Sterile Technique


Article Author:
Karie Tennant


Article Editor:
Cynthia Rivers


Editors In Chief:
Casey Ciresi


Managing Editors:
Avais Raja
Orawan Chaigasame
Khalid Alsayouri
Kyle Blair
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Abbey Smiley
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beenish Sohail
Hajira Basit
Phillip Hynes
Sandeep Sekhon


Updated:
4/3/2019 11:53:00 AM

Introduction

The purpose of creating a sterile field is to reduce the number of microbes present to as few as possible. The sterile field is used in many situations outside the operating room as well as inside the operating room when performing surgical cases. [1][2][3]Sterile fields should be used outside the operating room when performing any procedure that could introduce microbes into a patient. A few examples of this would be inserting a Foley Cather, an arterial line, and a central line. Inside the operating room, sterile fields are created when practitioners identify the back table that will be used, the mayo stand that will go up to the field, and finally the patient and the surgical site itself.

Equipment

Sink/automatic sink, sterile scrub brush with nail pick, antiseptic soap, and sterile gown/gloves drying towel.

Personnel

Anyone that is performing an invasive procedure requires sterile technique.

Technique

Sterile fields should always be established as close as possible to the time of the procedure and should not be left unattended. When a sterile field is opened and exposed for a long time before the procedure, the risk is higher for the items to get contaminated from airborne microbes. If left unattended the risk is higher that someone might have accidentally contaminated the field. Both of these put the patient at risk for a hospital-acquired infection (HAI).

It is important to arrange the furniture before opening supplies when creating a sterile field in the operating room, because of kicking up microbes as you are moving around. The furniture should be 12 to 18 inches from the walls or any objects that could contaminate the field.[4][5]

Place the back table, ring stand and mayo stand in their locations before opening items. Before opening any supplies, all packages must be checked to ensure the integrity of the packaging materials. There should not be any holes or tears in the outside wrappers. If the integrity is intact, then it is safe to proceed with placing the back table pack on the back table (this item is always opened first). The back table allows a large surface to open all other supplies onto it during set-up and is the main sterile field. Once the back table cover is opened, it is important to note that an imaginary 1-inch border exists along the edges of the table. This border is considered unsterile and should be avoided when tossing items onto the field; another area considered unsterile is anything below table height. Once the back table is opened, bend down and move the table closer to the wall by grasping the lower leg of the table. This allows less chance of someone contaminating the table and gets it out of the way.

The next item is the ring stand that will hold the basin sets; open the first flap away from you, then each side flap, and lastly the flap closest to you. Bend down and marry (move) the ring stand closer to the back table and close the space between them. The sterile flap will be against the back sterile table drape.

Open up sterile supplies needed for the procedure; open peel packs by checking the integrity of the package, identify there is an indicator in the package, and that the indicator has changed color. The indicator only informs us that the items have been exposed to a sterilant. Open wrapped items by performing the same method used with the basin set; open the flap away from you first, then the sides, and finally, the flap closest to you. When opening peel packed items, ensure there is an indicator and that it has turned color. Open the peel pack and do not slide any item near the edges of the wrapper, the one-inch border exits for peel pack items as previously discussed. When flipping the items into the basin or onto the back table, be careful not to extend your arm over the sterile field.

To open the instrument trays, ensure there is a plastic lock that identifies an indicator change, a label with the Julian date, and load number and make sure it is the correct set for the procedure. Look at the outside container for any moisture or condensation; if there is moisture, do not use and retrieve another set. If there is not any condensation, then proceed by grasping the latches and flip open, this will automatically break the plastic locks. Lift the lid straight up and step back before flipping the lid over; this will ensure that dust or particles will not fall into the tray. Once you flip the lid over, check again for moisture and remove the paper filter. To check the filter for any holes, lift it toward a light to ensure there are not any pin size holes. If the filter looks good then careful look into the pan for an indicator; do not lean over the pan. If you cannot see an indicator, you will look more closely after you are gowned and gloved. Until you are scrubbed in the instruments are complete for now; once you are gowned and gloved, you will carefully pick up the inside basket and hold it in front of you until the circulating nurse checks the bottom filter and checks the bottom of the tray for moisture. This is also a good time to find the inside indicator. If you cannot find an indicator, do not use the tray. Once the nurse verifies the instrument tray and you see an indicator, you can proceed to place the instruments on the back table.

