Aseptic technique; transporting sterilized items; washing instruments in the scrub sink; airway fires - Clinical Issues

AORN Journal, August, 2002 by Ramona Conner

Question: Is it acceptable aseptic technique for an unscrubbed person to help establish the sterile field? To expedite cataract procedures In our ombulatory surgery center, one surgical technologist retrieves the instruments from the flash sterilization unit and brings them to the sterile field wearing sterile gloves but no gown. This person then helps the scrub person set up the sterile field, drape the patient, and gown and glove the surgeon. We enjoy the results of decreasing set up time, do not have an Increased Infection rate or adverse outcome rate related to the practice, and would like to continue; however, some staff members question the appropriateness of this practice.

Answer: Only people who have performed a surgical hand scrub and donned a sterile gown and gloves should touch the sterile field. Conscientious hand hygiene practices and adherence to the principles of aseptic technique are cornerstones of surgical infection control practices. Skin is a major source of potential contamination of the surgical field. A surgical hand scrub should be performed and sterile gowns and gloves should be worn by anyone coming in contact with the sterile field.

One of the fundamental principles of aseptic technique is that sterile people touch only sterile items or areas. Unsterile people must not touch or reach over a sterile field. (1) Only a gowned and gloved person should help another person don a sterile gown and gloves, place sterile drapes, or prepare the sterile field. (2) Reaching over the sterile field with uncovered arms to prepare the back table, allowing the drape to fall against unsterile attire while placing sterile drapes, or gowning and gloving another person easily could result in contamination of the sterile field. AORN's "Recommended practices for maintaining a sterile field" states "Personnel within the sterile field should wear caps, masks, and sterile gowns and gloves." (3)

Surgical site infection is a major cause of patient injury, mortality, and the escalating cost of health care. In 1992, an estimated 2.6% of nearly 30 million (ie, 780,000) surgical procedures resulted in surgical site infections. Each infection was estimated to increase hospitalization by an average of seven days and add more than $3,000 in charges. (4) With the disturbing increase in antibiotic-resistant bacteria, now is the time for added vigilance in the practice of aseptic technique.

Lowering standards and taking short cuts in the practice of aseptic technique in an effort to reduce expenses or decrease turnover time may not provide any cost savings in the long run and may jeopardize the safety and health of the patient. Perioperative nurses have an ethical obligation to protect the patient's health and safety. If the scrub person needs help preparing the sterile field, gowning and gloving the surgeon, draping the patient, or performing any other activities at the sterile field, the person helping should scrub, gown, and glove according to established routine procedures.

Question: What Is the proper way to transport flash-sterilized Items from the sterilizer located in the substerile room to the OR? Our two methods of doing this are to have the scrub person retrieve the tray using towels for protection from burns or for the circulating nurse to don sterile gloves and use sterile towels to retrieve the tray. I have seen both methods used without a problem, but one of our RNs believes the circulating nurse should not retrieve the sterile tray. Our infection control officer says that we should be using closed containers designed for flash sterilization, but we do not have the budget to purchase these expensive trays. Can we continue to use the procedures we have been using, or should we submit a request to purchase closed containers?

Answer: The use of closed containers designed for flash sterilization is a safe and increasingly popular method for transporting flash sterilized items to the point of use. If closed containers are not available, however, careful use of the principles of aseptic technique can be applied to remove items safely from the sterilizer and deliver them to the sterile field.

The key is to consider carefully the ways in which a device actually might become contaminated along the route from the sterilizer to the sterile field and eliminate as many of them as possible. The circulating nurse can remove small items and single instruments from the sterilizer, but extreme care must be used to perform this difficult maneuver safely and aseptically. Large instrument trays require the circulating nurse to reach over the tray with uncovered arms, which potentially can contaminate the contents of the tray or cause a burn of the circulating nurse's hand or unprotected arm if he or she accidentally comes in contact with the hot walls of the sterilizer chamber.

In addition, to avoid a back injury, the circulating nurse must carry the heavy tray too close to his or her body. Unless the circulating nurse is in a sterile gown, the instrument tray can be contaminated by unsterile clothing. Large instrument trays are too heavy for an unsterile person to remove safely from the sterilizer.