Common Breaks in Sterile Technique: Clinical Perspectives and Perioperative Implications

Article Outline

• Abstract
• Categories of Breaks in Sterile Technique
• Common Breaks in Sterile Technique
  • Sterilization
  • Setting Up and Opening
    • Not checking sterility indicators
    • Not noticing tears in sterile packaging
    • Not recognizing soaked-through spots
    • Contaminating the sterile field, instruments, or supplies
    • Improperly delivering solutions
    • Improperly moving tables
    • Leaving sterile supplies open too long
  • Surgical Hand Antisepsis
  • Gowning
  • Gloving
  • Positioning the Patient
  • Performing the Surgical Skin Prep
  • Draping
    • Removing sticky strips
    • Contaminating the ends of sheets
    • One scrubbed person placing the drapes
    • Moving a drape
    • Passing off the suction tubing or ESU cords improperly
    • Suture, suction, or ESU active electrode falling
    • X-ray cassette draping
  • Environmental Concerns
    • Dirt on lights
    • Turbulent airflow during surgery
    • Bacterial shedding
  • Surgical Technique
    • Electrosurgery
    • Tissue retraction
    • Dissection
    • Spray, bone dust, and debris
    • Handing off specimens
    • Irrigating the surgical wound
    • Avoiding sharps injuries
• Containing the Contamination of a Break in Sterile Technique
• Corrective Action and Reporting
• Conclusion
• Examination. Continuing Education Program
  • Common Breaks in Sterile Technique: Clinical Perspectives and Perioperative Implications
    • Questions
• Learner Evaluation. Continuing Education Program
  • Common Breaks in Sterile Technique: Clinical Perspectives and Perioperative Implications
    • Objectives
    • Content
• References
• Biography
• Copyright

Abstract 

Prevention of health care-associated infections, specifically surgical site infections, is a fundamental responsibility of the perioperative team. Breaks in sterile technique can and do occur, even for the most conscientious perioperative practitioners. Surgical site infections are associated with unnecessary patient pain and suffering and increased lengths of hospital stay and health care costs. Prevention of surgical site infections, therefore, takes on great significance in today's dynamic health care environment. Key responsibilities of perioperative nurses are to recognize and correct common breaks in sterile technique that are made in preparation for and during a surgical procedure and to implement methods to prevent future occurrences.

Key words: sterile technique, aseptic technique, asepsis, surgical site infections, health care-associated infections

Preventing infections in the surgical patient is a primary responsibility of every member of the perioperative team. One of the expected outcomes for surgical intervention is that the patient is free from signs and symptoms of infection.¹ Health care-associated infection (ie, an infection that a patient acquires during the course of receiving treatment for other conditions in a health care setting) is one of the top 10 leading causes of death in the United States today.² In a recent update, the Centers for Disease Control and Prevention estimated that health care-associated infections account for approximately 1.7 million infections and 99,000 associated deaths each year in US hospitals alone; of these infections, 22% are surgical site infections (SSIs).³

The economic burden of SSIs is significant. de Lissovoy et al,⁴ using data from the 2005 Healthcare Cost and Utilization Project National Inpatient Sample, identified SSIs in hospital discharge records for seven categories of surgical procedures performed:

The primary study outcomes were the rate of SSI by surgical procedure category and the effect of SSI on hospital length of stay and cost. The researchers identified 6,891 cases of SSI among the 723,490 surgical hospitalizations in the sample (ie, 1%). On average, an SSI increased length of stay by 9.7 days and increased costs by $20,842 per admission. The researchers then projected these results to the national level. National estimates of SSI would result in an additional 406,730 hospital days and hospital costs would exceed $900 million. An additional 91,613 patient readmissions for treating the SSIs would account for an estimated 521,933 extra days of care at a cost of approximately $674.4 million.⁴

For health care facilities, the escalating costs of treating SSIs were further affected in July 2008 when the Centers for Medicare & Medicaid Services announced new payment and coverage policies.⁵ A final acute care inpatient prospective payment system rule that updated Medicare payments to hospitals for fiscal year 2009 provided additional incentives for hospitals to improve the quality of care provided to patients with Medicare by including payment provisions to reduce preventable medical errors that occur in hospitals. If a condition is not present on admission but is subsequently acquired during the hospital stay, Medicare will no longer pay the additional cost of the hospitalization; furthermore, the patient is not responsible for the additional cost. Initially, hospitals were not reimbursed for infections associated with vascular catheters and coronary artery bypass graft surgery. As of October 1, 2008, hospitals are no longer reimbursed for SSIs after select elective procedures, including certain orthopedic surgeries and bariatric surgeries.⁵ The 2009 Joint Commission National Patient Safety Goals also include requirements for reducing the risk of health care-associated infections, specifically SSIs, and state that best practices for preventing SSIs should be implemented.⁶

The sources of surgical site microbial contamination may be either resident flora (ie, endogenous microorganisms) or transient flora (ie, exogenous microorganisms). Resident flora are bacteria or microorganisms considered to be permanent residents of the skin and are not readily removed by hand washing.⁷ Transient flora are bacteria or microorganisms that colonize the superficial layers of the skin and are more easily removed by hand washing or use of a hand rub agent.⁷ Transient flora are easily transmitted to hands from patients and inanimate surfaces. Microbial contamination of the surgical site can cause an SSI. The risk of an SSI increases with the dose of bacterial contamination and the virulence of the bacteria.⁸

One potential cause of exogenous microbial contamination in the OR is a break in sterile technique. A key responsibility of perioperative nurses is to recognize and correct common breaks in sterile technique that are made in preparation for and during a surgical procedure and to implement methods to prevent future occurrences.

