Time for unused sterile setups; maintaining instrument count sheets; gowning off back tables; plants in the OR; count discrepancies

AORN Journal, August, 2004 by Carol Petersen

QUESTION: Recently, a surgeon was two hours late for his scheduled surgical procedure. Unfortunately, we were not notified of the delay before opening the sterile supplies. We do not have a formal policy dictating the length of time a sterile setup can remain open before the start of the procedure. Nursing staff members traditionally have limited the time frame for holding a sterile setup to one hour. The delayed procedure was a large reconstructive procedure involving many expensive supplies. Some nurses believed it was acceptable to hold the room for two hours so the costly supplies would not be wasted. Other nurses were adamantly opposed to holding the room for two hours and insisted the time frame should be limited to one hour. We want to do the right thing for patients and still be cost conscious. What is AORN's recommended time frame for holding a sterile setup before the start of a surgical procedure?

ANSWER: There is no specified amount of time designated during which a sterile setup can remain open and still be considered sterile. Continuous, direct observation is one of the critical factors in this issue. The potential for contamination and bacterial growth increases with the passage of time; therefore, several things should be considered when determining the appropriate amount of time to hold an open sterile setup. These considerations include but are not limited to

* the type of procedure;

* the duration of the procedure;

* the availability of staff members to monitor the setup;

* the cost of monitoring versus discarding the setup; and

* infection control practices (eg, traffic control, air exchange rates).

AORN and the Hospital Infection Control Practices Advisory Committee (HICPAC) for the Centers for Disease Control and Prevention recommend preparing sterile fields as close as possible to the time of use. The sterile field then should be maintained and directly monitored constantly before and during the procedure. (1,2)

Health care facilities can establish internal policies that limit the amount of time the sterile field remains open before the start of the surgical procedure to serve as a guideline for staff members and to provide time same level of care to all surgical patients. The policy should include constant monitoring of the open setup. The individual monitoring the setup, however, does not have to be an RN. Anyone who has been properly trained in aseptic technique and has the competency to monitor a sterile field can do this. It is not appropriate to tape the doors of time OR closed or use other means of securing the doors as an alternative to monitoring.

When the length of the delay is unknown, it may be possible to use all or part of the sterile setup for another procedure if the first patient has not entered the room. This may minimize processing costs and is preferable to discarding the entire sterile setup. If the setup is used for another procedure, that procedure must be performed in the room in which the sterile supplies were opened. Moving the opened sterile setup from one room to another could result in contamination.

QUESTION: The recent publicity regarding retained instruments or sponges has prompted a debate among surgery department staff members. Currently, we have an individualized count sheet for each instrument set. Each sheet includes a space for the instrument technician to verify that all the instruments have been returned to the sterile processing room. Additionally, we record the results of the count on the OR record. Should the individualized count sheets remain with the patient's chart or can we keep them in the department?

ANSWER: A count sheet is a helpful tool to expedite counting instruments. AORN recommends the use of preprinted, standardized count sheets that correspond with the instrument set but makes no recommendations about including the count sheet with the patient's chart. AORN's "Recommended practices for sponge, sharp, and instrument counts" states,

   Sponge, sharps, and
   instrument counts should
   be documented on the
   patient's intraoperative
   record. Documentation of
   counts should include,
   but not be limited to,
   types of counts (ie,
   sponges, sharps, instruments,
   miscellaneous
   items) and the number of
   counts; names and titles
   of personnel performing
   the counts; results of surgical
   item counts; notification
   of the surgeon;
   instruments remaining
   with the patient or
   sponges intentionally
   retained as packing;
   actions taken if count discrepancies
   occur; and
   rationale if counts are not
   performed or completed as
   dictated by policy? (3 (p233))

Some liability insurance carriers, however, may require that count sheets be included with the patient's chart. Check with your insurance carrier for specific requirements. If your carrier requires that a copy of the count sheet remain with the patient's record, your forms committee should approve the document.

QUESTION: Recently, we started using a new custom pack that contains four sterile gowns. Usually, only four gowns are needed. As a cost containment practice, staff members who scrub have started to gown off the back table to avoid opening another gown. I find this troubling and think they should gown on a separate sterile surface. Is it acceptable for the first scrub person to gown and grove off the sterile back table?