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Maintaining the Sterile Field: A Roundtable of Expert Advice
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By JohnRoark
Maintaining the sterile field withinthe operating room (OR) is the responsibility of every healthcare worker (HCW)in that room. The topic is as vast as it is essential. We’ve assembled ahandful of experts to ask for their feedback on some key issues in preservingthe sterile field, and culled their responses for an at-a-glance review of somebasics and beyond.
The Panel of Experts:
Nancy Bjerke, RN, MPH, CIC – Independent infectioncontrol consultant and co-chair of the APIC Practice Guidance Council (NB)
Joan Blanchard, RN, MSS, CNOR, CIC – Perioperative nursing specialist at AORN’sCenter for Nursing Practice (JB)
Deborah Gardner, LPN, PA – 3M technicalservice manager (DG)
Barbara Gruendemann, RN, MS, FAAN, CNOR – Co-authorof Infection Prevention in Surgical Settings (BG)
Mary Luzinski, RN, BSN,MS, CIC – Infection control coordinator, St. Joseph Regional Medical Center, Milwaukee, Wis. (ML)
Trish Pyeatt-Rowe, RN, BSN, CNOR – Research scientist with Kimberly-Clark HealthCare (TPR)
Lisette H. Swenson – U.S. marketing manager for MölnlyckeHealth Care, Inc. (LS)
What potentially dangerousshortcuts to aseptic technique have you witnessed?
“Shortcuts are costly in the long run. Manufacturers arepreparing products for us that are efficient, better and improved. However,their label instructions do not follow standard aseptic technique. Just becausethe manufacturer says you can go from left to right and up and down, it is notthe appropriate procedure for prepping a site. You start at the center; you goin concentric circles out. You never go back over a missed area with theexisting applicator. You cannot go from dirty back to clean to catch up a dirtyarea. People know that, but they’re following the manufacturer. I see it everyday.” – NB
How can clinicians best maintain the sterile field when itcomes to patterns of movement within the field?
“The person who is scrubbed should remain close to thesterile field and not move away from the immediate area. When the scrub personis in sterile attire, moving from the sterile field increases the risk ofcontamination. When there is a need to move, scrubbed persons should move fromsterile location to sterile location; if turning is required they should turnback-to-back or face-to-face, keeping a safe distance from the other person.Arms and hands should always be kept within the sterile field. The scrubbedperson should avoid changing levels ( i.e, sitting only when the entireprocedure will be done at that level). The scrubbed team should keep movement toa minimum.” – JB
“An individual must face the sterile field at all times.When two people are side-by-side, they’ll reach around the back of the otherindividual and try to reach for something, or in some cases they’ll actuallypass sterile to dirty and get on the other side. That is one of the majorinfractions that we observe for in the OR. People, in their rush to pass to theother side, do not realize that a sufficient distance needs to exist betweenthe dirty and the sterile. They brush against one another and becomecontaminated. You never turn your back to the sterile field – that’s afundamental principle.” – NB
When maintaining a sterile field, what arecommon misconceptions or errors made concerning instrumentation?
“I often see heavy trays – not contained in a rigidcontainer, but wrapped with a sterile wrap – picked up, put on a ring standand opened. They are not held up and inspected for minute tears or breaches ofsterility in that regard. It’s often hard to do – you have small circulatorsor scrub nurses, the trays are heavy, and they just don’t take that extra 10seconds to lift them up and see: Are there any tears on the corners of thistray? Can I still use this tray? If it hasn’t been inspected, then the wholeset has to be considered contaminated.” – TPR
“Some people look at theoutside of the pack, and just because the color of the indicator tape haschanged, they assume that it’s sterile, when in fact it’s not. The tape ismerely an indication that it has been through some type of heat process. Theonly way to truly tell is by the indicator inside the tray.” – TPR
“Onemisconception involves transporting instruments from an autoclave. The autoclavemay be in an open hallway; the scrubbed person goes to the autoclave to remove asterilized item, which is in an open mesh pan. This puts the scrubbed person atrisk for being contaminated as well as the sterile instrument. There are specialenclosed instrument containers that can be used for autoclaving, which allowsthe circulator to transport the instrument and decrease the possibility ofcontamination. The scrubbed person can then remain at the sterile field.” –JB
What about surgical equipment (other than instrumentation) within thesterile field?
