Heath care-associated infection is a major problem for patient safety, and its prevention is a high priority. Surgical site infection accounts for 20% of hospital-wide infections, and rigorous adherence to the principles of asepsis by all scrubbed personnel is the foundation of surgical site infection prevention. General hand hygiene is critical to preventing health care-associated infection; health care providers should always practice hand-washing before and after every patient contact, even after wearing gloves.
The goal of sterile, or aseptic, technique is to minimize possible sources of infection. Sterile technique is the use of practices that restrict microorganisms in the environment and prevent contamination of the surgical field. Sterility will apply to surfaces of some objects or to substances that will be introduced into a patient’s body. There are objects that do not have the potential to be made sterile. For example, hands can be made clean but not sterile. “Scrubs” from the locker room dispenser are not sterile, nor are surgical masks. Only specific, deliberately prepared surfaces or substances are considered sterile. The space in which sterile objects may interact—undisrupted by non-sterile objects—is a sterile field. An important point to bear in mind is that a person or thing will have only a particular portion of its surface designated as sterile and, therefore, within a sterile field. Every other surface is considered non-sterile, and any non-sterile surface may contaminate a sterile surface.
Sterile fields are defined by the sterile surfaces of two operating room (OR) components (for example, a sterile instrument on a sterile tray). Typically, on scrubbed surgical personnel (by “scrubbed,” meaning hands washed according to OR protocol, donning sterile gown and sterile gloves), the sterile surface would extend approximately from the chest to the waist on the torso and from elbows to the tips of gloved fingers on the upper limb. The rest of the scrubbed person is not sterile and is a possible source of contamination for the sterile area.
On a patient, only the prepared surface of the body and the sterile drape are considered within the sterile field. Note that edges of otherwise sterile surfaces are not sterile because they must contact (or appose) non-sterile objects. Therefore, the physical edges of a sterile drape—or any surface of the drape below the space defined by the other sterile objects of the field—are not considered sterile.
NOTE: This entire module is also available in PDF Format.
This clinical skills module provides a framework for teaching the importance of and the principles behind sterile (or aseptic) technique. Following participation in this module, learners should be able to:
Medical students should be offered scrub training to learn sterile technique prior to entry into any operating room. Students who opt to attend surgical cases during the pre-clinical years ought to be fully trained prior to their first operating room experience and then offered a refresher course or video prior to any clinical clerkships or electives that are surgically based.
A typical OR visit may be as follows:
Generally, scrubbing in means a sequence of procedures wherein one attains a sterile surface, including:
The surgical hand scrub is a process to reduce skin flora of hands, nails and forearms, and is performed outside the OR at the scrub station. Once completed, one must carefully reenter the OR for gowning and gloving.
Finally, once gowned and gloved, a person’s movements must take into consideration the sterile fields. Remember that the sterile field is considered from the nipple line on the anterior chest to the waist. Typically, when moving, hands should be kept directly in front of the chest, but clear of the face or other non-sterile areas. When passing OR personnel or non-sterile things, one’s back should be directed toward the non-sterile surfaces of these OR obstacles. Never reach around someone’s back. Once part of the sterile field, the sterile surface must face the prepared surface of the patient or other sterile surfaces.
Steps Before Starting Surgical Hand Preparation:
Protocol for Surgical Scrub with a Medicated Soap:
Surgical Hand Preparation Technique with an Alcohol-based Handrub Formulation:
Gowning Technique Procedural Steps:
The following checklist may be used as a component of the training session and/or as a component of a performance assessment as part of an objective structured clinical examination.
|Correctly place the surgical cap, mask and eye protection|
|Correctly open the packet of surgical scrub soap|
|Turn on the water correctly|
|Correctly clean beneath fingernails|
|If using surgical scrub brush, scrub hands and forearms correctly|
|Keep hands and forearms elevated and avoid contamination while entering door to OR|
|Accept the drying towel properly, without contaminating it against his or her body|
|Dry hands properly, using a separate sterile area of the towel for each hand|
|Properly dispose of the used towel|
|Receive and don the surgical gown properly|
|Receive and don gloves without contaminating gown or gloves|
|Turn properly to close off the back of the gown|
Direct observation of the learner performing appropriate surgical hand preparation and demonstrating appropriate assisted gowning and gloving techniques is the best way to assess a learner’s mastery of sterile technique. Using the provided checklists to assess important points of surgical preparation can assist in scoring learner performance and assessing competence. This can be done in an OSCE or as an isolated training and evaluation.
There are a number of videos or DVDs available that many medical schools and hospitals use for further understanding of this process. If learners feel they need more help, they should ask if these are available at their institution. Many institutions will automatically show them, or learners will be given a practice session by an experienced OR nurse.
The first time in the OR can be an anxiety-provoking experience because of the learner’s fear of making an error. If learners make a mistake, they should understand that teachers have been in the same situation, and learners should understand that they are learning.