Back to Basics: Sterile Techniques

Sterile technique is an essential patient safety principle that reduces the risk of microbial transmission to patients during surgery. The ability to establish and maintain a sterile environment is an important skill for all peri-operative team members. Understanding the principles of sterile technique is crucial for anyone entering the peri-operative environment.

Establishing and maintaining a sterile field when performing surgical or other invasive procedures
prevents microbial contamination, which can pose a serious risk of infection for patients. All peri-operative team members who are involved in these procedures are responsible for providing patients with a safe environment of care and should be vigilant in safeguarding the sterility of the field by ensuring that everyone present in the OR follows the principles and processes of sterile technique. As patient advocates,peri-operative nurses have the professional responsibility to speak up when there is a breach in the sterile field and to correct that breach immediately.

Sterile technique begins when the team members don surgical attire and should be performed according to the recommendations in AORN’s “Guideline for surgical attire.” Sterile technique also requires adherence to hand hygiene and the surgical hand scrub, both of which are addressed in AORN’s “Guideline for hand hygiene.”  To establish and maintain a sterile field properly, peri-operative
team members must perfect several techniques. This article discusses some of the sterile technique concepts essential to providing safe care for patients.

Gowns and Gloves
Perioperative team members wear sterile gowns and gloves to prevent direct contact between their skin and clothing and the patient. Before donning sterile gowns and gloves, peri-operative team members should perform hand hygiene according to the recommendations in AORN’s “Guideline for hand hygiene.” After performing the surgical hand scrub, the scrub person should don a sterile gown and gloves while adhering to the following recommendations:

  • Don gowns and gloves away from the main instrument table, taking care not to contaminate the gowns or gloves. This helps to prevent water droplets or skin antiseptic solution on wet hands from dripping on the instrument table.
  • Ensure that arms are completely dry before donning the sterile gown.
  • Touch the inside of the gown only when picking it up to prevent the front of the gown from becoming contaminated.
  • Avoid touching the sterile wrapper of the gloves or the gloves themselves until after donning the gown. Keep hands covered by the gown sleeves to prevent the gloves from becoming contaminated before they are donned.
  • After the hands pass through the cuffs of the gown, consider the cuffs to be contaminated, and completely cover the cuffs with sterile gloves.
  • Consider gowns to be sterile in the front from the chest to the level of the sterile field.
  • Consider the shoulders, neckline, and axillary regions of the gown to be non-sterile, which is why peri-operative team members should not stand with their hands tucked under their axilla.
  • Consider the back of the gown to be non-sterile because it cannot be constantly monitored.
  • Consider the sleeves of the gown to be sterile from two inches above the elbow to the cuff, circumferential around the arm.

Sterile Drapes
Sterile drapes are used to establish the sterile field and to provide a barrier that minimizes the passage of microorganisms from non-sterile to sterile areas and reduces the risk of infection for patients. Peri-operative team members should place sterile  drapes not only on the patient but on equipment and furniture used in the sterile field and should handle the drapes in a manner that prevents them from becoming contaminated. Peri-operative team members should also use sterile drapes when placing central venous catheters and peripherally inserted central catheters and when performing guide wire
exchanges.14,15 The top, bottom, and sides of any non-sterile equipment (eg, a Mayo stand) must be covered with sterile drapes before a team member brings the equipment tothe sterile field. AORN provides the following additional recommendations for scrubbed team members handling sterile drapes:

  • Handle sterile drapes as little as possible.
  • Control sterile drapes when handling to prevent them from coming into contact with non-sterile areas.
  • Shield the sterile gloved hands when draping by cuffing the drape over the gloved hands, which helps protect the gloved hand from coming into contact with non-sterile areas or items.
  • Avoid leaning across an non-sterile area to place a drape to prevent the front of the gown from becoming contaminated.
  • Place sterile drapes from the surgical site to the peripheral area.
  • Avoid moving the drape after it has been positioned over the surgical site.
  • Consider items that fall below the top surface of the surgical drape to be non-sterile.
  • Consider the upper portion of the fluoroscope unit (C-arm) drape to be non-sterile.

Preparing the Sterile Field
Establishing a sterile field decreases the risk of microbial contamination of patients and is key in the prevention of infection. Failure to prepare the sterile field using aseptic practice has been associated with SSIs. The sterile field should be prepared as close as possible to the time of use, in the location that it will be used, and should not be moved.

Opening Sterile Items
Peri-operative team members should open, transfer, and dispense sterile items onto the sterile field in a manner that maintains both the sterility of the sterile field and the item being opened. Team members should inspect items being introduced to the sterile field for correct processing, packaging, and package integrity. Sterility is event-related and depends on package integrity. The passage of time does not affect the sterility of the item, but certain events, such as the amount of handling of the item or environmental
conditions, may affect the sterility. If an item is labeled with an expiration date, team members should check the date and not use the item if the date has passed. If a sterile package has a sterilization chemical indicator, team members should verify that the appropriate color change has occurred.

Covering Sterile Fields
The AORN “Guideline for sterile technique” states that sterile fields can be covered if performed “in a manner that allows the cover to be removed without bringing the part of the cover that falls below the sterile field above the sterile field.” Peri-operative team members should use two sterile cuffed drapes to cover the sterile table or area that is to be covered as follows:

  • Place the first drape over the table or area horizontally with the cuff at or just beyond the halfway point.
  • Place the second drape from the opposite side, and position the cuff so that it completely covers the cuff of the first drape.
  • When removing the drapes, peri-operative team members should place their hands within the cuff of the top drape and lift the drape up and away from the table and toward themselves. Remove the bottom drape in the same manner but from the opposite side.

A culture of safety for patients in the peri-operative setting begins with the basic principles of surgical attire, hand hygiene, and sterile technique. When a peri-operative team member enters the surgical setting, he or she has a duty to protect the patient. The “first, do no harm” principle applies to adhering to and implementing the principles of aseptic and sterile technique to protect the patient. When breaches do occur, peri-operative Registered Nurses must be immediate advocates for patients by identifying and taking corrective action to minimize risk or harm.

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