Principles of Asepsis

ST210 Concorde Career College 1

Sterile

Because sterility cannot be assured 100% of the time… **When in doubt, throw it out!

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practicing sterile technique

     The goal is to

keep microbes to an irreducible minimum

Strict adherence is necessary for the protection of the patient that is undergoing evasive surgery Several concepts and applications are key to the implementation of sterile technique Use of common sense is a must Are there gray areas?

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practicing sterile technique

    

There is no compromise in sterile technique Sterility cannot be taken for granted; it must constantly be checked and maintained Surgical team members constantly monitor their own technique, as well as that of the other team members Breaks are identified and corrective actions are taken Each team member must be expecting and be able to accept critique from others

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Keeping microbes to an irreducible minimum

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Living tissue cannot be sterilized

   

The skin of the patient and surgical team members harbors microbes that cannot be removed via the skin prep, hand washing, or surgical scrub Adequate prep of some surgical sites is impossible due to the presence of a large number of microbes The wound may have already been exposed to contaminants Infection may already be present

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Environmental hazards are present



Environmental decontamination may be ineffective



Airborne contaminants may come in contact with the sterile field



Destruction of microbial barriers results in contamination



Movement in or around may cause contamination

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Sterility is not absolute and cannot be effectively proven at all times

    

Chemical indicators (external and internal) only verify exposure to the sterilization process. They are not proof of sterility.

All types of packaging materials for sterilization have disadvantages Human error can effect the outcome of the sterilization process Handling and storage conditions may compromise sterility Microbes that have not yet been identified may be a threat

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Surgical Conscience

 THE HONESTY AND MORAL INTEGRITY TO UPHOLD STRICT STERILE TECHNIQUE   An STSR must be conscientious enough to

recognize

and

correct

breaks in technique An individual who hesitates or refuses to admit a break in sterile technique has no place in the operating room 9

SURGICAL CONSCIENCE

THE SURGICAL TECHNOLOGIST MUST BE ABLE TO RECOGNIZE AND CORRECT BREAKS IN STERILE TECHNIQUE, WHETHER THEY ARE COMMITTED IN THE PRESENCE OF OTHERS OR ALONE.

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FUNDAMENTALS OF ASEPTIC TECHNIQUE

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“Considered Contaminated”

  A situation where one or more of the principles of asepsis

may

have been violated The term “

considered

” means that the situation has been thought about carefully and a decision has been made to “deem” or “regard” the situation in the same manner as a “blatant” or “gross” contamination 12

PRINCIPLE # 1

  

A STERILE FIELD IS CREATED FOR EACH SURGICAL PROCEDURE.

Must be appropriately attired prior to entering the sterile field Movement in and around the sterile field must not compromise the sterility of the field

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PRINCIPLE # 1 cont.

 THE STERILE FIELD CONSISTS OF a separate, sterile area that in a larger sense consists of the

surgical site

itself, the

draped portions of the patient and OR table

, the

sterile portions of the gowns

and

gloves

and the

draped ring stands

,

Mayo stand

, and

back table

.

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PRINCIPLE # 1 cont.



AS TIME PASSES

there is a likelihood that a sterile field has become contaminated by error or by airborne contaminants. Therefore, it should be created as close to the time of use as possible. After the sterile supplies have been opened, the room must be monitored.

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PRINCIPLE # 1 cont.

 If a case is switched to another OR, and the sterile supplies and instruments have already been opened, the back table should

NEVER

be covered with a sterile drape to be moved to another room.

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PRINCIPLE # 1 cont.



CHEMICAL INDICATORS-

Internal or external monitors

change color

when exposed to the sterilization process. If the indicator did not change to the appropriate color, the items should be considered unsterile. 17

PRINCIPLE # 1 cont.

 Instruments, such as knife blades, that come in contact with the

skin

should not be reused. The instrument should be set in a designated area to prevent further use on deeper tissue. 18

PRINCIPLE # 1 cont.

 Personnel should not reuse instruments used during

open bowel

or dirty portions of the procedure and scrubbed team members should regown and reglove before returning to use sterile instruments from the clean setup.

