The Effect of Different Surgical Hand Scrubbing Methods and the Duration of Scrubbing Time on the Bacterial Flora
Phase: NA
Conditions: Surgical Scrubbing, Surgical Site Infection
Sponsor: Saglik Bilimleri Universitesi Gulhane Tip Fakultesi

 
 
 
 
 
 
 
The Effect of Different Surgical Hand Scrubbing Methods and Duration of Scrubbing 
Time on the Bacterial Flora 
(November, 5, 2019) 
 
Emine ARICI PARLAK, PhD 
Emine İYİGÜN, Professor 
 
 
 
 
 
 
 
 
 
 
 
 

 
Study Protocol And Statistical Analysis Plan 
Aim 
The aim of this study is to compare evidence-based surgical hand scrubbing methods in 
order to prevent surgical site infections. 
Study Setting  
This study was conducted at the Department of Operating Room of the Gülhane 
Training and Research Hospital in Ankara, Turkey between November 2019 and April 2020. 
Hypothesis  
1. Method 
H0: There is no difference between the effectiveness of different surgical hand scrubbing 
methods on the bacterial flora in the hand  
H1: There is a difference between the effectiveness of different surgical hand scrubbing 
methods on the bacterial flora in the hand. 
2. Time  
H0: There is no difference between the effectiveness of different the duration of scrubbing time 
on the bacterial flora in the hand. 
H1: There is a difference between the effectiveness of different the duration of scrubbing time 
on the bacterial flora in the hand. 
Method and Participants 
The research is a randomized controlled prospective study. The universe of the research 
will be surgeon and operating room nurses in Gülhane Training and Research Hospital.  
Sample Size 
The sample size is at least 180 people for one-way analysis of variance with G * Power 
version 3.1.19 software to determine a medium level (0.25) effect size between 4 groups at 0.80 
power and 0.05 type I error level calculated (Tsai, 2016). Participants will be divided into 4 
groups by randomization method.  

Randomization 
✓ Group I: The participants in the first group performed the surgical hand scrubbing for 1 
minute and with using nail brush (n=45).  
✓ Group II: The participants in the second group performed the surgical hand scrubbing 
for 1 minute and without using a nail brush (n=45).  
✓ Group III: The participants in the third group performed the surgical hand scrubbing for 
2 minute and with using nail brush (n=45).  
✓ Group IV: The participants in the fourth group performed the surgical hand scrubbing 
for 2 minute and without using a nail brush (n=45). 
Inclusion Criteria: 
-Being a surgeon or operating room nurse 
-Having six months and more surgical experience 
-Agree to participate in the research 
Exclusion Criteria: 
-Not wanting to participate in the research 
-Being allergic to the skin due to surgical antiseptic use 
-Being latex allergy 
- Wounds and abrasions on the hand and nail edges 
-To have used a systematic antibiotic at the data collection stage and within two weeks 
Volunteers' Exclusion Criteria (Different from Exclusion Criteria): 
• Participants want to leave the research 
• Expected surgery time is less than 1,5 hours. 
• A tear / puncture in the glove during the operation. 
• During the operation, data collection will be terminated in cases where the sterility of the 
glove is impaired. 
The interventions  
Standard Protocol in All Groups 
• The application will take place during the first surgeries entered in the morning. 

• All groups will be used hand antiseptic (4% Chlorhexidine gluconate) which is used in the 
operating room. 
• It will be examined whether the nails are smaller than 2 mm. If the nails are long, individuals 
will be asked to cut their nails with the help of disposable nail scissors before surgical hand 
scrubbing. 
• There will be no nail polish on the nails and there will be no jewelry on the hand and the ring. 
• 3 ml of antiseptic solution will be used at each washing stage. 
Scrubbing Stage 
Group I: Surgical hand scrubbing group using a brush (only nails) (Total scrubbing time 1 min) 
1. The bottom of the nails is cleaned under running water with a disposable nail brush (30 
seconds). 
2. Hands and forearms are washed by scrubbing them towards the elbow for 30 seconds with 
the help of 3ml antiseptic solution. 
3. Hands and forearms are thoroughly rinsed under running water. 
4. Hands and forearms are washed by scrubbing them towards the elbow for 30 seconds again 
with the help of 3 ml antiseptic solution. 
5. Hands and forearms are rinsed thoroughly under running water. 
Group II: Surgical hand scrubbing group (Control group) without brush (Total scrubbing time 
2 min) 
1. Hands and forearms are washed by scrubbing towards the elbow for 30 seconds with the help 
of 3 ml antiseptic solution. 
2. Hands and forearms are thoroughly rinsed under running water. 
3. Hands and forearms are washed by scrubbing them towards the elbow for 30 seconds again 
with the help of 3 ml antiseptic solution. 
4. Hands and forearms are rinsed thoroughly under running water. 
Group III: Surgical hand scrubbing group using a brush (only nails) (Total scrubbing time total 
2 minutes) 

