Once both gloves are donned - stretch the folded cuff and pull over the gown cuff to secure the gown within the glove

 

Repeat for the second hand

Once Scrubbed:

 

If the gown has a “wrap around” this must be used, by undoing the tie and handing out the tie for the wrap section to another scrubbed person - and tying it at the front of the gown

For disposable gowns the “wrap around” can be wrapped either by the circulator or another scrubbed person - by handing out the paper tag with the tie for the wrapped section attached. The circulator grasps the paper tag only and the scrubbed practitioner turns and then pulls the tie free and ties at the front of the gown

Post Procedure:

 

Once the surgical procedure is complete the gown and then the gloves are removed - the wrap is untied and the ask the circulator to undo the back ties

Pull the gown forward and down over your  gloved hands – therefore folding it onto itself and discard as hazardous infectious waste or into a red alginate bag

Remove your gloves are removed by ensuring glove is in contact with glove surface and the skin is in contact with the skin.

Facemasks (only handling the ties) and single-use visors and goggles must be discarded immediately after use.

 

Reusable visors and goggles must be cleaned between patients using a chlorine based solution

 

Inspect your hands post procedure for any signs of contamination

 

Decontaminate your hands using the seven step technique prior to touching any clean surfaces or the patient

 

Any contaminated hats or theatre attire must be changed

 

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Provenance

Record: 3936
Objective:
  • To standardise the procedure for surgical hand antisepsis, gowning and gloving.
  • To reduce and inhibit growth of bacteria under the surgical gloved hand for the duration of the procedure.
Clinical condition:

N/A

Target patient group: N/A
Target professional group(s): Allied Health Professionals
Midwives
Secondary Care Doctors
Secondary Care Nurses
Adapted from:

Evidence base

Evidence Level A & C

References / Associated Documentation
AfPP Standards and Recommendations for Safe Perioperative Practice (2016). Fourth Edition Association for Perioperative Practice, Harrogate, UK.

AfPP Standards and Recommendations for Safe Perioperative Practice (2011). Third Edition Association for Perioperative Practice, Harrogate, UK.

Arrowsmith VA, Taylor R. Removal of nail polish and finger rings to prevent surgical infection. Cochrane Database of Systematic Reviews 2012, Issue 5. Art. No.: CD003325. DOI: 10.1002/14651858.CD003325pub2.

British Standards Institution 2000. Medical Gloves for Single Use: requirements and testing for freedom from holes. BS EN 455-1 London BSI British Standards

CDC Guideline for prevention of Surgical Site Infection 1999.
http://www.cdc.gov/HAI/ssi/ssi.html

EU Standard – EN13795 Surgical Drapes, Gowns and Clean Air Suits, used as medical devices, for patients, clinical staff and equipment.

Lipp A, Edwards P. Disposable surgical face masks for preventing surgical wound infection in clean surgery. Cochrane Database of Systematic Reviews 2002, Issue 1. Art. No.: CD002929. DOI: 10.1002/14651858.CD002929.

The Royal Marsden Hospital Manual of Clinical Nursing Procedures. 2004 6th Edition Blackwell Publishing. Oxford.

Tanner J, Dumville JC, Norman G, Fortnam M. Surgical hand antisepsis to reduce surgical site infection. Cochrane Database of Systematic Reviews 2016 Jan 22;(1):CD004288. DOI:10.1002/14651858.CD004288pub3. https://www.ncbi.nlm.nih.gov/pubmed/26799160 (Accessed 2nd August 2017)

Tanner J, Swarbrook S, Stuart J. Surgical hand antisepsis to reduce surgical site infection. Cochrane Database of Systematic Reviews 2008. Issue 1. ArtNo: CD004288. DOI:10.1002/14651858.CD001288pub2.

Tanner J, Parkinson H. Double gloving to reduce surgical cross-infection. Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD003087. DOI: 10.1002/14651858.CD003087.pub2.

Health Professions Council - Standards of Conduct Performance & Ethics (2008) www.hpc-uk.org/assests/documents/10002367FINALcopyofSCPEJuly2008 (Accessed 17th May 2012)

NMC (2008) The Code: Standards of Conduct, Performance and Ethics for Nurses and Midwives www.nmc-uk.org/Publications/Standards/The-Code (accessed 17th May 2012)

Medicines & Healthcare products Regulatory Agency (2008) One Liners Issue 56 (March) London. 

Safeguards for Invasive Procedures. The Management of risks (2009) 2nd Edition Association of Perioperative Practice ISBN 978-1-904290-13-1

WHO Guidelines on Hand Hygiene, First Global patient  safety Challenge, Clean care is Safer Care (2009)
http://whqlibdoc.who.int/publications/2009/9789241597906_eng.pdf

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Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.0

Related information

Appendix 1

World Health Organization (WHO) Guidelines on Hand Hygiene, First Global patient safety Challenge, Clean care is Safer Care (Pages 59 – 60) -  Surgical hand preparation with an alcohol-based formulation

 

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Appendix 2

Protocol for surgical scrub with an antiseptic solution

Protocol for surgical scrub with an antiseptic solution

Yes

No

N/A

Dress in appropriate theatre blues OR waterproof apron is worn over clinical uniform / dress

     

Within Operating Theatres - ensure hat covers all hair

     

Within Operating Theatres - ensure facemask covers nose and is donned appropriately

     

Ensure eye protection is worn

     