Finally, open a gown and gloves for yourself on the mayo stand. The gowns’ wrapper will serve as a small sterile field to open your gloves and towel. This is where you will come to first after performing your surgical scrub and will dry, gown and glove.

Once all the necessary items are opened, it is time to complete the next step, the surgical hand scrub. Hand hygiene is the most important item you can perform to prevent infections.

The surgical hand scrub can be accomplished in one of two ways: the 5-minute scrub or the counted brush stroke method.

Hand Washing

Hand washing is now considered an event-related practice, which is performed before and after specific tasks. Handwashing should last 15 seconds up to a minute or more if the hands get very dirty.[6][7][8][9]

  • Ensure all jewelry is removed
  • Wet hands and forearms and up 2 inches past the elbow
  • Apply antiseptic soap start with rubbing hands together
  • Interlace fingers of each hand and rub repeatedly, this will ensure all the space between each finger is cleaned
  • Take right hand and apply soap to the left forearm and rub vigorously up to 2 inches above the elbow, ensure all sides are cleaned
  • Repeat with left arm to right forearm
  • Once all services have been cleaned it is time to rinse
  • Rinse with arms pointed down into the sink, to assist with removing all soap and transient flora still left on surfaces.

Always perform a hand wash before performing a surgical scrub. The surgical scrub purpose is to reduce microbes to the absolute minimum and is always completed right before gowning and gloving or any invasive procedure. It is not possible to sterilize a person’s skin, but reducing the number of microbes to a minimum is paramount.

Before starting the scrub ensure the scrub top is tucked into the scrub pants, and avoid splashing water on the scrubs. Bacteria can easily harbor in moist environments.

The Counted Scrub Method

  • Remove all jewelry
  • Perform hand washing as discussed
  • Unwrap a sterile scrub brush and remove nail cleaner. Hold the brush in one hand while cleaning the subungual area on each finger, perform this under running water. Discard the nail cleaner in the trash
  • You will scrub on hand and are then proceed to the other hand and arm
  • Start the count stoke method by starting with the nails and cuticles, using a circular motion on the top of the nails for 30 strokes
  • Each finger is divided into four sides; each side perform ten strokes for a total of 40 strokes for each finger
  • Once the fingers are completed proceed to the palm for 30 strokes, and then the dorsal side of the hand for 30 strokes
  • The forearm is next, and it is divided into four planes (planes are from the wrist to two inches above the elbow) each plane is scrubbed separately performed in a circular motion for ten strokes each
  • While scrubbing this area remember to keep hands higher than the elbows at all times and keep arms from touching your body.
  • Do not rinse until you finish both hands and arms
  • Proceed to the next hand and forearm with the same brush strokes that you did for the first hand and arm.

Make sure you do not touch any surface already scrubbed, if you accidentally bump the sink or touch your skin where scrubbed, you must scrub that area for an extra minute.

After both arms are scrubbed, rinse the hands and arms by passing through the running water in a one-way direction. Once the arm has passed through the water, raise the arm to the same height as before with hands above the elbow to allow the water to drip down and off the elbow. The purpose of this is to allow the water to go from cleanest area to the lesser clean area. If you need to pass through again with the same hand and arm, it is fine to do so to ensure all soap residuals are removed. Repeat for the other hand and arm.

Once the scrub is complete, you cannot touch any non-sterile surface, if you do you must re-scrub. Proceed to where the gown and gloves were opened by holding arms above the elbows and arms away from scrubs.

The Timed Scrub

  • Remove all jewelry
  • Perform hand washing as discussed
  • Unwrap a sterile scrub brush and remove nail cleaner. Hold the brush with one hand while cleaning the subungual area on each finger, perform this under running water. Discard the nail cleaner in the trash.
  • You will scrub on one hand, and arm then proceed to the other hand and arm
  • Start the timed method by starting with the nails and cuticles, then proceed to the fingers; 2 minutes for the entire hand
  • Once the nails and fingers are completed proceed to the palm and dorsal sides of the hand for 1 minute total
  • The forearm is next, and it is divided into four planes (planes are from the wrist to two inches above the elbow) each plane is scrubbed separately performed in a circular motion for 1 minute for all four planes
  • While scrubbing this area remember to keep hands higher than the elbows at all times and keep arms from touching your body
  • Do not rinse until you finish both hands and arms
  • Proceed to the next hand and forearm with the same timing that you did for the first hand and arm
  • Make sure you do not touch any surface already scrubbed, if you accidentally bump the sink or touch your skin where scrubbed, you must scrub that area for an extra minute.

