Purpose: Basic principles and practices provide guidelines for establishing and maintaining a sterile field. All individuals involved in surgical interventions have a responsibility to provide and maintain a safe environment. Adherence to aseptic practices aids in fulfilling this responsibility. Aseptic practices are implemented preoperatively, intraoperatively, and postoperatively to minimize wound contamination.
RECOMMENDED PRACTICE I
Scrubbed persons function within a sterile field.
1. Personnel within the sterile field should wear caps, masks, and sterile gowns and gloves to prevent microorganisms from being transferred to the surgical site during the surgical procedure.(1)
2. Materials for gowns should be selected according to AORN's "Recommended practices for use and selection of barrier materials for surgical gowns and drapes."(2)
3. Surgical gowns should establish a barrier that minimizes the passage of microorganisms between nonsterile and sterile areas.(3) To reduce transfer of microorganisms, surgical hand scrubs performed before donning sterile gowns and gloves should follow AORN's "Recommended practices for surgical hand scrubs.(4)
4. To avoid contamination of the sterile field, scrubbed persons should don sterile gowns and gloves from a sterile area other than the main instrument table.(5)
5. Scrubbed persons should inspect gloves for integrity after donning. Intact gloves establish a barrier that minimizes the passage of microorganisms between nonsterile and sterile areas. Wearing two pairs of gloves (ie, double-gloving) may be indicated for some procedures to reduce the potential for contact with blood and body fluids.(6) Policies and procedures of the practice setting dictate when double-gloving should be considered.
6. Sterile gowns should be considered sterile in front from the chest to the level of the sterile field. Gown sleeves are considered sterile from two inches above the elbow to the cuff, circumferentially. The area of sterility of the gown front extends to the level of the sterile field because most scrubbed persons work adjacent to a sterile bed and/or table. Maintaining sterility of gown sleeves prevents contamination as the scrubbed person's arms move across the sterile field. The neckline, shoulders, underarms, sleeve cuffs, and gown back are areas of friction and, therefore, not considered effective microbial barriers. The gown back is considered nonsterile because it cannot be constantly monitored.(7) Sleeve cuffs become contaminated when the scrubbed person's hands pass beyond the cuff.(8)
7. Sterile gloves that become contaminated should be changed immediately. There are two methods for changing contaminated gloves. The preferred method is for one member of the sterile team to glove another member. If this is not possible, the contaminated glove should be changed by the open-glove method.(9)
RECOMMENDED PRACTICE II
Sterile drapes should be used to establish a sterile field.
1. Surgical drapes should be selected according to AORN's "Recommended practices for use and selection of barrier materials for surgical gowns and drapes."(10)
2. Surgical drapes should establish an aseptic barrier that minimizes the passage of microorganisms between nonsterile and sterile areas.(11)
3. To prevent contamination from nonsterile areas, sterile drapes should be placed on the patient, furniture, and equipment to be included in the sterile field.(12)
4. Sterile drapes should be handled as little as possible. Rapid movement of draping materials creates air currents on which dust, lint, and other particles can migrate.(13)
5. To minimize contamination of the surgical site, draping material should be maintained in a compact manner, held higher than the OR bed, and placed from the surgical site to the periphery. Some procedures may require modified draping techniques (eg, extremities).(14)
6. During draping, gloved hands should be protected by cuffing the drape material over the gloved hands to reduce the potential for contamination.(15)
7. When positioned, the portion of the surgical drape that establishes the sterile field should not be moved. Shifting or moving the sterile drape can compromise the sterility of the field.(16)
RECOMMENDED PRACTICE III
Items used within the sterile field should be sterile.
1. Packaging materials should meet the criteria identified in AORN's "Recommended practices for selection and use of packaging systems."(17)
2. Methods of disinfection, sterilization, and handling of sterile items should be in accord with AORN's "Recommended practices for high-level disinfection"(18) and AORN's "Recommended practices for sterilization in the practice setting."(19) High-level disinfection reduces the risk of microbial contamination but does not ensure the same margin of safety that sterilization provides. Sterilization provides the highest level of assurance that an object is void of viable microbes.(20)
3. To ensure that only sterile items are presented to the sterile field, all items should be inspected immediately before presentation to the field for proper packaging, processing, seal, package container integrity, and inclusion of a sterilization indicator. If an expiration date is provided, it should be checked before opening the package and delivering the contents to the field.(21)
RECOMMENDED PRACTICE IV
All items introduced to a sterile field should be opened, dispensed, and transferred by methods that maintain sterility and integrity.
1. To prevent contamination from passing an unsterile arm over a sterile item, unsterile persons should open wrapped sterile supplies by opening the wrapper flap farthest away from them first. Open each of the side flaps next. The nearest wrapper flap should be opened last.(22)
2. All wrapper edges should be secured when supplies are presented to the sterile field. Securing the loose wrapper edges prevents them from inadvertently contaminating the sterile field.(23)
3. Sterile items should be presented to the scrubbed person or placed securely on the sterile field. Items tossed onto a sterile field may roll off the edge and become contaminated or cause other items to be displaced.(24)
4. Sharps, heavy objects, and contents of rigid container systems should be presented to the scrubbed person or opened on a separate surface. These heavy items may penetrate the sterile barrier if dropped onto the sterile field.(25)
5. When dispensing solutions, the solution receptacle on the sterile field should be placed near the table's edge or held by the scrubbed person. The entire contents of the container should be poured slowly to avoid splashing. Any remaining fluids should be discarded. Placing the solution receptacle near the edge of the sterile table allows the unscrubbed person to pour fluids without contamination.(26) Splashing can cause strike through and splash back from nonsterile surfaces to the sterile field.(27) The edge of a container is considered contaminated after the cap has been removed; therefore, the sterility of the contents cannot be ensured if the cap is replaced.(28) Reuse of open containers may contaminate solutions due to drops contacting unsterile areas and then running back over container openings.