Ensure other protective attire is worn e.g. X-ray gowns

     
       

Open the sterile scrub brush packet and place on scrub sink

     

Run water at comfortable temperature and steady flow

     

Use elbows throughout to dispense solution and adjust taps

     

Ensure all rinsing is performed from the fingertips to the elbow using the water flow and not the hands

     

Ensure hands are above the elbows at all times

     

Wet hands and forearms and apply 5mls of antiseptic solution

     

Pre Scrub / Pre wash the hands and forearms using the 7 step technique (stated in the Clinical SOP Surgical scrub, gowning and gloving document) and rinse

     

Use the nail pick to clean under nails under running water

     

Wet hands and forearms and apply 5mls of antiseptic solution

     

Working from the fingertips down to just below the elbows, wash the hands and forearms using the 7 step technique for 1 minute and rinse

     

Apply solution and use scrub brush to scrub nails only 30 seconds each hand and rinse

     

Apply solution and wash hands and forearms (not to elbows) using the 7 step technique for 1 minute and rinse

     

Drain water from elbows and turn off taps

     
       

Open inner wrap of sterile gown using the edges of the wrap only

     

Pick up one towel, open and dry one hand from the fingertips to the elbows

     

Repeat for the second hand

     

Pick up gown locating armholes - insert arms and let gown fall towards body keeping hands within the gown

     

Allow circulator to secure back ties

     
       

Accept sterile gloves onto surface and open packet

     

Use closed method of donning gloves

     

Don second pair of gloves

     

OR use open method of donning gloves

     

Ensure wrap around of gown is tied

     

Ensure hands remain within the sterile field at all times during surgical procedure

     

Change gown / gloves intra operatively if contaminated

     

On completion of the surgical procedure allow the circulator to undo the back ties of the gown

     

Remove gown by pulling it forwards over gloves hands and disposing of it into clinical waste / laundry

     

Remove gloves - with the glove to glove and skin to skin method

     

Remove face mask / visor and dispose

     

Decontaminate hands using the 7 step hand washing technique

     

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Appendix 3

Protocol for surgical hand preparation technique with an alcohol handrub formulation

Protocol for surgical hand preparation technique with an alcohol handrub formulation

Yes

No

N/A

Dress in appropriate theatre blues OR waterproof apron is worn over clinical uniform / dress

 

 

 

Within Operating Theatres - ensure hat covers all hair

 

 

 

Within Operating Theatres - ensure facemask covers nose and is donned appropriately

 

 

 

Ensure eye protection is worn

 

 

 

Ensure other protective attire is worn e.g. X-ray gowns

 

 

 

 

 

 

 

Pre Scrub/Pre wash

 

 

 

Open the sterile scrub brush packet and place on scrub sink

 

 

 

Run water at comfortable temperature and steady flow

 

 

 

Use elbows throughout to dispense solution and adjust taps

 

 

 

Ensure all rinsing is performed from the fingertips to the elbow using the water flow and not the hands

 

 

 

Ensure hands are above the elbows at all times

 

 

 

Wet hands and forearms and apply liquid soap or alternative prescribed hand wash product

 

 

 

Pre Scrub / Pre wash the hands and forearms using the 7 step technique (stated in the Clinical SOP Surgical scrub, gowning and gloving document) and rinse

 

 

 

Use the nail pick to clean under nails under running water

 

 

 

Dry hands using a sterile towel

 

 

 

Surgical hand preparation with an alcohol-based hand rub formulation

 

 

 

Put approximately 5ml (3 doses) of alcohol based hand rub in the palm the left hand

 

 

 

Dip the fingertips of the right hand in the hand rub (5 seconds)                                                                                        

 

 

 

Smear the hand rub on the right forearm up to the elbow, using circular movements ensuring all areas are covered

 

 

 

Put approximately 5ml (3 doses) of alcohol based hand rub in the palm the right hand

 

 

 

Dip the fingertips of the left hand in the hand rub (5 seconds) 

 

 

 

Smear the hand rub on the left forearm up to the elbow, using circular movements ensuring all areas are covered

 

 

 

Put approximately 5ml (3 doses) of alcohol-based hand rub in the palm of left hand, Rub both hands at the same time up to wrists, using the 7 step approach

 

 

 

Repeat the above sequence 3 times, let hands dry

 

 

 

Donning gown and gloves

 

 

 

Open inner wrap of sterile gown using the edges of the wrap only

 

 

 

Pick up gown locating armholes - insert arms and let gown fall towards body keeping hands within the gown

 

 

 

Allow circulator to secure back ties

 

 

 

 

 

 

 

Accept sterile gloves onto surface and open packet

 

 

 

Use closed method of donning gloves

 

 

 

Don second pair of gloves

 

 

 

OR use open method of donning gloves

 

 

 

Ensure wrap around of gown is tied

 

 

 

Ensure hands remain within the sterile field at all times during surgical procedure

 

 

 

Change gown / gloves intra operatively if contaminated

 

 

 

On completion of the surgical procedure allow the circulator to undo the back ties of the gown

 

 

 

Remove gown by pulling it forwards over gloves hands and disposing of it into clinical waste / laundry

 

 

 

Remove gloves - with the glove to glove and skin to skin method

 

 

 

Remove face mask / visor and dispose

 

 

 

Decontaminate hands using the 7 step hand washing technique

 

 

 

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