Maintaining the Sterile Field:
A Roundtable of Expert Advice
By John Roark
Maintaining the sterile field within the 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 a handful of experts to ask for their feedback on some key issues in preserving the sterile field, and culled their responses for an at-a-glance review of some basics and beyond.
The Panel of Experts:
- Nancy Bjerke, RN, MPH, CIC – Independent infection control consultant and co-chair of the APIC Practice Guidance Council (NB)
- Joan Blanchard, RN, MSS, CNOR, CIC – Perioperative nursing specialist at AORN’s Center for Nursing Practice (JB)
- Deborah Gardner, LPN, PA – 3M technical service manager (DG)
- Barbara Gruendemann, RN, MS, FAAN, CNOR – Co-author of 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 Health Care (TPR)
- Lisette H. Swenson – U.S. marketing manager for Mölnlycke Health Care, Inc. (LS)
What potentially dangerous shortcuts to aseptic technique have you witnessed?
“Shortcuts are costly in the long run. Manufacturers are preparing products for us that are efficient, better and improved. However, their label instructions do not follow standard aseptic technique. Just because the manufacturer says you can go from left to right and up and down, it is not the appropriate procedure for prepping a site. You start at the center; you go in concentric circles out. You never go back over a missed area with the existing applicator. You cannot go from dirty back to clean to catch up a dirty area. People know that, but they’re following the manufacturer. I see it every day.” – NB
How can clinicians best maintain the sterile field when it comes to patterns of movement within the field?
“The person who is scrubbed should remain close to the sterile field and not move away from the immediate area. When the scrub person is in sterile attire, moving from the sterile field increases the risk of contamination. When there is a need to move, scrubbed persons should move from sterile location to sterile location; if turning is required they should turn back-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 scrubbed person should avoid changing levels ( i.e, sitting only when the entire procedure will be done at that level). The scrubbed team should keep movement to a 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 other individual and try to reach for something, or in some cases they’ll actually pass sterile to dirty and get on the other side. That is one of the major infractions that we observe for in the OR. People, in their rush to pass to the other side, do not realize that a sufficient distance needs to exist between the dirty and the sterile. They brush against one another and become contaminated. You never turn your back to the sterile field – that’s a fundamental principle.” – NB
When maintaining a sterile field, what are common misconceptions or errors made concerning instrumentation?
“I often see heavy trays – not contained in a rigid container, but wrapped with a sterile wrap – picked up, put on a ring stand and opened. They are not held up and inspected for minute tears or breaches of sterility in that regard. It’s often hard to do – you have small circulators or scrub nurses, the trays are heavy, and they just don’t take that extra 10 seconds to lift them up and see: Are there any tears on the corners of this tray? Can I still use this tray? If it hasn’t been inspected, then the whole set has to be considered contaminated.” – TPR
“Some people look at the outside of the pack, and just because the color of the indicator tape has changed, they assume that it’s sterile, when in fact it’s not. The tape is merely an indication that it has been through some type of heat process. The only way to truly tell is by the indicator inside the tray.” – TPR
“One misconception involves transporting instruments from an autoclave. The autoclave may be in an open hallway; the scrubbed person goes to the autoclave to remove a sterilized item, which is in an open mesh pan. This puts the scrubbed person at risk for being contaminated as well as the sterile instrument. There are special enclosed instrument containers that can be used for autoclaving, which allows the circulator to transport the instrument and decrease the possibility of contamination. The scrubbed person can then remain at the sterile field.” – JB
What about surgical equipment (other than instrumentation) within the sterile field?
“Obviously, if you are going to use it and it cannot be sterilized, it has to be draped or covered with a sterile covering before you can move it into the sterile field. You need to make sure there is always a safe distance between anything that is not sterile and the sterile field. Twelve to 24 inches is usually considered safe.” – TPR
What should 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 are applied. 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 of current drapes, or if the individual needs to regown, that must be taken care of as well.” – TPR
“Gloves should be changed as soon as compromise is evident for protection of the surgical site and HCW.” – LS
“Contaminated gloves have to be changed. There is some controversy – some say that it’s OK if, for example, a couple of fingers get contaminated. Some clinicians, especially if it’s an emergency procedure, may just put a sterile glove over a contaminated glove. The proper way is to change that glove, and to have the circulating nurse, who is not sterile, remove that glove in such a way that it’s not going to contaminate the gown, and then have the scrub person put a new sterile glove on the surgeon or other sterile team member, using the open-gloving technique. The closed-gloving technique should not be used in changing gloves.” – BG
What are the primary safety issues in handling and placing sterile drapes within the sterile field?
“Once the drape is applied, it should not be moved or shifted. As we know, anything below waist level, or sterile field level, is considered contaminated. Sometimes, unfolding the drape incorrectly can lead to contamination, and certainly moving a drape, once it has been placed, is not considered safe.” – BG “There is a misconception that more layers of draping or ‘thicker’ drape materials create a better barrier, when in fact it is the material composition and performance of the drape materials utilized to manufacture the drape that creates that barrier.” – LS
“Layering is not usually necessary. It is counter-productive because it makes for more expense. It’s not really necessary because most of the drapes, both reusable and disposable, have increased barrier around the sections where the incisions are going to be made. The enhanced barrier qualities there prevent any moisture strike-through. Layering one drape on top of another is very counter-productive.” – BG
“When you create your sterile field, whether you use a specialty drape or you do what we call ‘squaring-off’ with individual drapes, you create a box around the area that you are going to cut. If that aperture were to slide one way or the other and you slide it back into place, what you have done is slid it over what is supposed to be your sterile surface. What you should do at that point is re-prep and re-drape.” – DG
“One of the most common shortcuts that I’ve seen pertaining to sterile drapes is not permitting the sterile skin prep to completely dry prior to applying the sterile drape.” – TPR
“People have a tendency to layer anywhere from two to five layers of drapes, thinking they have created a barrier. If you have five Kleenex tissues vs. one Kleenex tissue, the fl uid will still get through it, it is just going to take a little longer. More important than the amount of layers that you have is what is in that layer. Is it an impervious layer, or not?” – DG
What are the most important “commandments” when it comes to maintaining the sterile field?
“Limit the number of personnel in the OR – it affects the amount of bacteria that’s actually spread during the procedure. It stands to reason – the more people in the room, the higher the count of bacteria that are going to be in there. Only the people who are absolutely required to do the procedure should be allowed to be in the OR.” – TPR
“If there is a question regarding the sterility of an item, assume it is not sterile.” – JB
“Develop your surgical conscience. This comes from experience, but part of it is also not being afraid to speak up. Part of the nurse’s role in the OR, is to say, ‘This isn’t right.’” – DG “Aseptic technique is the mantra of perioperative nursing. It’s the common denominator, that really all surgical team members have to comply with, or adhere to. It is the foundation of what goes on at the sterile field. Perioperative nurses are the watchdogs of the 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 pretty discouraging.” – NB
“Keep your eyes on the sterile field. Never turn your back to it. Acknowledge when you have a break in technique. That’s called surgical conscience. Any time anything in surgery – not just sterile technique – is not right, you speak up. It’s not the place to keep quiet and tell somebody about it afterwards. You may see something that someone else on the team did not. You really count on everybody in the room to be focused on that patient.” – ML