After both arms are scrubbed, rinse the hands and arms by passing through the running water in a one-way direction. Once the arm has passed through the water, raise the arm to the same height as before with hands above the elbow to allow the water to drip down and off the elbow. The purpose of this is to allow the water to go from cleanest area to the lesser clean area. If you need to pass through again with the same hand and arm, it is fine to do so to ensure all soap residuals are removed. Repeat for the other hand and arm. Once the scrub is complete, you cannot touch any non-sterile surface, if you do you must re-scrub.

Proceed to where the gown and gloves were opened by holding arms above the elbows and arms away from scrubs.

Complications

Breaks in aseptic techniques or contamination of sterile field or supplies cause complications.

Clinical Significance

Using a sterile technique reduces the microbial count. This creates a sterile field and prevents infection.

Enhancing Healthcare Team Outcomes

All healthcare workers including nurses who assist physicians and surgeons should be fully aware of the importance of sterile techniques. Breaks in the technique can lead to infections in the patient, which leads to higher costs of healthcare. An infectious disease team should routinely audit all physicians and nurses involved in sterile procedures to ensure proper protocol is followed.[10]


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Sterile Technique - Questions

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Which of the following requires the use of sterile technique?



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Which of the following is a breach of sterile technique?



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Which of the following does not require aseptic technique?



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When the circulating nurse opens an inner sterile wrapper, which side is opened first?



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Sterile Technique - References

References

Handaya AY,Werdana VAP, Adherence to preoperative hand hygiene and sterile gowning technique among consultant surgeons, surgical residents, and nurses: a pilot study at an academic medical center in Indonesia. Patient safety in surgery. 2019;     [PubMed]
Chang YT,Chen G, Oral bacterial inactivation using a novel low-temperature atmospheric-pressure plasma device. Journal of dental sciences. 2016 Mar;     [PubMed]
Gandhi HS, Rationale and Options for Choosing an Optimal Closure Technique for Primary Midsagittal Osteochondrotomy of the Sternum, Part 2: A Theoretical and Critical Review of Techniques and Fixation Devices. Critical reviews in biomedical engineering. 2019;     [PubMed]
Araujo da Silva AR,Marques AF,Biscaia di Biase C,Zingg W,Dramowski A,Sharland M, Interventions to prevent urinary catheter-associated infections in children and neonates: a systematic review. Journal of pediatric urology. 2018 Dec;     [PubMed]
Zhu X,Yuan L,Li T,Cheng P, Errors in packaging surgical instruments based on a surgical instrument tracking system: an observational study. BMC health services research. 2019 Mar 19;     [PubMed]
Lorente L, Antiseptic measures during the insertion and manipulation of vascular catheters. Medicina intensiva. 2019 Mar;     [PubMed]
Siddiqui N,Friedman Z,McGeer A,Yousefzadeh A,Carvalho JC,Davies S, Optimal hand washing technique to minimize bacterial contamination before neuraxial anesthesia: a randomized control trial. International journal of obstetric anesthesia. 2017 Feb;     [PubMed]
Eberlin KR,Ring D, Infection after hand surgery. Hand clinics. 2015 May;     [PubMed]
Esposito MR,Guillari A,Angelillo IF, Knowledge, attitudes, and practice on the prevention of central line-associated bloodstream infections among nurses in oncological care: A cross-sectional study in an area of southern Italy. PloS one. 2017;     [PubMed]
Choi JH,Cho YS,Lee JW,Shin HB,Lee IK, Bacterial Contamination and Disinfection Status of Laryngoscopes Stored in Emergency Crash Carts. Journal of preventive medicine and public health = Yebang Uihakhoe chi. 2017;     [PubMed]

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