Surgical aseptic technique is a method employed to maintain asepsis and minimise the risk of introducing pathogens into a surgical wound (Rowley et al, 2010). It protects the patient from the impact of healthcare associated infections such as delayed recovery, longer hospitalisation, increased pain and increased morbidity (Phillips 2013). It should never be compromised for the sake of convenience of the caregiver. An emergency situation in which asepsis becomes a secondary concern is a rare occurrence. (Phillips 2013).
- Packaging content label
- Packaging integrity- the package is free from holes, punctures, tears, damage or rupture.
- The package is dry (Rationale 1, 2, 29) (Phillips, 2013: Association of periOperative Registered Nurses (AORN), 2010).
- Packages and equipment should be processed according to the manufacturer’s guidelines.
- Package is intact and has not been previously opened
- Expiry date is current
- Sterilisation indicator is present
Gown and gloving
- Resistance to microbial penetration(dry and wet)
- Cleanliness (from microbial particulate matter)
- No lint production
- Resistance to liquid penetration
- Bursting strength (dry and wet)
- Tensile strength (dry and wet)
- Using the cuff covered hands, place the glove wrapper in front of you like a book. First open the two sides then open the inner fold of the glove wrapper by grasping the two lower corners.
- Extend the right forearm. With the cuff covered left hand, pick up the right glove from the glove wrapper by grasping the fingers and lifting straight up and placing the glove on the right palm (which is in the cuff of the gown) thumb side down and the fingers are pointing towards the shoulder.
- Grasp the edges of the cuff with the cuffed left hand and the opposite edge with the cuffed right hand. Peel the glove over the right cuffed hand, the end of the sleeve and wiggle the fingers to extend them into the glove covered right hand. The cuff of the right glove is now covering the cuff of the right sleeve.
- Grasp the cuff of the right glove and underlying right gown sleeve with the covered left hand and extended fingers pulling the glove and cuff over the hand. The glove cuff must remain over the cuff of the gown.
- Repeat the sequence for applying the left glove (Phillips, 2013).
- With the left hand grasp the inner edge of the cuff of the right glove and lift from the wrapper while taking care not to touch the inner edge of the wrapper.
- Align the fingers of the right hand and insert the right hand into the glove, pulling it on while leaving the cuff turned down over the hand. Be sure to keep the thumb adducted into the palm of the hand until it is well inside the confines of the glove. Do Not adjust the cuff at this point.
- Slip the fingers of the sterile right hand into the everted left cuff on the sterile side of the glove.
- Align the fingers of the left hand and insert the fingers into the left glove, keeping the thumb adducted until well inside the glove. Pull the left glove on all the way unfolding the cuff of the glove over the cuff of the gown at the wrist.
- At this time pull the cuff of the right glove over the cuff on the sleeve over the right wrist (Phillips, 2013).
- Fingertip to above the elbow (Rationale 8).
- Below the nipple to waist level. Hands must be kept at or above waist level and below shoulder level and should be visible at all times in order to avoid inadvertent contamination (Rationale 8).
During the procedure
- The sterile field should be constantly observed and not left unattended at any time after is has been set up (Rationale 1).
- Conversation should be kept to a minimum in the surgical area and masks should be worn (Rationale 9).
- The number of individuals in the theatre and around the surgical field should be limited to essential personnel and to facilitate a minimum number of observers who are training (Rationale 9).
- Movement around the sterile field, including the opening and closing of doors should be kept to a minimum (Rationale 9, 22, 27, 28).
- Non-perforating devices should be used to secure equipment to the sterile field (Rationale 10).
- Non-sterile equipment should be covered with sterile barriers before placing them in or over the sterile field (Rationale 1).
- Staff scrubbed should stay within the sterile field during the intraoperative procedure and not walk around or go outside the operating theatre in their sterile gown and gloves (Rationale 11, 31).
- When changing positions scrub staff should pass back-to-back or face-to-face (Rationale 11).
- Scrubbed staff should avoid changing levels, such as sitting and standing (Rationale 11).
- A wide space should be observed between scrubbed staff and non-scrubbed staff. When moving about the theatre circulating practitioner should maintain a distance of 30cm from any area of the sterile field. (Rationale 9, 22) (Phillips, 2013).
- Circulating practitioner should face the sterile field on approach (Rationale 1).
- Circulating practitioner should not touch or lean over the sterile field (Rationale 1, 22).
- Circulating practitioner should not walk between two components of the sterile field (Rationale 1, 22) (Phillips, 2013).
- Hand hygiene practices should be followed prior to passing sterile items to the scrubbed person.
- It is the required item.
- The package integrity has been maintained.
- The sterilisation indicator is present.
- It has not exceeded its expiry date.
- The packaging is not wet (Rationale 2, 15).
- Place the wrapped instrument tray on a clean, dry table surface
- Check the external chemical indicator to be certain that the item has been exposed to the sterilisation process,
- Break the tape at the juncture between folds (Rationale 30), open the wrapper flap by lifting the side flaps off to the side so that both sides are off the end of the table
- To open the central flaps begin by opening the flap furthest away first to prevent contamination from passing an unsterile arm over the sterile items. The nearest flap should always be opened last. It is easiest opening the wrap with two people one standing on each side of the table.