A sterile field should be maintained and monitored constantly.
1. Sterile fields should be prepared as close as possible to the time of use. The potential for contamination increases with time because dust and other particles, stirred up by movement of personnel, can settle on horizontal surfaces. Direct observation increases the likelihood of detecting a breach of sterility.(29) Currently, there is no scientific data to support the practice of covering or not covering sterile fields. Removing the table cover may result in a part of the cover that was below the table level to be drawn above the table level. It is important to continuously monitor all sterile areas for possible contamination.(30)
2. Conversations in the presence of a sterile field should be kept to a minimum to reduce the spread of droplets.(31)
3. Surgical equipment (eg, cables, tubing) should be secured to the sterile field with nonperforating devices. Perforations in a barrier provide portals of entry and exit for microorganisms, blood, and other potentially infectious body fluids.
4. Nonsterile equipment (eg, Mayo stands) should be covered appropriately with sterile barrier material(s) before being introduced to or over a sterile field. Only sterile items should touch sterile surfaces.(32) The Mayo stand should be covered with a barrier material on the top, bottom, and all sides. Sterile barrier material also should be applied to the portion of the stand that will be positioned immediately adjacent to the sterile field.
RECOMMENDED PRACTICE VI
All personnel moving within or around a sterile field should do so in a manner that maintains the sterile field.
1. Scrubbed persons should remain close to the sterile field and not leave the immediate area. Walking outside the sterile field's periphery or leaving the OR in sterile attire increases the potential for contamination.(33)
2. Scrubbed persons should move from sterile areas to sterile areas to prevent contamination. If they must change positions, they should turn back to back or face to face while maintaining safe distances from each other.(34)
3. Scrubbed persons should keep their arms and hands within the sterile field at all times. Contamination may occur when arms and hands are moved below the level of the sterile field or into other nonsterile areas.(35)
4. Scrubbed persons should avoid changing levels and should be seated only when the entire surgical procedure will be performed at that level. When changing levels, exposure of the nonsterile portion of the surgical gown is likely.(36)
5. Unscrubbed persons should face sterile fields on approach, should not walk between two sterile fields, and should be aware of the need for distance from the sterile field. Establishing patterns of movement around the sterile field helps prevent contamination. Accidental contamination can be kept to a minimum by keeping sterile areas in view.(37)6. The number and movement of persons involved in a surgical procedure should be kept to a minimum. AORN's "Recommended practices for traffic patterns in the perioperative practice setting" should be followed.(38) Bacterial shedding increases with activity.(39) Air currents can pick up contaminated particles shed from patients, personnel, and drapes and distribute them to sterile areas.(40
RECOMMENDED PRACTICE VII
Policies and procedures for maintaining a sterile field should be written, reviewed annually, and readily available in the practice setting.
1. These recommended practices should be used as operational guidelines for developing policies and procedures within the practice setting. Policies and procedures establish authority, responsibility, and accountability and serve as operational guidelines. Introduction and review of policies and procedures should be included in the orientation and ongoing education of perioperative personnel to assist them in developing knowledge, skills, and attitudes that affect patient outcomes. Policies and procedures also facilitate development of performance improvement activities.
Open-gloving method: A method of donning sterile gloves in which the everted cuff of each glove allows the gowned person to touch the inner side of the glove with ungloved fingers and the outer side of the glove with gloved fingers.
High-level disinfection: A process that destroys all microorganisms with the exception of high numbers of bacterial spores.
(1.) "Recommended practices for surgical attire," in Standards, Recommended Practices, and Guidelines (Denver: AORN, Inc, 2000) 199, 200, 202; D M Fogg, "Infection control," in Alexander's Care of the Patient in Surgery, 11th ed, M H Meeker, J C Rothrock, eds (St Louis: Mosby, 1999) 137; S S Fairchild, Perioperative Nursing: Principles and Practice, second ed (Philadelphia: Lippincott, 1996) 151; "Recommended practices for use and selection of barrier materials for surgical gowns and drapes," in Standards, Recommended Practices, and Guidelines (Denver: AORN, Inc, 2000) 267.
(2.) "Recommended practices for use and selection of barrier materials for surgical gowns and drapes," 267.
(4.) "Recommended practices for surgical hand scrubs," in Standards, Recommended Practices, and Guidelines (Denver: AORN, Inc, 2000) 271; A J Mangram et al, "Guideline for prevention of surgical site infection, 1999," American Journal of Infection Control 27 (April 1999) 104, 108.
(5.) P A Mews, "Creating and maintaining a sterile field," in Perioperative Nursing Practice, ed M L Phippen, M P Wells (Philadelphia: W B Saunders Co, 1994) 157; C Spry, Essentials of Perioperative Nursing, second ed (Gaithersburg, Md: Aspen Publishers, 1997) 95; J A Kneedler, G H Dodge, eds, Perioperative Patient Care: The Nursing Perspective, third ed (Boston: Jones and Bartlett Publishers, 1994) 302.
(6.) Spry, Essentials of Perioperative Nursing, second ed, 99.
(7.) Mews, "Creating and maintaining a sterile field," 157; Fogg, "Infection control," 128; L Pierce, "Basic principles of aseptic technique," Plastic Surgical Nursing 17 (Spring 1997) 49.
(8.) Kneedler, Dodge, eds, Perioperative Patient Care: The Nursing Perspective, third ed, 304, 307; Fogg, "Infection control," 142.
(10.) "Recommended practices for use and selection of barrier materials for surgical gowns and drapes," 267-270.