Back to Article Outline

Categories of Breaks in Sterile Technique 

Breaks in sterile technique can be divided into four types:

Although quantifying type 4 breaks is not possible because they go unrecognized, it is intuitive to believe that some unrecognized breaks in sterile technique must occur.

The list of recognized breaks is long; theoretically, it is possible to break sterile technique in an infinite number of ways. Certain breaks in sterile technique, however, occur repeatedly, such as stabbing oneself with a needle and thus potentially exposing oneself to bloodborne pathogens, having the suction or electrosurgical unit (ESU) active electrode fall over the side of the OR bed, or brushing one's gown against an unsterile surface. Consider a classic example—the hole in the glove. If recognized immediately (ie, a type 1 break), containment (ie, solving the disruption of the sterile field and returning it to its former, uncontaminated state) is possible. If a needle was the culprit, the scrub person would pass the needle off the sterile field in its needle holder, the circulating nurse would remove the scrubbed person's glove, and the scrubbed person would don another glove.

With the passage of time, the problem becomes more complex (ie, a type 2 break). Suppose that the individual has set the contaminated needle on a Mayo stand containing other instruments. For absolute containment to be achieved with a type 2 break, the entire Mayo stand must be taken down and all of the instruments resterilized or new ones obtained, which may or may not be practical or possible. Invariably, the team pauses to determine what else has been contaminated. In these situations, the team does its best to cope with the contamination, but containment may not be possible (eg, during emergent surgery, for an unstable patient).

In a type 3 break, a scrubbed team member looks down and sees a hole in his or her glove. The individual does not know where or when the hole occurred and cannot say whether anything else has been contaminated. Potentially everything, including the incision, could have been contaminated. This is an example of a break in sterile technique that cannot be contained because this would require starting over completely: irrigating the incision with antibiotic solution, reprepping, redraping, and beginning again with all new instruments. Typically, this approach is not practical because the surgical procedure has started and time is of the essence, not just for cost reasons but for the patient's safety as well. The team has noticed the unintended contamination, but it would not be in the patient's best interest to start over. A better option for the patient might be to simply remove and replace any obviously contaminated items and supplies (eg, punctured gloves) and administer prophylactic antibiotics.

Back to Article Outline

Common Breaks in Sterile Technique 

Common breaks in sterile technique include difficulties encountered with sterilization, setting up and opening the sterile field, scrubbing and drying hands, gowning, gloving, positioning, prepping, draping, the OR environment, and surgical technique. Breaks in sterile technique can and do occur, even for the best and most conscientious perioperative practitioners.

Sterilization 

Preparation for a surgical procedure actually starts in the central processing department. Without sterilized instruments, there can be no sterile technique. Elaborate mechanisms, often only vaguely known to surgeons, are used to ensure quality control in the central processing department. Steam sterilization requires specific steam chamber temperatures and appropriate exposure times, and all parameters must be monitored regularly. Confirmation of sterilization parameters when using other methods (eg, low-temperature hydrogen peroxide gas plasma, ethylene oxide, ozone) may be more complex compared with steam sterilization.

There are numerous points in the decontamination and sterilization process where problems can occur. Despite advances in technology, disposable drapes and packaging remain water resistant rather than waterproof. Wet spots may occur from condensed steam that has soaked through a sterile package. These wet spots may wick contamination into the package. Perioperative personnel may not check sterility indicator tapes as required. These tapes turn a distinctive color and pattern when a defined level of exposure is reached. Knowledge is critical in the sterilization process. For instance, sterilization tape cannot be used again after it has gone through a sterilization cycle because it will have turned color, thus giving the impression that the item has been processed through a sterilization cycle when in fact it has not. Small holes or punctures may occur in the packaging that perioperative personnel may not notice even when they check the item. To ensure that items used in the sterile field are sterile, perioperative personnel preparing an OR for a procedure must inspect all items immediately before they are presented to the sterile field for

The item should not be used if any of these problems are identified during the inspection process.

Setting Up and Opening 

Assuming that the instruments are properly sterilized, the circulating nurse, scrub person, and other members of the perioperative team set up and open the instruments and supplies for the procedure. This process, although routine, may be fraught with opportunities for breaking sterile technique. The steps for preparing a sterile field require concentration and should never be hurried. All items introduced to the sterile field should be opened, dispensed, and transferred by methods that maintain both their sterility and integrity.⁹ The circulating nurse and scrub person are well versed in setting up and preparing a sterile field; they do this many times a day. In fact, they do it so often, it can become routine, and by sheer volume, some errors may seem inevitable.

Not checking sterility indicators 

All sterilized packages, regardless of size, should have sterility indicators on and in them. The color change is very easy to recognize. Overlooking this is very uncommon but can occur. The indicator should be visually inspected immediately to verify the appropriate color change for the selected sterilization process.⁹

Not noticing tears in sterile packaging 

Recognizing holes or tears in sterile packaging may not be as easy as it sounds. Metal trays may tear their covers at corners, and it is time consuming to examine them all. Small holes may be missed, especially when the scrub person and circulating nurse are hurrying. All items presented to the sterile field should be inspected immediately before presentation.

Not recognizing soaked-through spots 

Most sterile packages are wrapped in water-resistant packaging material. Waterproof packaging material (ie, plastic) does not tolerate heat well. It is possible to have questionable wet spots in the packaging material. If there is any possibility that moisture is present, the items should be considered unsterile, should not be used, and should be returned for reprocessing.