(IF 2 SEPARTE SET UPS ARE USED)

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PRINCIPLE # 1 cont.

 When removing instruments from the autoclave, the sterile team member must not touch the

edge

of the sterilizer with the instrument, tray, gown, or gloves.

 The inside of wrappers containing sterile items is considered sterile except for a 1-2

” perimeter

around the outside edge of the wrapper.

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PRINCIPLE # 1 cont.

 The

inner edge

of a heat sealed peel pack is considered the line between sterile and nonsterile.

 The flaps should be pulled back

without tears

in the peel pack itself.

 The contents must never be allowed to

slide over the edge

of the peel pack.

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PRINCIPLE # 1 cont.

 When opening a sterile wrapped item, the team member opens the (

1 ST

) flap

away

from the body. The side flaps are opened and secured in order one at a time. The

last

flap is pulled

toward

the body. The item is then transferred onto the sterile field or is taken from the package by a sterile team member.

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PRINCIPLE # 1 cont.

 The

top

of a sterile table is the only part considered sterile.  Any part of the

drape extending below the top

of the sterile table is considered

nonsterile

.

 Any item extending beyond or falling over the top of the sterile table edge is considered

contaminated

.

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PRINCIPLE # 1 cont.

 Any portion of a

hose or cord

that is hanging off of a sterile field is considered

contaminated

and

cannot

be pulled back up onto the sterile field. Two examples are the

Bovie

cord and

suction tubing

.

 Once sterile

drapes or towels

have been placed, they cannot be repositioned.  The portion of the drape that is below the

table level

is considered contaminated .

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QUESTIONABLE STERILITY



WHEN IN DOUBT , THROW IT OUT.

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INTEGRITY COMPLETE, NO BREAKS OR TEARS

 There must be no evidence of strike through, tears, or punctures; all seals must be intact; chemical indicators must have turned color to indicate exposure to sterilization conditions.

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PRINCIPLE # 1 cont.



STERILE

ITEMS MUST

NOT

BE STORED WITH

UNSTERILE

ITEMS.

 STERILE ITEMS FOUND IN UNSTERILE STORAGE AREAS SHOULD BE CONSIDERED

UNSTERILE

AND SHOULD NOT BE USED 27

PRINCIPLE # 1 cont.



IMPERVIOUS

- Not allowing moisture to penetrate (i.e., plastic drape).

PERMEABLE

- capable of allowing the passage of fluids or substances. 28

PRINCIPLE # 1 cont.

 If a package that is wrapped in a pervious woven material drops to the floor, the package is considered contaminated.  If the package is impervious and the floor is dry, the item can be transferred to the back table but should not be placed back in sterile storage. 29

PRINCIPLE # 1 cont.

CUASES OF CONTAMINATION

 Punctures, tears, or strike-through compromise the sterility of packages or drapes and is considered

contaminated

.

 If a permeable drape covers a sterile table or field and any liquid penetrates the drape, the drape must be considered

contaminated

.

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PRINCIPLE # 1 cont.

 Sterile packages should be stored on smooth,

clean, dry surfaces

to prevent damage of packaging materials.

 Sterile packages should be stored in a designated sterile supply storage area.

 Sterile packages should be

handled with clean, dry hands.

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PRINCIPLE # 1 cont.

 Unnecessary pressure should not be placed on sterile packs to prevent forcing air outward and allowing air to be pulled inward.

 Peel packs should be stored on their sides to prevent pressure that can rupture the package.

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PRINCIPLE # 1 cont.

   Use non-penetrating instruments to hold drapes and cords in place.

If towel clips used on the field puncture any draping material, the tips of the instrument must be considered contaminated and should be left in place until the end of the procedure.

If a penetrating towel clip is used and is removed for any reason, the STSR should pass the instrument off without touching the contaminated tips and a drape should be used to cover the area from which it was removed. 33

PRINCIPLE # 2



STERILE TEAM MEMBERS MUST BE APPROPRIATELY ATTIRED PRIOR TO ENTERING THE STERILE FIELD

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PRINCIPLE # 2 cont.