Applications made in Group I are applied in the same way as scrubbing for 2 minute. 
Group IV: Surgical hand scrubbing group (Control group) without brush (Total scrubbing time 
2 minutes) 
Applications made in Group IV are applied in the same way as scrubbing for 2 minute. 
Data Collection  
This research will take place in three stages. At all stages (before surgical hand 
scrubbing, immediately after and at the end of the surgery), culture will be taken from the active 
hands of the participants with the Glove Juice Method. At all stages, culture will be taken from 
the participants via Glove Juice Method. 
Glove Juice Method 
It is a method used to determine the number of bacteria on hand. In this method, 
individuals will be provided to wear gloves on their dominant hand. Powder-free sterile gloves 
were used for all sampling. Then, 50 ml of 'Tryptic Soy Broth' medium was placed inside the 
glove and all surfaces of the gloved hand were massaged for 60 seconds by the researcher. A 
sample was taken from the liquid in the glove using aseptic techniques and analyzed.  
Applications in Medical Microbiology Laboratory 
Before surgical hand scrubbing, samples taken with glove liquid technique were diluted 
1:10 in Müeller Hinton Broth broth in the laboratory (500 μl sample, 4.5 ml. Müeller Hinton 
Broth). And 300 μl of it was placed on 5% sheep blood agar plates with sterile micropipettes. 1 
ml each of the other samples (after surgical hand scrubbing and at the end of the surgery) was 
spread diluted into three 5 % sheep blood agar plates with sterile micropipettes. All samples 
were incubated at 35° C for 48 hours under atmospheric conditions. Total bacterial load was 
determined by counting the total colony forming units (CFU) on the plates. 
Ethical Approval  
For the implementation of the research, Ministry of Health, Provincial Health Directorate, 
Health Sciences University, Abdurrahman Yurtaslan received approval from Ankara Oncology 
Training and Research Hospital, Health Practice and Research Center Clinical Research Ethics 
Committee (decision no: 2019-02 / 218) 
 

Ethical Consideration 
Written permission and approval was obtained from the Oncology Training and 
Research Hospital, Health Practice and Research Center Clinical Research Ethics Committee 
before the study started (decision no: 2019-02 / 218). Surgeon and operating room nurses within 
Gülhane Training and Research Hospital were informed of the study and verbal approval was 
obtained. 
Statistical Analysis 
The data obtained from this study were evaluated by using the Statistical Package for 
the Social Sciences (SPSS,Inc.,Chicago,IL,USA) 22.0 software program.  After the data were 
transferred to the SPSS database, error controls were performed. Their compliance with a 
normal distribution was evaluated with Kolmogorov Smirnov test. The data determined were 
mean ± standard deviation (X ± SS), median and minimum-maximum (min-max) for the 
variables determined by the measurement and number (n) and percent (%) for the variables 
determined by counting. Since the variables determined by counting did not comply with a 
normal distribution, the difference between the four groups was evaluated by the Chi square 
test. The one-way ANOVA test was used to investigate the difference between the four groups 
regarding the measured values for values complying with normal distribution and the Kruskal-
Wallis test was used for the values that did not comply with a normal distribution. The 
Bonferroni correction was implemented to determine the source of the difference in group 
comparisons. In the comparison of four measurements within the group, the "Friedman Test" 
was used for data that did not conform to normal distribution. In order to understand from which 
measurement the difference arises, "Wilcoxon Test with Bonferroni Correction" was used as 
Post Hoc Test.The Mann-Whitney U test was used to investigate the difference between two 
groups of variables. A p value <0.05 was accepted as statistically significant.