Contaminating the sterile field, instruments, or supplies 

Perioperative textbooks emphasize this caveat: unsterile individuals must not touch or reach over a sterile field or allow any unsterile item to contaminate the field.¹⁰ All items should be delivered to the sterile field in a manner that prevents nonsterile objects or personnel from extending over the sterile field.⁹ If care is not taken, it is possible to touch the inside of a package while opening it. It is also possible for the outside of the package to touch the inside, sterile portion. Use of covered metal containers has helped minimize chances for contamination. The instruments are lifted out of the containers by recessed metal trays with hinged handles. A good rule when handing an item directly to a scrubbed person is to have both the opener (eg, circulating nurse) and receiver (eg, scrub person) concentrate on the act together, watching carefully to observe for inadvertent breaks in technique.

Charnley¹¹ recommends using as few sets of instruments as possible to minimize the risk of contamination when opening a sterile field and to avoid clutter, which increases the chance of breaking sterile technique. Few surgeons have followed his example.¹¹ Some larger procedures require opening of a large number of trays, many of which are only needed for an instrument or two. Some facilities have worked to consolidate sets and supply packaging. Some instruments can be packaged individually to minimize the number of sets being opened for one or two instruments, but this still requires opening numerous individual instruments. Obtaining consensus among surgeons regarding what is needed in an instrument set or procedure pack is not always easy. Having preassembled supply packs saves time in picking the case and opening for the procedure and minimizes the opportunity for contamination. If the contents of the pack are not selected carefully, however, supplies can be wasted.

Improperly delivering solutions 

Delivering solutions to the sterile field may not be easy. When solutions, such as normal saline irrigation, must be dispensed onto the sterile field, the scrub person should place the labeled solution receptacle near the edge of the sterile field to permit the circulating nurse to pour the solution without contaminating the sterile field, or the scrub person should hold the labeled solution receptacle while the circulating nurse pours the entire contents of the container slowly to avoid splashing.⁹ Any remaining fluid should be discarded because the edge of the container is considered contaminated after the contents have been poured.

Medications should be delivered to the sterile field in an aseptic manner. The circulating nurse should not remove the vial stoppers to pour the medication into a labeled receptacle on the sterile field. For example, bupivacaine hydrochloride can come in a flip-top bottle. It is easy to contaminate the medication if the circulating nurse attempts to flip off the top with a fingertip and pour the solution from the other side. This technique risks the finger touching the edge of the bottle and the solution becoming contaminated as it is poured over the edge. Instead, the circulating nurse should use a sterile transfer device (eg, sterile vial spike, filter straw, plastic catheter).⁹

Improperly moving tables 

The risk exists that unsterile scrub attire can touch sterile drapes on tables and stands. Tables are sterile only at table level; only the top surface of a draped table is considered sterile.¹⁰ The circulating nurse must always move draped tables by grasping them well below the sterile drape. The scrub person should not move tables by grabbing around the top and underside of the tabletop with gloved hands. If the scrub person needs to move the table, he or she should push on the top of the table with gloved hands.

Leaving sterile supplies open too long 

Situations have occurred in which the instruments and supplies for a procedure have been opened and set up but the procedure is delayed, for example, because of the need to repeat a test or because the surgeon is unavoidably delayed. Whatever the reason, instruments and supplies are left out. In the past, sterile drapes were used to cover tables in these situations, but this practice has been abandoned because of the risk of contaminating the sterile items when placing and removing the sterile drape. In particular, removing the drape could result in a part of the drape that was below the table level being drawn above the table level or air currents drawing microorganisms from a nonsterile area to the sterile field.⁹ The current recommendation, therefore, is that sterile fields should not be covered;⁹ this raises the question, how long is it safe to leave the setup open? There is no specified amount of time that a setup can remain open and unused and still be considered sterile; the sterility of an open field is event related, and the field requires continuous visual observation.⁹

Surgical Hand Antisepsis 

“The skin can never be rendered sterile, but it can be made surgically clean by reducing the number of microorganisms.”^10(p79) Transient and some resident bacteria can be removed by effective surgical hand antisepsis. Anecdotal evidence suggests that enforcement of hand antisepsis rules may be lax in some surgical suites. Perioperative personnel are on an honor system, but perceived lack of time may adversely affect individual hand antisepsis practices. The facility should implement a hand antisepsis policy that includes

A three- to five-minute, standardized, anatomic, timed method⁷ for surgical hand antisepsis using an antimicrobial scrub solution that has met US Food and Drug Administration requirements for surgical hand antisepsis should be used to reduce microbial bioburden.⁷ Alcohol-based solutions (eg, alcohol-based surgical hand rubs) reduce bacterial count on hands more rapidly than do antimicrobial soaps or detergents. A standardized protocol for their use should follow the manufacturer's written instructions.⁷

When drying scrubbed hands and forearms, the top half of the towel is held securely with one hand and the opposite fingers and hand are thoroughly blotted dry before moving to the forearm; the lower end of the towel is then grasped with the dried hand and the same procedure is used to dry the second hand and forearm.¹⁰ The towel should not touch the scrub suit.

Gowning 

Gowning should occur on a separate table. The front of a sterile gown is considered sterile from the chest to the level of the sterile field.⁹ Therefore, only the inner side of a sterile gown can be touched when picking it up, usually at the neck. As a result of the way gowns are folded, a fingertip inadvertently can graze the front of the gown if the fingertip strays from the inside of the gown. Another aseptic break in gowning another person can occur when a scrub person grazes the surgeon's shoulders with the gloved fingertips as the gown is “cinched up.”