THE ATTIRE WORN BY

STERILE

TEAM MEMBERS INCLUDEs A STERILE GOWN, STERILE GLOVES, MASK, and HAIR COVER  Team members must don sterile gown and gloves themselves using aseptic technique, or be gowned and gloved by another sterile team member 35

PRINCIPLE # 2 cont.

 The surgical gown is considered sterile from the

waist

to the

mid-chest line 2 inches PROXIMAL

to the in

front elbows

and on the sleeves.

 The

upper chest area

of the gown is considered contaminated because it cannot be viewed directly by the wearer and because of the possibility of the chin coming into contact with this part of the gown.

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PRINCIPLE # 2 cont.

 When standing at a table, the gown should be considered sterile to the

top of the operating table

or

the top of the back table

 The arms should contamination.

not

be folded with the hands in the axillary region. This region is considered contaminated because it cannot be viewed by the wearer and because of strike-through 37

PRINCIPLE # 2 cont.

   

Hands should never be allowed to fall below waist or table level.

The team member should

avoid raising the hands above the mid-chest line or over the head.

The back of the gown is considered

contaminated

because it cannot be viewed by the wearer.

When wearing a sterile gown, the

back should never be turned toward a sterile field

.

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PRINCIPLE # 2 cont.

 The stockinette cuffs of the surgical gown are considered

nonsterile

and should be covered by the cuff of the glove.

 A sterile person should sit only when the entire procedure will be performed sitting down and the hands

must not

fall into the lap.

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PRINCIPLE # 2 cont.

   A separate sterile surface should be used for gowning and gloving to avoid contamination of the back table.

The gown and gloves may be opened on a mayo stand or small table prior to the surgical scrub.

When using a platform, moving from a lower position to a higher position should be avoided as much as possible.

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PRINCIPLE # 3



MOVEMENT IN AND AROUND THE STERILE FIELD MUST NOT COMPROMISE THE STERILE FIELD

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PRINCIPLE # 3 cont.

STERILE TO STERILE



Only sterile members may touch sterile surfaces and items.



Nonsterile personnel must not touch sterile surfaces and items.



Walking between two sterile areas

should be

avoided

.

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PRINCIPLE # 3 cont.

STERILE INDIVIDUALS KEEP WITHIN THE STERILE FIELD

 Scrubbed personnel should stay close to the sterile field throughout the procedure.

 Movement within the sterile field should be kept to a minimum to avoid airborne contamination.

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PRINCIPLE # 3 cont.

    Sterile team members should pass each other face to face or back to back.

A sterile person should

always face

field to avoid contamination.

the sterile A sterile person should

turn their back

to a nonsterile person or area when walking past.

Talking should be kept to a minimum to prevent contamination from airborne moisture droplets.

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PRINCIPLE # 3 cont.

   A nonsterile person should keep at least 12-18 inches from

ANY

sterile item, area, or sterile field . Additionally, equipment and furniture that is not covered by sterile drapes must not be included in the sterile field and must be kept a minimum of 12-18 inches away from a sterile surface or item.

The STSR must be conscious of these nonsterile items and personnel and maintain the 12-18 inch distance 45

PRINCIPLE # 3 cont.

NONSTERILE TO NONSTERILE

 Nonsterile persons should

never reach over a sterile

field because of contamination from skin fallout .

 While pouring solutions

only the lip of the bottle

should be over the sterile basin while maintaining

12-18 inches

above the basin. To

accommodate this,

a scrub could move containers to be filled close to the edge.

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PRINCIPLE # 3 cont.

  Solutions must

never be recapped

because recapping contaminates the solution within the bottle. or reused When draping, a sterile person should

cuff their hands in the folds

of the drapes.

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PRINCIPLE # 3 cont.

 When draping a nonsterile surface to create a sterile field, the nonsterile person should cuff the hands within the underside folds of the drape or table cover; the drape should be opened away from the body toward the far side of the table first, then toward them last 48

CREATING THE STERILE FIELD

 The

mask must be applied prior

to creation of the sterile field and is worn by

all individuals in the presence

sterile field.

of the  The OR doors

should be closed

creation of the sterile field.

prior to 49

CREATING THE STERILE FIELD



A NUMBER OF TASKS MUST BE PERFORMED QUICKLY AND EFFICIENTLY PRIOR TO INITIATION OF THE SURGICAL PRODCEDURE

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CREATING THE STERILE FIELD cont.



