Maintaining Asepsis Within a Sterile Field in Surgery

In order to advance in our knowledge of nursing practice we must keep in mind the basic information of the daily tasks that we perform which truly make a difference. One such basic but extremely important task in the perioperative setting is maintaining asepsis within a sterile field. Perioperative nursing practice is in part guided by the American Nurses Association (ANA)’s Code of Ethics. Maintaining asepsis is a fundamental skill in accepting responsibility and being accountable within this framework of ethics. The AORN Explications for Perioperative Nursing outline this framework in Appendix A of the AORN Perioperative Standards and Recommended Practices, 2008 edition.

The American Heritage Dictionary of the English Language gives us two definitions of asepsis. The first is: The state of being free of pathogenic microorganisms. A second definition that applies to surgical asepsis as well is: The process of removing pathogenic microorganisms or protecting against infection by such organisms. The state of being free of pathogenic microorganisms is truly the most accurate of the two definitions when applied to the surgical field, the second definition speaks to the process leading to asepsis..

The Association of periOperative Registered Nurses (AORN) provides guidance in maintaining a sterile field within the 2008 Perioperative Standards and Recommended Practices. “Recommended Practices (RPs) for Maintaining a Sterile Field" is the specific RP pertaining to maintaining a sterile field and asepsis. This document is intended to be a guideline for establishing and maintaining a sterile field. Within this recommended practice are seven recommendations for maintaining asepsis within a sterile field.

The first of the seven recommendations speaks to the fact that scrubbed persons should function within a sterile field. The process of maintaining the sterile field begins with the scrub person’s hand antisepsis at the scrub sink. Surgical hand antisepsis should be performed according to the antiseptic manufacturer’s instructions, so that the product is used in the most efficient manner. The purpose of hand antisepsis is to reduce the microbial count and decrease the chance that microbes will be transferred. The scrub person then enters the operative suite, dries hands and arms in an aseptic manner and dons a sterile gown and gloves from a table that has been separated from the main instrument table. This is done to prevent contamination of the sterile field.

Sterile field draping is addressed in the second recommendation. Sterile drapes should be used to establish a sterile field. The selection of draping materials should be done by consulting AORN and AAMI guidelines. The purpose of sterile surgical drapes is to establish a sterile aseptic barrier between sterile and unsterile areas and to prevent microbe transfer between these areas. Drapes should be placed on the patient, equipment and furniture that is to be included in the sterile field. The scrub person should place the drape at the surgical site and unfold the drape with fanning or moving it from the area in which it is placed, since this movement may compromise the sterile field.

Items used within the sterile field should be sterile. While opening sterile supplies onto the sterile field, all packages should be inspected for integrity and quality before opening. In order to assure quality control each sterile item or tray of sterile items must include a sterilization indicator. The indicator must be inspected before opening to note whether the indicator color has changed to the appropriate color for the indicator type. An appropriate color change will verify that the sterilization process was completed. The package being opened should be intact with no evidence of water stains. If water stains are present, the item must be considered contaminated, and is not to be introduced to the sterile field.

Recommendation 4 outlines how sterile items are to be handled to maintain their sterility and the asepsis of the sterile field. These items must be opened, handled, dispensed, transported and stored in a manner that maintains the item’s sterility. Should a breach in the package integrity occur during any stage of handling, the contents will become unsterile. The factors that impact sterility of an item from time of sterilization until usage are called event-related sterility. This category of sterilization assurance does not use expiration labels, as was the case before event-related sterility came into practice. One simple way to understand event-related sterility is to realize that every movement from one place to another, or the environmental conditions (surrounding sterile items) is considered an event. If the event is related to a practice that would not promote sterility, the item is no longer sterile. One such event would be the package wrapping on a sterile tray is slid across a wire rack, causing tears in the wrap. The event is tearing the wrap which is a break in the integrity of the wrap causing the items inside to become unsterile.

A sterile field must be maintained and monitored or watched at all times. When a delay occurs in the expected start time of a surgical procedure, at least one staff member from the OR team must be present while the sterile field remains open. Another concept related to continual monitoring of the sterile field is that sterile supplies and equipment should be opened as close to possible of when the surgical case will begin. Also, the sterile supplies should only be opened for one patient in one room at a time. Sterile fields should not be covered because the cover at the non-sterile area below the table surface will contaminate the sterile table top items when removing the cover (even though the cover was originally sterile). One other item outlined in this fifth recommendation, refers to items being secured to the field. If this is necessary, non-penetrating devices should be used (such as non-penetrating towel clips).

When moving around the sterile field, personnel should either move back-to-back or face-to-face to assure continued asepsis of the field and of the sterile personnel apparel. The seventh and last of these recommendations is to fashion the departmental policies and procedures after these RPs and to review them on a regular basis. This review should be done with the departmental team members as well as administrative staff, so that the policy intent is well communicated to the whole team.

Diana Beck, RN, MSN, CNOR, is perioperative education specialist at St. Mary’s Good Samaritan, Inc. in Centralia, Ill.

References:

Association of periOperative Registered Nurses (2008). Perioperative Standards and Recommended Practices. Pages 565-574. 652. Denver.

Houghton Mifflin Company (2006). The American Heritage® Dictionary of the English Language, Fourth Edition. Accessed Jan. 5, 2009 at www.dictionary.com