- Contents should be presented to the scrubbed person to prevent contamination of the contents by:
- The circulating practitioner gently peels open the package to allow the scrub practitioner to take the inner package by grasping it or using a forceps.
- Open on a separate surface, by breaking the seal on the side of the lid, raising the lid up away from the tray.
- The inner basket is sterile.
- Supplies should never be opened into the container and basket because the top edge of the container is not considered sterile
Moving sterile trolleys
Leaving sterile items opened
Dealing with contamination
Rationale 1: To prevent contamination of the sterile field.
Rationale 2: To ensure sterility of the item.
Rationale 3: To reduce the number of micro-organisms present on the staff member's skin.
Rationale 4: The gown protects the wearer and the patient from cross-contamination (Phillips 2013).
Rationale 5: To prevents water being dripped onto the working sterile field (Rothrock 2015).
Rationale 6: To identify any holes.
Rationale 7: The gloves are handled through the fabric of the gown sleeves. This ensures that no skin is exposed and provides the most assurance against contamination (Kennedy, 2013).
Rationale 8: The scrub practitioner cannot constantly observe the back of the gown, so it is deemed unsterile. Perspiration may gather under the arms, and the collar touches the skin of the scrub practitioner. The gown is considered unsterile below the level of the sterile trolley (Rothrock, 2015).
Rationale 9: To prevent airborne contamination. Microorganisms in droplets are forcibly expelled through talking, coughing or sneezing.
Rationale 10: To prevent creating holes in the sterile drapes.
Rationale 11: To avoid contaminating the sterile gown.
Rationale 12: To prevent a sharps injury.
Rationale 13: The edges of sterile enclosures are considered unsterile.
Rationale 14: A sterile forceps may be used as an extension of the scrub practitioner's hand to ensure a margin of safety between fields (Phillips, 2013).
Rationale 15: To prevent contamination of the object.
Rationale 16: To prevent spillage causing strikethrough contamination.
Rationale 17:To prevent the label and expiry date being obscured in the event of spillage.
Rationale 18: Reuse of opened containers may contaminate the solutions.
Rationale 19: To prevent further contamination of the sterile field.
Rationale 20: To create a new sterile field.
Rationale 21: The records kept for the decontamination process should be able to prove retrospectively that the instrument has passed through each stage of the sterilisation process. Records need to be kept for traceability purposes (Phillips, 2013 ).
Rationale 22: To prevent personal shedding over the sterile field. The average individual sheds an estimated 4000 to 10,000 viable contaminated particles from the skin per minute. The major areas of microbial shedding include the head, neck, axillae, hands, groin, perineum, legs and feet (Phillips, 2013).
Rationale 23: Using sterile technique helps prevent contamination of the surgical environment and can help reduce the incidence of SSI (Kennedy, 2013).
Rationale 24: Drawing the cuff over the hand may result in contamination of the cuff (Kennedy, 2013).
Rationale 25: Moisture from the freshly scrubbed arms and hands which has dripped on the gowning table can contaminate the surgical gown and gloves (Phillips, 2013).
Rationale 26: Opening sterile items and setting up a sterile as close to the time of surgery decreases exposure to possible contamination within the environment (Phillips, 2013).
Rationale 27: Rapid movement of draping materials creates air currents on which dust, lint, and other particles can migrate (AORN, 2010).
Rationale 28: Moving tables stirs air currents that can contaminate the sterile field (AORN, 2010).
Rationale 29: Accidental wetting of a package contaminates the contents. Packaging must always be handled with dry clean hands and placed on a dry surface (Phillips, 2013).
Rationale 30: Removing the tape increases the risk of tearing the paper wrap (Phillips, 2013).
Rationale 31: Sterility cannot be assured without direct observation of the sterile field (Phillips, 2013).
Association of periOperative Registered Nurses (AORN). (2010) Recommended practices for maintaining a sterile field. Perioperative Standards and Recommended Practices. AORN Inc. Denver CO 2010: 91-99.
The Association for Perioperative Practice (AfPP). (2016) Standards and recommendations for safe perioperative practice. Harrogate. The Association for Perioperative Practice, 171-228.
Hopper, WR, Moss, R (2010) Common breaks in sterile technique: clinical perspectives and perioperative implications. AORN Journal 91(3): 350-367.
Kennedy, L (2013) Implementing AORN recommended practices for sterile technique. AORN Journal 98(1): 15-23.
Phillips, N (2013) Berry and Kohn’s Operating Room Technique 13th Edition. St Louis, MO., Elsevier, 252-266.
Rothrock J. (2015) Alexander's care of the patient in surgery (15th ed.). St Louis, Mosby.
Rowley S, Clare S, Macqueen S, Molyneux R (2010) ANTT V2: An updated practice framework for aseptic technique. British Journal of Nursing 19(5): S5-S11.