Sterile package checks; aseptic technique; floor drains; orthopedic room air exchanges; active electrode insulation

AORN Journal, Sept, 2004 by Ramona Conner

QUESTION: I work in an ambulatory surgery center in which only ophthalmic procedures are performed. When custom surgical eye packs arrive at our facility, we remove them from the box and check the plastic wrapping in which the packs arrive for holes before placing them on storage shelves. This is done at the end of the surgery day when time allows. Every so often, we do find holes, and usually, they are very small. I then call the company, report a hole in the pack, and send it back to the company for a credit or a replacement.

This is the only OR environment in which I have worked, so I assumed that checking the packs for integrity in advance was the standard of practice in all ORs. One of the nurses with whom I work, however, has worked in acute care facility ORs. She says that she never checked packs for holes ahead of time. Instead, she checked the pack for any obvious holes immediately before opening it. There is not time before surgery to check as carefully as we do, so she probably would have missed tiny holes.

I was taught that if there is a hole in the plastic wrapping in which the sterile pack is contained, that pack is no longer sterile, regardless of the size of the hole. Do other ORs check sterile packs for holes before they are opened? If so, does it matter what size the hole is? What is the standard of practice for checking sterile packs for holes before opening them on the back table?

ANSWER: The integrity of all sterile packages should be checked immediately before they are opened. If there is any visible damage to the outer wrap, no matter how small or minor, the sterility of the package contents is questionable. The package should not be considered sterile if there is any doubt about the sterility of the package contents. AORN's "Recommended practices for maintaining a sterile field" states,

   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. (1)

Although sterile package integrity should be checked immediately before use, the practice of performing an additional check ahead of time is an added safety measure that also may save time and money. Checking sterile package integrity upon delivery to the department may allow sufficient time to obtain replacement supplies and facilitate return of the product to the manufacturer for credit without creating any delays in patient care or the surgery schedule. Care should be taken to remove damaged packages from the supply chain to prevent accidental use. Even if packages are checked when they are received in the facility, however, each sterile package should be inspected again for integrity immediately before it is opened onto the sterile field.

QUESTION: Are there variations of accepted room cleaning and sterile technique standards for different areas of surgery? In other words, are there different guidelines for procedures performed in the OR versus procedures performed in a minor room, procedure room, cardiac catheterization laboratory, invasive radiology suite, or gastrointestinal endoscopy suite?

ANSWER: There are no "major" and "minor" procedures when it comes to aseptic technique. All surgical procedures should have sterile instruments and supplies, and surgical team members should practice careful aseptic technique for all surgical patients. It does not matter where in the facility the surgery is performed. The principles of aseptic technique should be applied to all surgical procedures.

All of the aforementioned locations should be cleaned according to AORN's "Recommended practices for environmental cleaning." (2) All patients are considered potentially infected with bloodborne and other pathogens. All surgical procedures, therefore, must be considered potentially infectious, and the same environmental cleaning procedures must be implemented in all locations in which surgical procedures are performed. Between procedures, equipment and furniture that are visibly soiled should be cleaned with an Environmental Protection Agency (EPA)-registered hospital-grade germicidal agent. Walls, doors, surgical lights, and ceilings should be spot cleaned if they are soiled with blood, tissue, or body fluids. It is only necessary to clean a 3-ft to 4-ft area around the surgical field when it is visibly soiled. It usually is not necessary to clean the entire floor after every procedure. At the end of the day's schedule when no additional procedures are planned, the room should be terminally cleaned. If the facility provides 24-hour services, a protocol should be established so that all designated areas are terminally cleaned one time during a 24-hour period.

Anesthesia equipment may be a factor in the transmission of infectious organisms. Proper cleaning, disinfection, or sterilization of this equipment may be overlooked when it is located in areas of a facility other than the OR. The same procedure for cleaning and disinfecting this critical equipment must be followed in every location in which anesthesia is administered. Anesthesia equipment should be cleaned according to AORN's "Recommended practices for cleaning and processing anesthesia equipment." (3)