Healthcare workers (HCWs) are heroes in today’s hospitals but even they would be rendered far less powerful without the help of their trustiest companion: aseptic technique. This sidekick wears a gown though — not a cape — that is surely of proper size, material, and cleanliness of course.
Aseptic technique is still of utmost importance, according to the Association of periOperative Registered Nurses (AORN)’s most recent recommended practices for maintaining a sterile field. The document was approved in November 2005, and was published in the February 2006 AORN Journal.
The guidelines are just that — guidelines — but should be followed whenever possible, says Byron Burlingame, RN, BSN, MS, CNOR, a perioperative nursing specialist at AORN’s Center for Nursing Practice.
“We’re a standards-setting body and not a legal body,” Burlingame says. “We realize that in some settings our standards cannot be put in to practice, but you need to get as close to them as possible.” The tried and true methods have been proven over time.
“Everything is basically the same as it has been for several years,” Burlingame says. “The principles are the same as they have been and what (we) have is very good as long as it is followed. But if there is research that is done that reveals new trends or reveals a practice that should be changed, we will go through the recommended practices process and consider that recommendation.”
Aseptic technique is a controlled set of conditions that reduce the amount of microorganisms in a field, the goal of which is to protect patients from infection and to control the spread of pathogens.
Healthcare-acquired infections (HAIs) are potentially life-threatening to patients, kill thousands of people every year, and burden the medical industry with millions, if not billions, of wasted dollars.
But even routines that involve cleaning, sanitizing and disinfecting are not always enough to prevent the spread of pathogens. Pathogens can gain access to a patient via their own body or through furniture, equipment, healthcare workers, the surrounding environment and procedures such as surgery, and the insertion of catheters, intravenous lines and other objects.² Which patients are vulnerable? All of them. Which patients are most vulnerable? Anyone with an impaired immune system.
Ironically, the patient is the most common source of pathogens,² for when a patient enters the hospital, they don’t just bring a suitcase and insurance papers; they bring their own microorganisms that usually are innocuous, but that often wreak havoc within 72 hours of surgery. Patients are therefore prepped by having hair shaved from the surgical site, and by being cleansed, then disinfected with alcohol, iodine or chlorhexidine gluconate.²
Surgical site infections (SSIs) are the most common post-surgery complication, according to Dale W. Bratzler and David R. Hunt, the authors of a white paper titled, “The surgical infection prevention and surgical care improvements projects: national initiatives to improve outcomes for patients having surgery,” published in Clinical Infectious Diseases. “Patients who experience a postoperative complication have dramatically increased hospital length of stay, hospital costs and mortality,” the paper states. “On average, the length of stay for patients who have a postoperative complication is 3-11 days longer than the length of stay for patients who do not experience complications.”
To address this topic, members of leading organizations launched in 2003 the Surgical Care Improvement Project (SCIP). Supporters include the Centers for Disease Control and Prevention, the American College of Surgeons, the Agency for Healthcare Research and Quality, and the American Hospital Association. The organization’s main goal is to reduce national “preventable surgical morbidity and mortality by 25 percent by 2010.”
SCIP performance measures focus on four areas in which “the incidence and cost of complications in surgery is high and there is a significant opportunity for prevention,” including prevention of:
2. Venous thromboembolism
3. Adverse cardiac events
4. Respiratory complications
Since SSIs are major component of preventable illness, everything within reason needs to be done to keep them at bay. Fortunately, aseptic technique is completely within reason.
HCWs must wash their hands before and after they touch each patient, every time, no exceptions. According to the Centers for Disease Control and Prevention (CDC), hands “should be rubbed vigorously during washing for at least 20 seconds with special attention paid to the backs of the hands, wrists, between the fingers and under the fingernails.”5
The faucet should then be turned off with a clean, dry paper towel (or a foot pedal should be used). Since fluid is a potential mode of pathogen transport and it follows the laws of gravity, one should hold hands below the elbows while scrubbing, and above the elbows while drying.²
Gloves, goggles, masks and eye shields should always be worn in the OR, hair should be out of sight, and jewelry should be removed.² When donning PPE, HCWs must avoid letting sterile material touch anything that is not sterile.