FURNITIRE NEEDED TO CREATE A STERILE FIELD

 BACK TABLE- Back table pack  RING STAND- Basin set  MAYO STAND- Gown and gloves  ADDITIONAL STAND TO OPEN INSTRUMENTS  PREP STAND 51

CREATING THE STERILE FIELD cont.

 Check dates on packages before opening.

 If and item is double wrapped it will be necessary to open both wrappers at that time.

 If an item is only wrapped one time or wrapped more than twice, it must be considered contaminated.

 When adding items to the sterile field, be careful not to drop heavy items on the sterile field since they could puncture the barrier covering the unsterile surface.

52

CREATING THE STERILE FIELD cont.

 Nonsterile surfaces that will have sterile drapes applied are draped first toward the sterile person to prevent contamination of the gown and to avoid reaching over the nonsterile surface 53

Breach of the Sterile Field

What occurs when one of the principles of asepsis are violated and the goal of keeping the microbial count within the sterile field to an irreducible minimum is not met

54

Breach of the Sterile Field #1 

Disregard the contamination

• Only one application and is temporary the patient’s life is at immediate risk • Once the patient is stabilized, the contamination must be reported and appropriate corrective measures taken • The surgeon may want to give systemic prophylactic antibiotics to the patient 55

Breach of the Sterile Field #2 

Remove the sterile item from the sterile field

• The most common action chosen • • Appropriate for most situations The contaminated item is removed and replaced • Any items subsequently contaminated must also be removed 56

Breach of the Sterile Field #3 

Cover the contaminated item or area

• Due to timing or other circumstances, the contaminated item cannot be removed • An impervious drape should be used to cover the item or area to reestablish the sterile field 57

OPENING THE BACK TABLE PACK

 Check integrity  Remove outer wrapper  Check inner package  Orient on back table  Break the seal  Unfold accordingly

WITHOUT PULLING FLAPS BACK ON TABLE TOP AND TOUCHING ONLY EDGES OF BACK TABLE DRAPE

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OPENING BASIN SET

 Check integrity  Orient basin set  Break the seal  Unfold the first flap away from you  Unfold each side flap with respective hands  Pull flaps

down

instead of

out

hitting sterile back table to avoid 59

OPENING SMALL WRAPPED PACKAGE (such as initial gown on mayo) ONTO A CLEAN SURFACE

 Check integrity  Orient package  Break seal  Open first flap away from you  Unfold each side flap with respective hands  Pull the last flap toward you 60

OPENING A PEEL PACK

      Check integrity Orient package by grasping one edge of the peel pack in each hand Slowly separate the sides of the peel pack

(do not change hands halfway through opening)

Balance the item to keep it between the edges of the glue Maintain a safe distance Transfer the item by projecting it onto the sterile field without dropping it below waist level or breaking the plane of the sterile field 61

OPENING THE INSTRUMENT SET (Rigid Container System)

 Set on suitable surface  Verify external indicators  Break the seals and release the lid  Lift the lid straight up 12-18 inches then step back 12-18 inches from the tray  Invert the lid and inspect the inside  Remove the retainer and check the filter 62

OPENING THE INSTRUMENT SET (Wrapped)

       Set on suitable surface Verify external indicators Orient set where the first flap opens away from you Break the seal Open the first flap away from you by reaching around the side – opposite side form sterile field Unfold each side flap with respective hands (Pull flaps

down

instead of

out

) Pull last flap toward yourself 63

SCRUBBING, GOWNING, AND GLOVING

 Once the initial sterile filed has been established, the STSR: • All personal needs are attended to, PPE is donned (eyewear, lead aprons, etc.) • • • • • •

perform scrub, dry, gown, and then glove

Set up case Perform the initial count Drape the prepped area Create sterile field TIME OUT!

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