The white cuffs at the wrists of the gown are made of soft, permeable material that is not waterproof. The sleeve cuffs are considered unsterile when the scrubbed person's hands pass beyond the cuff and also because they tend to collect moisture and are not an effective bacterial barrier.⁹, ¹⁰ If the surgical gloves do not cover the cuffs, contamination may occur from inside out or from outside in. This is especially dangerous when the clinician's hands are deep in the patient's body, such as in the abdominal cavity.

Gloving 

There are three methods of gloving: open, closed, and assisted.¹⁰ The open method is fraught with potential for aseptic breaks, for obvious reasons. It is difficult not to touch any part of the skin to the sterile glove exterior; therefore, this method should be performed with care. It is not acceptable to tolerate poor open gloving technique; rather, it is better to start over. The open method is used for many minor procedures, from emergency department suturing to administering spinal anesthesia, but it can be used during a surgical procedure when the scrub person discovers a hole in the glove. He or she may change the glove by having the circulating nurse pull it off and then proceed to put on a new glove using the open method. It would be better to be regloved using the assisted method, but the scrub person may not wish to or be able to disturb the team.

The closed method is better, but not perfect. The scrub person uses the cuff of the gown or the gown itself to perform a modified open technique. When the scrubbed person's hands protrude through the sleeve cuffs, the cuffs should be considered contaminated.⁹

The assisted method is the usual way to glove the surgeon and his or her assistants. Although it is the safest, it also can be complex. As the scrub person spreads the glove apart, the surgeon's skin or hair may touch the glove exterior as the hand enters the glove. The key is for the scrub person to spread the glove as widely and as circumferentially as possible. Neither the scrub person nor the surgeon should hesitate to mention if a possible break in technique is suspected.

Sterile gloves that become contaminated in any manner should be changed as soon as possible.⁹ Scrubbed personnel should inspect gloves for integrity after donning them.⁹ When a hole in a glove is identified, the surgical team should attempt to isolate all equipment suspected of being contaminated. Irrigating the incision and applying additional drapes should be considered.

Double gloving is increasingly popular. Many surgeons wear two gloves to apply the drapes, discard the outer pair of gloves after draping the surgical site but before beginning the procedure, and then don new outer gloves after draping. Tactile sensation may be diminished, but the trade-off is that a small hole in the outer glove may not penetrate through the inner glove. The Centers for Disease Control and Prevention, the American College of Surgeons, and the American Academy of Orthopaedic Surgeons support the practice of double gloving during invasive procedures.⁸, ¹², ¹³

Another possible break can occur when turning the gown after gowning and gloving. The scrub person may turn his or her gown with another scrubbed person or turn it with a nonscrubbed person (eg, the circulating nurse). If the scrub person turns with a nonscrubbed person, the scrub person hands the tie for turning to the nonscrubbed person; care must be taken to prevent the tie from striking the nonscrubbed person's bare hand as it traverses the cardboard tab. This break in technique may go unnoticed, especially if it occurs quickly or if staff members are hurrying. One solution is to insist on turning with a scrubbed person; however, often this is not possible for the scrub person because no one else is scrubbed in at the time.

Positioning the Patient 

Some of the positions required for optimal surgical exposure may make draping the patient awkward. Typically, this is not a problem with abdominal surgery or other procedures performed in the supine position. Positioning should always be accomplished with draping in mind; any awkwardness in draping increases the chance of a break in technique. The portion of the sterile surgical drape that establishes the sterile field should not be moved after it has been placed; moving the sterile drape may compromise the sterility of the field.⁹

Performing the Surgical Skin Prep 

Skin cannot be sterilized; it is merely disinfected. The goal of performing a surgical skin prep is to reduce the risk of postoperative SSIs by

In the past, vigorous washing was recommended, and clinicians believed that the longer the skin was prepped (eg, 10 minutes), the better. It was later theorized, however, that long, vigorous washing could actually increase dangerous flora by bringing to the surface deeper bacteria lurking in the dermis or could cause damage to the patient's skin; therefore, rapid, gentle washing might be best.

The basic tenets of prepping are to

A common error is to not follow this principle rigorously. Another error is for the circulating nurse to don the prep gloves and pick up the unscrubbed extremity; when prepping the extremity, the circulating nurse moves his or her hand from the unscrubbed section (eg, ankle) to a scrubbed section (eg, lower calf). This action breaks technique by contaminating the already scrubbed area. Using positioning devices and draping them appropriately during the scrub process can prevent this problem.

Draping 

Draping is very important for minimizing the chance of breaks in sterile technique. The principle is simple: sterile drapes are used to establish a sterile field in which to operate.⁹ During surgical site draping, the potential for complications abounds. When clinicians are moving in the sterile field, their gowns can billow, even when the gowns are turned and tied. All personnel moving in or around a sterile field should do so in a manner that maintains the sterile field without contaminating it. Nonscrubbed personnel should maintain a distance of at least 12 inches from all parts of and people in the sterile field.⁹

The sterile area of the gown front extends from the chest to the level of the sterile field.⁹ Without proper care and attention to detail, it is easy to contaminate the front of the gown when draping the sterile field. For example, when placing a rolled towel around an extremity, the clinician leans forward and it is easy to contaminate the front of the gown on the arm board or OR bed. This may go unrecognized because the clinician is concentrating on applying the rolled towel. Another common error is to touch the prepped skin or tourniquet when rolling the towel. The rolled towel concept was classically used to establish a proximal border. A stockinette was then rolled up to it and the cuff of the stockinette was used to secure half-sheets with nonperforating clamps. This technique is being used less because of the availability of disposable, waterproof, adhesive plastic sheets, applied circumferentially around the extremity. In situations where disposable drapes may not be available, the stockinette method is still useful.

