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1.7: Sterile Procedures and Sterile Attire

  • Page ID
    9985
  • Sterile procedures are required before and during specific patient care activities to maintain an area free from microorganisms and to prevent infection. Performing a surgical hand scrub, applying sterile gloves, and preparing a sterile field are ways to prevent and minimize infection during surgeries or invasive procedures.

    Surgical Hand Scrub

    Skin is a major source of microorganisms and a major source of contamination in the OR setting (CDC, 2010). Since skin cannot be sterilized, members of the surgical team must wear sterile gloves. The purpose of the surgical hand scrub is to significantly reduce the number of skin bacteria found on the hands and arms of the OR staff (Kennedy, 2013). A surgical hand scrub is an antiseptic surgical scrub or antiseptic hand rub that is performed prior to donning surgical attire (Perry et al., 2014) and lasts two to five minutes, depending on the product used and hospital policy. Studies have shown that skin bacteria rapidly multiply under surgical gloves if hands are not washed with an antimicrobial soap, whereas a surgical hand scrub will inhibit growth of bacteria under gloved hands (Kennedy, 2013).

    Types of surgical hand scrubs

    Surgical hand scrub techniques and supplies to clean hands will vary among health care agencies. Most protocols will require a microbial soap-and-water, three- to five-minute hand scrub procedure. Some agencies may use an approved waterless hand scrub product. See Checklist 11 for the steps to follow when scrubbing with medicated soap.

     

    Checklist 11: Surgical Hand Scrub with Medicated Soap

    Disclaimer: Always review and follow your hospital policy regarding this specific skill.
    Safety considerations:
    • All personnel entering the operating room (OR) or a specific sterile procedure must perform a surgical hand scrub.
    • Hands must be free from rings, watches, and bracelets. Nails should be free from any nail enhancements, artificial extenders, acrylics, wraps, and tips. Nail polish must be free from chips or cracks. Research shows that the amount of bacteria is nine times higher on rings and on the skin beneath the fingernails.
    • All skin on the forearm and hands (including cuticles) should be free from open lesions and breaks in skin integrity. Any allergies to the cleansing products should be reported to the manager.
    • If hands touch anything during cleaning, the entire procedure must be started from the beginning.

     Steps

     Additional Information

    1. Remove all jewellery. Jewellery harbours microorganisms.
    Remove Jewelry

    Remove jewellery

    2. No artificial nails, extenders, or chipped nail polish should be worn in the OR. Artificial nails, extenders, and chipped nail polish can harbour microorganisms.
    3. Inspect hands for sores or abrasions; cover or report to supervisor as required. Open sores can harbour microorganisms.
    4. Ensure sleeves are at least two to three inches above the elbows. This step prevents sleeves from becoming moist.
    5. Clean hands with ABHR or soap and water to remove visible debris. Hand hygiene is recommended by the Association of periOperative Registered Nurses (AORN).
    Hand hygiene with ABHR

    Hand hygiene with ABHR

    6. Turn on water. Regulate the temperature of the water. Warm water is recommended to prevent drying out of hands.
    Wet hands

    Wet hands

    7. Apply the required amount of microbial soap to hands. A good amount of soap is required to create lather for a three- to five-minute scrub.
    8. Keeping hands above elbows, start timing; scrub each side of each finger, between fingers, under each nail with a nail file, and the back and front of hands for the recommended time, according to agency policy. Nail files work more effectively than a nail brush. Clean the subungal area (under the fingernails) with a nail file. Nail brushes are not recommended as they may damage the skin around the nail.
    9. Scrub the arms, using an up-and-down motion, keeping hands above the elbows at all times. Wash each side of the arm from wrist to elbow for one minute. Keeping hands above the wrist allows for the microorganisms to slide off the hands into the sink.
    10. Repeat the entire process with the other hand and forearm. Use an equal amount of time to wash each hand.
    11. With hands raised, rinse hands and arms by passing them through running water, letting the water drip down from the fingertips to the elbow. This step allows for all the soap to be rinsed off from cleanest to dirtiest area.
    12. Proceed into the operating room (keep hands above the waist), and dry arms using a sterile towel, starting at the fingertips and working down toward the forearms using a dabbing motion. This step prevents contamination of the hands and adheres to the principles of sterile technique.
    Data source: ATI, 2015a; Bartlett, Pollard, Bowker, & Bannister, 2002; Kennedy, 2013; WHO, 2009a
    Watch a video or demonstration to learn how to perform hand hygiene using the traditional hand scrub method.
    Watch a video or demonstration to learn how to perform surgical hand scrub using an alcohol-based hand rub method.