Drapes are imperative in the creation of a sterile field and should always be opened by someone who has properly cleaned, disinfected and protected any area of their body that will come in contact with the drapes. The person should first open the part of package that is furthest from them, and should not lean closely over the drape or allow it to get near the floor.² It is unnecessary to use two layers of drapes, according to Burlingame and several other sources.
“These are traditionally made of very durable material and you don’t see a lot of holes being poked in them,” Burlingame says. “And they’re generally placed very well.”
While drapes can be the source of infections, that scenario is rare, he adds. In the case of cloth drapes on an equipment table, a plastic or otherwise impermeable object should be placed beneath them.
Beyond the OR
Obviously the most important site for flawless aseptic technique is the OR because of the invasive procedures that occur there. Clinical areas may not lend themselves to the strict aseptic technique of the OR, but as much precaution as possible should still be taken. Outside the OR, aseptic technique is sometimes called “medical asepsis” or “clean technique.”²
HCWs who are facilitating bedside surgical dressings, for instance, do not have the luxury of a highly controlled environment such as an OR, but the procedure still requires hand washing, use of PPE, the creation of a sterile field and the avoidance of non sterile items.
The isolation unit in particular requires strict aseptic technique adherence to contain germs that patients in the unit may have, and to keep germs away from immune-compromised patients. Pressure systems restrict the flow of pathogens, but this protection can be breached by HCWs who do not wash hands carefully, wear appropriate PPE, or who move non sterile items into the isolation unit.
Other areas and procedures that require high aseptic standards include:
- Drain care
- Respiratory suction
- Urinary catheter insertion
- Intravascular procedures
- Wound care
- Vaginal exams (during labor) ²
Only individuals who are scrubbed sufficiently and who are wearing appropriate PPE should be allowed in a sterile field. Once inside the field, they should not turn away from the area at any time during the procedure, and they should not reach below the patient. When a nurse from outside the sterile field opens a package of tools, he or she should not touch the tool. ²
HCWs do sometimes use less aseptic technique vigilance outside the OR than they should, Burlingame says. Hope, however, is on the horizon.
“One of the things that is happening is that many of the accrediting agencies are requiring the same level of care throughout (the facility),” he says. “Compared to five years ago (irresponsible behavior outside the OR) is happening much less frequently today than a few years ago.
“For example, in radiology when they first started doing a lot of the radiological procedures they had very little aseptic technique knowledge and now they have learned it from interactions with the OR,” he adds. “We have expanded our knowledge to the other areas of the hospital as they have started to do more complex sterile procedures in them.”
The key is to make the set up of procedural areas as close to an OR set up as possible, says infection control nurse Barbara Lecy, RN, BSN, CIC, at the Mayo Clinic in Rochester, Minn. “In procedural areas we try to create a similar environment, through the design of the rooms (etc.),” she says. “The surfaces are all very cleanable, there’s dress code and hand washing and skin preparation for the patient that are all followed in a similar fashion to the surgical suites.
Those are all things we have in place procedurally to ensure that the aseptic mindset is there.
“But sometimes I think healthcare providers become too comfortable with the idea that (for example), ‘I have a sterile disposable procedure tray here in front of me and if I just do a good job of opening that up I don’t have to worry so much about whether my tie hanging in the way,’” she adds.
No “grey area” should exist in any clinical setting. If there is doubt that an item is sterile, the item should be deemed non-sterile. End of story. Other recommendations:
- Aseptic packages or areas should be opened or created close to the time of use
- Damp or wet areas should be considered nonsterile
- The back of a clinician is not considered sterile (since the clinician cannot see that area, they cannot guarantee that it has stayed away from non-sterile materials)
- No one should talk, laugh, sneeze or cough across a sterile field
- The outer inch of a sterile area should not be considered sterile
- HCWs with colds should try to stay home, but if they have to attend work, should wear two masks
- Hazardous waste should be promptly removed
- Bodily fluid drainage receptacles should be cleaned and emptied frequently, and drainage tubing should be kept below the patient level
- Soiled or damp areas should be cleaned immediately
- Containers of liquids should be closed except during use²
A staff that is savvy about aseptic technique is invaluable and the best way to garner such a crew is to tailor education depending on the staff member’s experience and their exposure to patients, according to Burlingame.