Removing sticky strips 

The disposable adhesive sheets have sticky strips that must be pulled off. The ends of these strips can be difficult to control, so they may become contaminated and thus may contaminate drapes or gowns.

Contaminating the ends of sheets 

When circumferentially wrapping plastic sheets around an extremity, great care must be taken to prevent the ends of the sheets from becoming contaminated and falling back onto the field. This can be remedied by first covering most of the table and arm boards with sterile half-sheets. Then, after a scrubbed team member places the extremity drape, another scrubbed person inserts the extremity through the incise hole and the rest of the extremity drape is placed over previous drapes.

One scrubbed person placing the drapes 

Even with the help of the circulating nurse, it is difficult for one scrubbed person to place the drapes without breaking sterile technique. If at all possible, draping should be a team task.

Moving a drape 

During a procedure, it may seem convenient to “adjust” the drapes for additional exposure. This should not be done. The portion of the surgical drape that creates the sterile field should not be shifted or moved after it is positioned; doing so can compromise the sterility of the field.⁹

Passing off the suction tubing or ESU cords improperly 

A common error is for the suction tubing or ESU cord to be passed off in such a way that not enough length is left for use on the sterile field. It may be human nature to tug on the cords to get more play, but this should not be done. When a sterile item extends beyond the sterile boundary, it is considered contaminated and should not be pulled onto the sterile field.¹⁰ If there is any doubt about the sterility of an item, the item should be replaced.

Suture, suction, or ESU active electrode falling 

Based on this same principle, if any item falls beyond the sterile field, it must be considered contaminated and, therefore, cannot be brought back up onto the sterile field.¹⁰ Although how far off the sterile field is considered “below the field” may bring up the politics of containment, the prudent course of action is to remove the item carefully from the sterile field without causing further contamination. A nonscrubbed surgical team member then places it in a designated receptacle.

X-ray cassette draping 

Draping an x-ray cassette with a sterile plastic cover can be the cause of a break in technique. Since the advent of portable fluoroscopy (ie, C-arm), two common errors are possible: neglecting to drape the C-arm and contaminating the drapes when swinging the C-arm for a lateral image. To reduce the chance of a break in technique, nonsterile equipment should be covered with sterile barrier materials before being introduced to or brought over a sterile field; sterile barrier material should be applied to the portion of any nonsterile equipment that will be positioned immediately adjacent to the sterile field.⁹ Furthermore, staff members from the radiology department should receive instruction regarding the principles of aseptic technique to help reduce the chance of a break in technique (eg, proper cleaning of equipment before bringing it into the OR from outside the restricted area of the surgical suite).¹⁵

Environmental Concerns 

Numerous environmental concerns should be considered to ensure compliance with aseptic technique. Some environmental concerns include dirt falling from overhead lights, turbulent airflow during surgery, and bacterial shedding from personnel.

Dirt on lights 

Dirt from overhead lights falling into the incision may be inevitable, unless sterile lighting is invented. Therefore, lights always should be meticulously damp dusted before the first scheduled surgical procedure of the day and after each procedure with a facility-approved hospital detergent/disinfectant and water.¹⁵

Turbulent airflow during surgery 

Turbulent airflow in the OR can increase the patient's risk of acquiring an SSI. In theory, talking can accelerate the eventual contamination of the mask. Talking, as well as the number of people present in the OR, should be kept to a minimum during procedures. An increase in the amount of talking and the number of people present can increase the number of airborne microorganisms.¹⁶

Open OR doors are conduits for potentially contaminated air. Each surgical suite should have strict rules about which doors should remain shut unless entrance or exit is required. Directional airflow, positive air pressure, and use of high-efficiency particulate air (HEPA) filters help mitigate this problem, but some older surgical suites may not have all three components. Traffic in and out of the OR should be kept to a minimum. The doors to the OR should remain closed except when personnel are entering or leaving or patients, supplies, or equipment are being moved in or out of the OR.¹⁶ The air pressure in the OR should be maintained under positive pressure with a specified number of total room air exchanges per hour depending on the area in the surgical suite.¹⁷

Frequently opening and closing doors in the OR also increases the risk of insects entering the OR. Every OR should have a protocol to handle this sort of occurrence because this can occur even when the OR suite has sealed windows or no windows at all. Flies and other insects manage to get into the surgical suite—through bay doors in the receiving area, vents to the outside, or doors opened as people enter the hospital. The principle of containment starts with covering the incision with a hand towel while efforts ensue to kill the insect or move it out of the room. One trick to minimize increased air turbulence when trying to catch a fly is to turn out all the lights except one that is away from the sterile field to lure the insect to the light. Typically, these simple measures suffice. If the problem becomes frequent, the infection control and plant operations personnel should be notified so that they can initiate an investigation. All possible entrances to the facility should be evaluated to identify potential problems (eg, the bay doors in receiving being left open). A closed-door policy in the surgical suite should be enforced.