    Applying Sterile Gloves

    Sterile gloves are gloves that are free from all microorganisms. They are required for any invasive procedure and when contact with any sterile site, tissue, or body cavity is expected (PIDAC, 2012). Sterile gloves help prevent surgical site infections and reduce the risk of exposure to blood and body fluid pathogens for the health care worker. Studies have shown that 18% to 35% of all sterile gloves have tiny holes after surgery, and up to 80% of the tiny puncture sites go unnoticed by the surgeon (Kennedy, 2013). Double gloving is known to reduce the risk of exposure and has become common practice, but does not reduce the risk of cross-contamination after surgery (Kennedy, 2013).

    To apply sterile gloves, follow the steps in Checklist 12.

    Checklist 12: Donning Sterile Gloves

    Disclaimer: Always review and follow your hospital policy regarding this specific skill.
    Safety considerations:
    • Choose the right size of gloves. Gloves come in multiple sizes. Make sure the gloves are tight enough so that objects are easy to pick up.
    • Sterile gloving does not replace hand washing. Hands must be washed before and after any procedure.
    • Gather all supplies and prepare your patient for the procedure prior to applying gloves.
    • Ensure the patient does not have a latex allergy prior to applying sterile gloves.

     Steps

     Additional Information

    1. Remove all jewellery. Jewellery harbours more microorganisms than do hands.
    Remove Jewelry

    Remove jewellery

    2. No artificial nails, extenders, or chipped nail polish should be worn. Artificial nails, extenders, and chipped nail polish can harbour additional microorganisms.
    3. Inspect hands for sores and abrasions. Cover or report to supervisor as required. Open sores can harbour microorganisms.
    4. Ensure sleeves are at least two to three inches above the elbows. This step prevents sleeves from becoming moist, and prevents the transfer of microorganisms from the sleeves.
    5. Clean hands with ABHR or soap and water. This step decreases the bacterial count on hands and prevents contamination of sterile equipment.
    Hand hygiene with ABHR

    Hand hygiene with ABHR

    6. Clean surface to open sterile field and raise its height to waist level. All sterile items must be kept above waist level.
    7. Inspect packaging for sterility. All sterile items must be checked for sterility prior to use. Always examine sterile glove packaging for expiry date, intactness, and tears. The package should be dry. Sterile gloves have outer packaging that must be removed prior to starting the procedure of applying sterile gloves.
    image

    Inspect outer packaging

    8. Open sterile packaging by peeling open the top seam and pulling down. Open sterile packaging without contaminating inner package.
    open sterile glove packaging

    Open sterile glove packaging

    9. Place inner package on working surface and open up to see right and left gloves. Start with dominant hand first. Open packaging. This step prepares sterile surface to perform sterile application of gloves.
    Place inner packaging on clean surface

    Place inner packaging on clean surface

    Open packaging

    Start with dominant hand

    Open packaging

    Open packaging

    10. Pick up glove for dominant hand by touching the inside cuff of the glove. Do not touch the outside of the glove. Pull glove completely over dominant hand.  This step allows ease of application.
    Book pictures 2015 219