“You would not give the same education to a housekeeping person that maybe you would to the nursing assistant who is in there helping out with positioning, compared to the surgical scrub person,” he says.
Another tip is to do frequent walkthroughs of areas where high-risk activities take place. Burlingame used to do such walkthroughs and found them very helpful.
“If you see (dangerous) things happening then a committee or a team may be developed to look at the situations and to bring them to the forefront,” he says. “ …Form a team if it’s truly necessary, but don’t take up everyone’s time if it’s not.
“Do you need to do every six months an inservice on aseptic technique? I don’t think you do unless there’s an identified problem,” he adds. “If you’re ripping the back table drapes on every other case, you need to create your team and hopefully your team will find something like that your pans are being packed wrong and that’s what’s making the rip. Well, then you need to educate central sterile (CS) that they need to take a different way to package their pans. The education needs to be there, but it needs to be situation-based.”
Manufacturers occasionally write product directions that are not compliant with aseptic technique, according to Nancy Bjerke, RN, MPH, CIC, and independent infection control consultant. “You cannot go from dirty back to clean to catch up a dirty area,” Bjerke says. “People know that, but they’re following the manufacturer. I see it every day.”³
Burlingame, however, thinks this is a rare practice.
“Many of the manufacturers do utilize AORN standards to help them, knowing full well that they are research based,” he says. “We do not support any product nor do we say any products are bad but as a general rule the manufacturer’s recommendations are based upon very stringent standards.”
Burlingame contends that when a new person enters a clinical setting, they should first receive extremely clear, simple instructions. In ORs that he has worked in, he always told newcomers, whether they were “the housekeeper or a sales rep from outside the facility or wherever,” that, “‘Our drapes are all blue. We wear blue scrubs … You do not touch anything that is blue except for yourself.’ That helped to give them the concept.”
Burlingame also told such people that they weren’t allowed within a foot of the sterile field.
“When you are giving people the education, you need to make it applicable to something that they will understand and that is graspable at the moment,” he says. “You need to focus the education to that person’s level of understanding but still iterate at that level of understanding the importance (of aseptic technique).
“Everybody is keeping their eye on that sterile field,” he adds. “You know as a circulating nurse how close you can get and when you have a student in the room, one eyeball is always on that student making sure that they’re not too close. The people at the sterile field — the scrub person, the surgeon, the assistant — are also keeping a half an eye on that type of a thing.”
To be extra careful, even people on the perimeter of a sterile field could scrub up and protect themselves to the extent of those within the field, but this is not necessary, Burlingame says. According to him, ample research has shown that as long as all people near the sterile field follow current aseptic standards, infection risk decreases acceptably.
The biggest roadblocks to proper aseptic technique are time, haste, and distraction, says Lecy. “To perform aseptic technique well you really must focus on what you’re doing,” she says. Another potential problem: personal protective equipment (PPE). “We struggle sometimes with dress code,” she says. Practitioners occasionally remain in their street clothes while doing small, minimally invasive procedures such as an aspiration or joint injection, and males in particular sometimes forget that neck ties can easily swing out of place and into suspicious territory.
Aseptic education is vital, but if it is not followed up, the information can sometimes fall by the wayside, Lecy believes. “You should bring those principles back on some kind of a regular basis to staff working in those environments, because you do tend to forget some pieces sometimes. Of course the challenge is to do it in a way that’s interesting so that they hear the message,” she says.
“Role modeling certainly has an influence,” Lecy adds. “If you observe someone who you respect or someone who is in authority doing it wrong it might suggest to you that that’s an acceptable way to do it. That’s where orientation is so important. But even once a new employee has been shown the correct way and they get into the work setting, if they find that their coworkers are not following that, then there’s a real decision for that employee to make. Do they go back to their trainer and say, ‘this is what I understood but I see something different,’ or do they just drop into the flow and say, ‘Well, that was theory but this is real life?”
The Blame Game
Passing the buck isn’t applicable when it comes to aseptic technique, because infection prevention is the responsibility of an entire team — not just an individual, Burlingame says.