Bacterial shedding 

Dirty skin can release microorganisms into the air. Keeping this in mind, everybody in the OR, including observers and anesthesia care providers, should cover their skin as much as is practical. In the restricted areas of the surgical suite, surgical attire and hair coverings are required.¹⁶ Nonscrubbed personnel should wear long-sleeved jackets that are buttoned or snapped closed to prevent bacterial shedding from bare arms.¹⁸

Surgical Technique 

Dead cells are a natural food source for bacteria, which cause SSIs. Furthermore, antibiotics carried in the bloodstream cannot reach necrotic tissue, because it has no blood supply. Major sources of tissue necrosis are electrosurgery, retraction, and dissection. Other concerns involving surgical technique include dealing with spray, bone dust, and debris; handing off specimens; irrigating the surgical wound; and avoiding sharps injuries.

Electrosurgery 

In 1926, William T. Bovie, MD, an American biophysicist, and Harvey Cushing, MD, a neurosurgeon, developed electrosurgical technology, thermal coagulation by electrical energy, to minimize intraoperative bleeding.¹⁹ One drawback of electrosurgery is the production of char, a by-product of thermal coagulation. If bacteria are present in the wound, the addition of charred tissue, a nutrient source for bacteria, is an invitation for the bacteria to flourish. Therefore, the scrub person should clean the active electrode tip away from the incision frequently to remove char and debris.²⁰

Electrosurgery has become indispensable in modern surgery. Some surgeons use the cutting modality of electrosurgery as a dissecting tool. The higher current slices through the tissue and coagulates at the same time, which may be preferable to using a knife. This is especially true for dissecting periosteum off bone or cutting through muscle. The char left behind in crevices created by implants, metal, cement, or allografts, however, may create a possible focus of infection because no blood supply can get to it. Bacteria can go into a state of suspended animation, protected by a coat of bioslime (ie, a coating produced by some bacteria that enables them to resist host defenses like phagocytes).²¹ Over time, the bacteria can establish colonies in dead tissue.²¹ Many such colonies can be eradicated over time, especially in a healthy person. Occasionally, however, one of the colonies may create an abscess, resulting in a deep wound infection.

This theory can offer one explanation for why infections around implants can be so chronic. Charnley believed that some painful joint replacements could be caused by a low-grade infection.²² The model for this is chronic osteomyelitis, where bacteria lie dormant in bone and produce intermittent flare-ups. Electrosurgery should be used prudently to avoid providing microorganisms in a surgical incision with char, a ready nutrient supply. When electrosurgery is used, diligent irrigation should be used to remove as much of the char as possible.

Tissue retraction 

Retractors facilitate exposure of the surgical site but can cause tissue injury and necrosis, which can produce detritus, increasing the patient's risk of infection. Even a skin hook can kill cells when used for tissue exposure. Although self-retaining retractors are very helpful for surgeons, they have drawbacks. In return for exposure, self-retaining retractors can cause tissue necrosis and, with time, cell death, especially if too much pressure is applied. In theory, releasing the blades or teeth of the retractor at periodic intervals eases the lack of blood supply to the tissues and gives the tissue a chance to recover from the pressure. Releasing the self-retaining retractor causes loss of surgical exposure, however, so frequently this practice is not possible or practical.

Dissection 

Using a variety of instruments, the surgeon begins dissection and develops tissue planes for deep exposure. The surgeon uses forceps and scissors to incise the fascia as well as identify and spread or cut the muscle. He or she may use electrosurgery to minimize muscle bleeding. The surgeon may tie, clip, or coagulate vessels. Whether the dissection is sharp (eg, scissors, knife, electrosurgery) or dull (ie, fingers, peanuts, elevators), cell death occurs.

Spray, bone dust, and debris 

Any aerosol produced during surgery should be dealt with cautiously. Particles may rise in the air, touch unsterile surfaces, and fall back in. This is especially true of bone debris when power tools are used. The classic example is the high-speed burr, which throws a spray of bone debris into the air. Power lavage also can be a culprit. Overzealous spraying can bring microorganisms back into the incision. The lights over the field are not far away and are unsterile. Spray and debris can rise to touch the surfaces and fall back. When possible, shields (eg, lavage units) should be used to prevent the aerosol from being dispersed away from the point of use.

Handing off specimens 

Specimens should be handled carefully in a manner that protects and secures the specimen and also prevents contamination of the personnel handling the specimen.²³ Typically, the scrub person hands off the specimen to the circulating nurse. It is best for the scrub person to pick up the specimen with an instrument (eg, forceps) and pass the instrument off the field with the tissue. Transferring the specimen into the specimen container with the intention of keeping the instrument presupposes that the tissue will drop neatly off of the instrument. More often, the tissue sticks to the instrument and needs to be manipulated against the side of the container, contaminating the instrument in the process. It is best practice to pass off the tissue and the instrument by placing both into the specimen container.

Irrigating the surgical wound 

Although studies have not definitively determined whether it is necessary to add antibiotics to irrigation solution, this practice may be beneficial. Irrigation rinses away dead cells, blood, and bacteria and prevents drying of the tissues. Bacteria, invisible to the naked eye, may be settling in the wound throughout the procedure. Irrigation is important during the procedure, as well as during closure. Pausing to irrigate at frequent intervals may help reduce the patient's risk of acquiring an SSI. This is particularly easy to accomplish when an interruption in surgery occurs (eg, taking an x-ray, preparing an implant).