    Grasp the glove of the dominant hand

    Insert hand into opening

    Insert hand into opening

    Pull glove on up to wrist

    Pull glove on up to wrist

    11. Insert gloved hand into the cuff of the remaining glove. Pull remaining glove on non-dominant hand and insert fingers. Adjust gloves if necessary. This ensures proper fit of gloves.
    Book pictures 2015 225

    Place gloved hand under the cuff

    Book pictures 2015 226

    Insert fingers

    Pull glove up to wrist

    Pull glove up to wrist

    12. Once gloves are on, interlock gloved hands and keep at least six inches away from clothing, keeping hands above waist level and below the shoulders. This step prevents the accidental touching of non-sterile objects or the front of the gown.
    Keep hands above waist level and away from clothing

    Keep hands above waist level and away from clothing

    13. To remove gloves, grasp the outside of the cuff or palm of glove and gently pull the glove off, turning it inside out and placing it into gloved hand. Doing this, prevents the contamination of the hand when removing glove.
    2 inch below the cuff

    Grasp the outside of the glove 1/2 inch below the cuff

    Book pictures 2015 235

    Turn glove inside out

    Book pictures 2015 236

    Place inside-out glove in gloved hand

    14. Take ungloved hand, place fingers inside the other glove, and pull glove off inside out. This step prevents the contamination of gloved hand touching ungloved hand.
    Insert finger under the cuff

    Insert finger under the cuff

    Book pictures 2015 239

    Remove second glove inside out

    15. Perform hand hygiene. This removes powder from the gloves, which can irritate the skin; it also prevents contamination from potential pinholes in the gloves.
    Hand hygiene with ABHR

    Hand hygiene with ABHR

    Data source: ATI, 2015b; Berman & Snyder, 2016; Kennedy, 2013; Perry et al., 2014; Rothrock, 2014
    Watch this Donning Sterile Gloves video for a demonstration on donning sterile gloves.

    Setting up a Sterile Field

    Aseptic procedures require a sterile area in which to work with sterile objects. A sterile field is a sterile surface on which to place sterile equipment that is considered free from microorganisms (Perry et al., 2014). A sterile field is required for all invasive procedures to prevent the transfer of microorganisms and reduce the potential for surgical site infections. Sterile fields can be created in the OR using drapes, or at the bedside using a prepackaged set of supplies for a sterile procedure or wound care. Many sterile kits contain a waterproof inner drape that can be set up as part of the sterile field. Sterile items can be linen wrapped or paper wrapped, depending on whether they are single- or multi-use. Always check hospital policy and doctor orders if a sterile field is required for a procedure. See Checklist 13 for the steps for preparing a sterile field.

    Checklist 13: Preparing a Sterile Field

    Disclaimer: Always review and follow your hospital policy regarding this specific skill.
    Safety considerations:
    • Check physician orders and hospital policy regarding procedure.
    • Instruct patient how to assist throughout the procedure (e.g., lying still, not talking over the sterile field or touching sterile objects).
    • If required, check dressing on wound to assess for required supplies needed for the procedure.
    • Offer analgesic and/or bathroom to ensure patient comfort throughout the procedure.
    • Explain procedure to the patient and give an approximate time frame for completing the procedure.

    Steps

     Additional Information

    1. Perform hand hygiene, gather supplies, check equipment for sterility, and gather additional supplies (gauze, sterile cleaning solution, sterile gloves, etc.). Gathering additional supplies at the same time will help avoid leaving the sterile field unattended. Prepackaged sterile kits may not have all the supplies required for each procedure.
    Hand hygiene with ABHR

    Hand hygiene with ABHR

    2. Place package on clean, dry, waist-level table. A clean, dry surface is required to set up a sterile field.

    Items below waist level are considered contaminated.

    Prepare sterile field as close to the time of procedure as possible.

    Waist high, dry clean surface

    Place package on waist-high, dry, clean surface

    3. Remove the outside sterile packaging and discard. This allows more space to set up a sterile field.
    4. Grab the outer surface’s outermost tip (corner of folded drape) and open the flap away from you. The one-inch border on the sterile field is considered non-sterile. Make sure your arm is not over the sterile field.