“Obviously, if you are going to use it and it cannot besterilized, it has to be draped or covered with a sterile covering before youcan move it into the sterile field. You need to make sure there is always asafe distance between anything that is not sterile and the sterile field. Twelve to 24 inches is usually considered safe.” – TPR
Whatshould be done in the event of sterile gloves becoming contaminated?
“If gloves become contaminated during a procedure, they are removed as quickly as possible, and new gloves areapplied. If necessary, if there is a known contamination of the sterile field,that area needs to be readdressed. Either new drapes are applied on top ofcurrent drapes, or if the individual needs to regown, that must be taken care ofas well.” – TPR
“Gloves should be changed as soon as compromise is evidentfor protection of the surgical site and HCW.” – LS
“Contaminated gloveshave to be changed. There is some controversy – some say that it’s OK if,for example, a couple of fingers get contaminated. Some clinicians, especiallyif it’s an emergency procedure, may just put a sterile glove over acontaminated glove. The proper way is to change that glove, and to have thecirculating nurse, who is not sterile, remove that glove in such a way that it’snot going to contaminate the gown, and then have the scrub person put a newsterile glove on the surgeon or other sterile team member, using theopen-gloving technique. The closed-gloving technique should not be used inchanging gloves.” – BG
What are the primary safety issues in handling andplacing sterile drapes within the sterile field?
“Once the drape is applied, it should not be moved orshifted. As we know, anything below waist level, or sterile field level, isconsidered contaminated. Sometimes, unfolding the drape incorrectly can lead tocontamination, and certainly moving a drape, once it has been placed, is notconsidered safe.” – BG “There is a misconception that more layers ofdraping or ‘thicker’ drape materials create a better barrier, when in factit is the material composition and performance of the drape materials utilizedto manufacture the drape that creates that barrier.” – LS
“Layering is notusually necessary. It is counter-productive because it makes for more expense.It’s not really necessary because most of the drapes, both reusable anddisposable, have increased barrier around the sections where the incisions aregoing to be made. The enhanced barrier qualities there prevent any moisturestrike-through. Layering one drape on top of another is very counter-productive.”– BG
“When you create your sterile field, whether you use a specialty drapeor you do what we call ‘squaring-off’ with individual drapes, you create abox around the area that you are going to cut. If that aperture were to slideone way or the other and you slide it back into place, what you have done isslid it over what is supposed to be your sterile surface. What you should do atthat point is re-prep and re-drape.” – DG
“One of the most common shortcuts that I’ve seenpertaining to sterile drapes is not permitting the sterile skin prep tocompletely dry prior to applying the sterile drape.” – TPR
“People have atendency to layer anywhere from two to five layers of drapes, thinking theyhave created a barrier. If you have five Kleenex tissues vs. one Kleenextissue, the fl uid will still get through it, it is just going to take a littlelonger. More important than the amount of layers that you have is what is inthat layer. Is it an impervious layer, or not?” – DG
What are the most important “commandments” whenit comes to maintaining the sterile field?
“Limit the number of personnel in the OR – it affects theamount of bacteria that’s actually spread during the procedure. It stands toreason – the more people in the room, the higher the count of bacteria thatare going to be in there. Only the people who are absolutely required to do theprocedure should be allowed to be in the OR.” – TPR
“If there is aquestion regarding the sterility of an item, assume it is not sterile.” – JB
“Develop your surgical conscience. This comes from experience, but part of itis also not being afraid to speak up. Part of the nurse’s role in the OR, isto say, ‘This isn’t right.’” – DG “Aseptic technique is the mantraof perioperative nursing. It’s the common denominator, that really allsurgical team members have to comply with, or adhere to. It is the foundation ofwhat goes on at the sterile field. Perioperative nurses are the watchdogs ofthe sterile field and of aseptic technique. They have a huge responsibility, and it’s terribly important for a good, positive outcome for the patients after their surgery.” – BG
“It’s either black or white in the OR. It’s either sterile or it’s not sterile. The gray that I see in my consulting business is prettydiscouraging.” – NB
“Keep your eyes on the sterile field. Never turnyour back to it. Acknowledge when you have a break in technique. That’scalled surgical conscience. Any time anything in surgery – not just steriletechnique – is not right, you speak up. It’s not the place to keep quiet andtell somebody about it afterwards. You may see something that someone else onthe team did not. You really count on everybody in the room to be focused onthat patient.” – ML