“When you get into an OR setting, the team functions so much as a team that I would not say that any one party is more guilty of forgetting than another party,” he ascertains. “You may find many people who blame the physicians instantly for that, but I have worked with many, many good physicians at the same time and I’ve worked with some other people in other roles who are not nearly as good, so overall I would say there is no team member who is sloppier than the next. It all depends on who you’re working with.”
If a staff member makes an aseptic slip, it may be the fault of improper education.
“I believe it’s a requirement of the facility to educate all levels of the staff,” Burlingame says. “You need to give appropriate staff level education and make sure that they really do understand the magnitude ... it is up to the facility to educate them.”
Fortunately, “surgical consciousness” is typically high, he adds.
“You get involved in lots of things but that sterile field is number one in your brain,” he says.
Still though, mistakes happen and some people have tendencies toward sloppiness. The medical industry culture is changing, however, and its members are becoming more open to hearing that they may have made a mistake. A lot of progress has occurred on this front, Burlingame says.
“A few years ago in the ‘olden days’ the surgeon was the captain of the ship and you never challenged the surgeon,” he says. “Some nursing staff (members were) the secondary captain of the ship and you never challenged them either. Today the evolution has occurred — as it has in the airline industry — that anybody speaks up. I would not say it’s perfect, because it’s not, but the migration is definitely occurring in that direction.”
HCWs are ultimately responsible for the safety of patients, but aseptic technique can’t prevent or remedy every situation, for there are many factors that can lead to infection.
“Did this patient have an infection somewhere else on the body?” Burlingame asks. “Maybe the patient is very debilitated — for instance, a patient that has just received “x” weeks of chemotherapy. There are patient-centered (aspects) here, and there are technique-centered (aspects). Some fit into the realm of postoperative care. Is the bandage changed as often as it should be?
Are they getting soaked and getting ignored by the patient because the patient didn’t understand that they were supposed to change the dressings? A patient infection is a many-faceted situation.”
The Mayo Clinic in Rochester, Minn. embarked on a successful education mission when staff members of the surgical services department told their managers and educators that they thought aseptic technique needed to be reviewed.¹ Specific concerns were:
- Reuse of sterile solutions containers
- How to deliver items to a sterile field
- What to do with packages that have dropped
In response to these concerns, two clinical educators organized representatives from each specialty. The group identified issues and solutions, and set up a workshop around their findings. The workshops were held during two 50-minute weekly in-service programs and were taped for staff members who were not available during the meetings.
The first part revolved around a hypothetical story of a patient who suffered from a surgical wound infection, and the second part went into the specifics of scrubbing, ways to prevent cross-contamination, and how to properly don PPE. Communication, surgical scrub and cleaning practices were also reviewed through the series.
The presentations met the infection control continuing education criteria of the Association of Surgical Technologists, as well as the state board of nursing, and therefore provided contact hours for participants.
The presenters utilized slides, videos and lecturers, and found that while aseptic technique is of utmost importance, humor was a valuable thread through the program.¹ Interaction was also beneficial. For example, when draping was being discussed, some participants first demonstrated improper techniques, and then demonstrated the right approach.
Overall, the continuing education courses not only increased staff knowledge levels, but also brought colleagues closer together because each person learned more about what other departments do, and because staff members collaborated. Aseptic technique practices improved after the course¹ but organized follow up sessions are still imperative, according to Lecy.
“You have to have some built in annual competencies,” she says. “That’s the only way. Otherwise years go by and how do you know that the tenure employee is still following the correct technique? There has to be annual required training, and competencies and with some of those things it should be a returned demonstration or at least a verbalization of what the steps are and how it’s done correctly. Observational audits are important too.”
1. AORN’s recommended practices for maintaining a sterile field. AORN Journal. Vol.
73, No. 2. February 2001.
2. www.answers.com/topic/aseptic-techniquesurgical-term3. Maintaining the sterile field: a roundtable of expert advice. Infection Control Today. January 2005.
4. Bratzler D, Hunt D. The surgical infection prevention and surgical care improvement projects: national initiatives to improve outcomes for patients having surgery. Clinical Infectious Diseases. August 2006.