    The inside of the sterile packaging is your sterile drape.

    Stand away from your sterile field when opening sterile packaging.

    Opening first flap

    Open first flap

    5. Grab the side flaps and open outwards, and let it lie flat on the table. Touch only the one-inch border on the sterile field. Do not reach over the sterile field.
    Second flap

    Second flap

    Third flap

    Third flap

    6. Grasping the outermost corner, pull the last flap toward you, and lay it flat on the table. This step creates an open sterile field.
    Remove forceps prior to opening last flap

    Remove forceps prior to opening last flap

    Open last flap towards you

    Open last flap towards you

    7. Using sterile forceps, rearrange sterile equipment on the sterile field in order of usage. This step saves time for completing sterile procedure; it also limits the amount of time the sterile field is exposed to air.
    Book pictures 2015 713

    Arrange sterile items on field

    Sterile field

    Sterile field

    Adding Sterile Items to a Sterile Field 
    8. Supplies can be opened (following packaging directions), then gently dropped onto the sterile field.

     

    Gently drop items onto the sterile field or use sterile forceps to place sterile items onto the field.

    If using equipment wrapped in linen, ensure sterility by checking the tape for date and to view chemical indicator (stripes on the tape ensure sterility has been achieved).

    When using paper-wrapped items, they should be dry and free from tears. Confirm expiry date.

    Do not flip or toss objects onto the sterile field.

    Adding sterile items to sterile field

    Add sterile items to sterile field

    Adding sterile supplies

    Add sterile supplies

    9. Add solution to the sterile tray by pouring the solution carefully into the receptacle:
    • Verify solution and expiry date.
    • Open cap and place face up on non-sterile surface.
    • Hold bottle two inches above receptacle and pour the required amount slowly and without splashing.
    • If bottle is multi-use, recap and label it with the date and time of opening. Most sterile solutions are good for 24 hours.
    Do not touch the edge of the solution receptacle. Place the receptacle near the edge of the sterile field.
    Sterile solution

    Sterile solution

    Adding sterile solution to the sterile field

    Add sterile solution to the sterile field

    This ensures the sterility of the solution and the use of the correct solution.

    It also ensures the bottle of solution does not come in contact with the sterile field.

    Lastly, it verifies the type of solution required for the procedure.

    Be careful not to drip solution onto the sterile field, causing contamination. (When liquid permeates a sterile field it is called strike through.)

    Data source: ATI, 2015c; Berman & Snyder, 2016; Kennedy, 2013; Perry et al., 2014; Rothrock, 2014
    Read this Surgical Aseptic Technique and Sterile Field PDF for information about surgical asepsis and setting up a sterile field at the bedside.

    Sterile Attire in the OR

    Wearing sterile surgical attire (sterile gowns, closed gloving, and masks) and PPE is essential to keep the restricted and semi-restricted areas clean and to minimize sources of microbial transmission and contamination. It is important to minimize the patient’s exposure to the surgical team’s skin, mucous membranes, and hair by the proper application of surgical attire. An extensive list of recommendations for surgical attire can be located on the Association of periOperative Registered Nurses (AORN) website at Recommendations for surgical attire (Braswell & Spruce, 2012).

    Watch a video or demonstration to learn how to don surgical attire.
    Watch a video or demonstration to learn how to apply a sterile gown independently.
    Watch a video or demonstration to learn how to apply sterile gloves using the closed gloving method.
    Watch a video or demonstration to learn how to apply sterile gloves using the assisted gloving technique.

    Critical Thinking Exercises

    1. Name four differences between a medical hand wash with soap and water and a surgical hand scrub.
    2. When preparing a sterile field, is the first flap open toward the health care provider or away from the health care provider?
    3. Name two reasons for performing hand hygiene before and after applying sterile gloves.