Avoiding sharps injuries 

The Occupational Safety and Health Administration requires health care facilities to protect their workers from exposures to bloodborne pathogens and to have a written exposure control plan.²⁴ The Occupational Safety and Health Administration bloodborne pathogen standard requires protection through the use of universal precautions, engineering controls, work practice controls, organizational controls, and communication. It also mandates that employers maintain a log of injuries from contaminated sharps.²⁵ Personnel should report all exposure incidents (eg, needle sticks and other blood exposures) to the health care organization according to the facility policy; prompt reporting allows employers to provide timely and confidential postexposure evaluation, intervention, and testing and appropriate prophylaxis.²⁶

One drawback of the bloodborne pathogen standard is that because the protocol is time consuming, some employees may be reluctant to admit that a needle stick occurred. There are the problematic issues of paperwork, time, and unwanted injections. “Mini” sticks, where there is a question as to whether or not the needle really penetrated, are often the result of using a curved needle. When the problem is announced, the team should freeze, dispose of the needle and suture in a manner that maintains the surgical count, and inspect the glove and affected hand. The incident must be reported and protocols followed.

Bone sticks may accompany attempts to reduce fracture fragments with one's gloved fingers. If at all possible, instruments should be used to manipulate the fragments, although there will always be a situation during which the surgeon wants or needs to hold a fragment of bone in place manually. Bone tamps should always be used when tamping bone grafts down rather than doing it manually with the fingers.

Back to Article Outline

Containing the Contamination of a Break in Sterile Technique 

What should be done if a break in technique has occurred but time has elapsed before the break is recognized (ie, a type 2 or type 3 break)? How can the extent of contamination be determined? How can the contamination be isolated and contained? One recommendation is to institute the use of a watchword, whereupon all surgical team members freeze. Team members would then communicate the dilemma, discuss options, and identify and implement a solution so the procedure can proceed. One facility implemented the FCC plan: freeze, communicate, and contain, using the watchword “Boppo.” The importance of freezing is that when a break is discovered, no one moves, which keeps the contamination from spreading. Communication is crucial at this point. Different options for resolution may be voiced, and all opinions should be considered valid. The circulating nurse, scrub person, surgeon, assistants, and anesthesia care provider all may have valuable input. The team must reach a consensus on how to proceed.

Consider the situation of a knife blade penetrating a sterile drape. The first person to notice the problem clearly says, “Boppo,” and all team members freeze while the situation is assessed and options are discussed. One team member might question whether the area is contaminated because the knife blade was sterile before it went through the sterile drape. One team member might want to investigate to determine how many layers of sterile drapes were penetrated. How can this be accomplished safely and efficiently? The team might discuss this option but decide that in the effort to determine the level of contamination, drapes would have to be pulled up, which would further spread the contamination. Another team member might suggest using scissors to cut a wide patch out of the drape to see the extent of the contamination. One team member might question whether antibiotic prophylaxis is advisable. In the end, the team decides that the basic principle of sterile technique applies: if in doubt, treat it as contaminated. Cooperatively, the team decides that the knife blade and handle should be discarded immediately, not placed on the Mayo stand or back table, and the hole should be covered with a new, impermeable drape. The team determines that additional antibiotics are not required because an antibiotic was administered 15 minutes before the initial incision. At this point, the surgeon determines whether it is safe to continue surgery.

Occasionally, heated disagreements may occur regarding how to handle a break in technique. The attending surgeon has the ultimate responsibility for determining when to resume the procedure, but what if the circulating nurse, scrub person, or an assistant (eg, RN first assistant) disagrees? The dictatorial ways of the old-time surgeons and “captain of the ship” philosophy have largely been modified by new policies and changes in the workplace environment. This has given rise to a healthier atmosphere in which there is more of a team approach.

Back to Article Outline

Corrective Action and Reporting 

When a break in sterile technique occurs and cannot be rectified, appropriate corrective actions should be implemented immediately unless doing so would compromise the patient's safety. If the patient's safety would be at risk, the break should be corrected as soon as it is safe to do so.⁹ In these situations, the policies and procedures of the health care facility should specify how to report the break in sterile technique to appropriate risk management personnel and how to revise the wound classification after a break in sterile technique occurs.⁹

Back to Article Outline

Conclusion 

For the surgical patient, acquiring an SSI leads to needless discomfort and treatments, as well as an increased hospital stay. For the health care facility, an SSI also means additional cost. A break in sterile technique is one potential cause of an SSI. As patient advocates, all members of the perioperative team must

With this knowledge and skill, each member of the perioperative team can proactively reduce the adverse effects of a break in sterile technique and, consequently, an SSI, ultimately improving the patient's surgical outcome.

Back to Article Outline

Examination. Continuing Education Program 

Common Breaks in Sterile Technique: Clinical Perspectives and Perioperative Implications 

PURPOSE/GOAL

To educate perioperative nurses about identifying and preventing common breaks in sterile technique.

OBJECTIVES

The Examination and Learner Evaluation are printed here for your convenience. To receive continuing education credit, you must complete the Examination and Learner Evaluation online at http://www.aorn.org/CE.

Questions 

Back to Article Outline

Learner Evaluation. Continuing Education Program 

Common Breaks in Sterile Technique: Clinical Perspectives and Perioperative Implications 

This evaluation is used to determine the extent to which this continuing education program met your learning needs. Rate the items as described below.

Objectives 

To what extent were the following objectives of this continuing education program achieved?

Content 

Back to Article Outline

References 

1. Petersen C. Perioperative Nursing Data Set: The Perioperative Nursing Vocabulary. 3rd ed. Denver, CO: AORN, Inc. In press.
   • View In Article
2. Centers for Disease Control and Prevention. Health-care associated infections (HAIs). http://www.cdc.gov/ncidod/dhqp/healthdis.htmlAccessed November 9, 2009
   • View In Article
3. Centers for Disease Control and Prevention. Estimates of healthcare-associated infections. http://www.cdc.gov/ncidod/dhqp/hai.htmlAccessed November 9, 2009
   • View In Article
4. de Lissovoy G, Fraeman K, Hutchins V, Murphy D, Song D, Vaught BB. Surgical site infection: incidence and impact on hospital utilization and treatment costs. Am J Infect Control. 2009;37(5):387–397
   • View In Article
   • Abstract
   • Full Text
   • Full-Text PDF (201 KB)
   • CrossRef
5. Medicare and Medicaid move aggressively to encourage greater patient safety in hospitals and reduce never events. [news release] Baltimore, MD: Centers for Medicare & Medicaid Services; July 31, 2008;http://www.cms.hhs.gov/apps/media/press/release.asp?Counter=3219&intNumPerPage=10&checkDate=&checkKey=&srchType=1&numDays=3500&srchOpt=0&srchData=&keywordType=All&chkNewsType=1%2C+2%2C+3%2C+4%2C+5&intPage=&showAll=&pYear=&year=&desc=false&cboOrder=dateAccessed November 9, 2009
   • View In Article
6. The Joint Commission. Accreditation Program: Hospital National Patient Safety Goals. http://www.jointcommission.org/NR/rdonlyres/31666E86-E7F4-423E-9BE8-F05BD1CB0AA8/0/09_NPSG_HAP.pdfAccessed November 9, 2009
   • View In Article
7. Recommended practices for hand hygiene in the perioperative setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2010;p. 75–89
   • View In Article
8. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999 (Hospital Infection Control Practices Advisory Committee). Infect Control Hosp Epidemiol. 1999;20(4):250–278
   • View In Article
   • MEDLINE
   • CrossRef
9. Recommended practices for maintaining a sterile field. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2010;p. 91–99
   • View In Article
10. Nicolette LH. Infection prevention and control in the perioperative setting. In:  Rothrock JC editors. Alexander's Care of the Patient in Surgery. 13th ed.. St Louis, MO: Mosby Elsevier; 2007;p. 75
    • View In Article
11. Charnley J. Surgical infection in orthopaedic surgery, Wrightington's “glass-house”. [in French] Rev Chir Orthop Reparatrice Appar Mot. 1969;55(3):231–233
    • View In Article
    • MEDLINE
12. American College of Surgeons. [ST-58] Statement on sharps safety. http://www.facs.org/fellows_info/statements/st-58.htmlAccessed December 7, 2009
    • View In Article
13. American Academy of Orthopedic Surgeons. Information statement: preventing the transmission if bloodborne pathogens. http://www.aaos.org/about/papers/advistmt/1018.aspAccessed December 7, 2009
    • View In Article
14. Recommended practices for preoperative patient skin antisepsis. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2010;p. 351–369
    • View In Article
15. Recommended practices for environmental cleaning in the perioperative setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2010;p. 241–255
    • View In Article
16. Recommended practices for traffic patterns in the perioperative practice setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2010;p. 101–104
    • View In Article
17. American Institute of Architects Academy of Architecture for Health. Guidelines for Design and Construction of Hospital and Health Care Facilities. In: Washington, DC: American Institute of Architects Press; 2006;p. 130–131
    • View In Article
18. Recommended practices for surgical attire. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2010;p. 67–73
    • View In Article
19. Ball KA. Surgical modalities. In:  Rothrock JC editors. Alexander's Care of the Patient in Surgery. 13th ed.. St Louis, MO: Mosby Elsevier; 2007;p. 219
    • View In Article
20. Recommended practices for electrosurgery. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2010;p. 105–125
    • View In Article
21. D'Ambrosio R, Masier R. Orthopaedic Infections. In: Thorofore, NJ: Slack, Inc; 1989;p. 53–55
    • View In Article
22. Charnley J. Acrylic Cement in Orthopaedic Surgery. In: Edinburgh, Scotland: Churchill Livingstone; 1970;p. 42
    • View In Article
23. Recommended practices for the care and handling of specimens in the perioperative environment. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2010;p. 269–276
    • View In Article
24. AORN guidance statement: Sharps injury prevention in the perioperative setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2010;p. 697–702
    • View In Article
25. Occupational Safety and Health Administration. Standards – 29 CFR. Bloodborne pathogens. – 1910.1030. http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=10051Accessed November 9, 2009
    • View In Article
26. Recommended practices for prevention of transmissible infections in the perioperative practice setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2010;p. 277–287
    • View In Article

• 1 Hidron AI, Edwards JR, Patel J, et al; National Healthcare Safety Network Team. NHSN update: antimicrobial-resistant pathogens associated with healthcare-associated infections: annual summary of data reported to the National Healthcare Safety Network at the Centers for Disease Control and Prevention, 2006-2007. Infect Control Hosp Epidemiol. 2008;29(11):996-1011.
• 1 Mews P. Establish and maintain the sterile field. In: Phippen M, Ulmer B, Wells M, eds. Competency for Safe Patient Care During Operative and Invasive Procedures. Denver, CO: Competency and Credentialing Institute; 2009:272.
• 2 Recommended practices for selection and use of surgical gowns and drapes. Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2010:127-131.
• 3 ANSI/AAMI PB70 Liquid Barrier Performance and Classification of Protective Apparel and Drapes Intended for Use in Health Care Facilities. Arlington, VA: Association for the Advancement of Medical Instrumentation; 2003.