Continuing Education Activity

Creating a sterile field is to reduce the number of microbes present to as few as possible. The sterile field is used in many situations outside the operating room as well as inside the operating room when performing surgical cases. Sterile fields should be used outside the operating room when performing any procedure that could introduce microbes into a patient. A few examples would be inserting a Foley catheter, an arterial line, and a central line. Inside the operating room, sterile fields are created when practitioners identify the back table that will be used, the mayo stand that will go up to the field, and finally, the patient and the surgical site itself. This review describes the preparation of a sterile field and highlights the role of the interprofessional team in ensuring antisepsis.

Objectives:

• Determine how to maintain a sterile technique.

• Identify the indications for a sterile technique.

• Interpret the clinical relevance of a sterile technique.

• Communicate the importance of care coordination among the interprofessional team to enhance the maintenance of sterile techniques during surgical and medical procedures, thereby improving outcomes.

Introduction

Creating a sterile field is to reduce the number of microbes present to as few as possible. The sterile field is used in many situations outside the operating room as well as inside the operating room when performing surgical cases.[1][2][3] Sterile fields should be used outside the operating room when performing any procedure that could introduce microbes into a patient. A few examples of this would be inserting a Foley catheter, an arterial line, and a central line. Inside the operating room, sterile fields are created when practitioners identify the back table to be used, the mayo stand that goes up to the field, and finally, the patient and the surgical site itself.

Equipment

The equipment needed to create a sterile technique includes:

• Sink or automatic sink
• Sterile scrub brush with nail pick
• Antiseptic soap
• Sterile gown and gloves
• Drying towel

Personnel

Anyone that is performing an invasive procedure should use sterile technique.

Technique or Treatment

Sterile fields should always be established as close as possible to the time of the procedure and should not be left unattended. When a sterile field is opened and exposed for a long time before the procedure, the risk of contaminated items by airborne microbes is higher. If left unattended, the risk is higher, such that someone might have accidentally contaminated the field. These put the patient at risk for a hospital-acquired infection (HAI).

When creating a sterile field in the operating room, it is important to arrange the furniture before opening supplies because of the spreading of microbes as you move around. The furniture should be 12 to 18 inches from the walls or any objects that could contaminate the field.[4][5]

Place the back table, ring stand, and mayo stand in their locations before opening items. Before opening any supplies, all packages must be checked to ensure the integrity of the packaging materials. There should not be any holes or tears in the outside wrappers. If the integrity is intact, it is safe to place the back table pack on the back table (this item is always opened first). The back table allows a large surface to open all other supplies onto it during set-up and is the main sterile field. Once the back table cover is opened, it is essential to note that an imaginary 1-inch border exists along the table's edges. This border is considered unsterile and should be avoided when tossing items onto the field; another unsterile area is anything below table height. Once the back table is opened, bend down and move the table closer to the wall by grasping the lower leg of the table. This allows less chance of someone contaminating the table and getting it out of the way.

The next item is the ring stand that holds the basin sets; open the first flap away from you, then each side flap, and lastly, the flap closest to you. Bend down and marry (move) the ring, stand closer to the back table, and close the space between them. The sterile flap is against the back sterile table drape.

Open up sterile supplies needed for the procedure; open peel packs by checking the integrity of the package; identify if there is an indicator in the package and if the indicator has changed color. The indicator only informs us that the items have been exposed to a sterilant. Open wrapped items using the same method used with the basin set; open the flap away from you first, then the sides, and finally, the flap closest to you. When opening peel-packed items, ensure there is an indicator and that it has turned color. Open the peel pack and do not slide any item near the edges of the wrapper; the one-inch border exits for peel-pack items, as previously discussed. When flipping the items into the basin or onto the back table, be careful not to extend your arm over the sterile field.

To open the instrument trays, ensure there is a plastic lock that identifies an indicator change, a label with the Julian date and load number, and make sure it is the correct set for the procedure. Look at the outside container for moisture or condensation; if there is moisture, do not use it and retrieve another set. If there is no condensation, proceed by grasping the latches and flipping them open, automatically breaking the plastic locks. Lift the lid straight up and step back before flipping the lid over; this ensures that dust or particles don't fall into the tray. Once you flip the lid over, check for moisture and remove the paper filter. To check the filter for any holes, lift it toward a light to ensure no pin-size holes. If the filter looks good, carefully look into the pan for an indicator; do not lean over the pan. If you cannot see an indicator, look more closely after being gowned and gloved. Until you are scrubbed in, the instruments are complete; once you are gowned and gloved, carefully pick up the inside basket and hold it in front of you until the circulating nurse checks the bottom filter and the bottom of the tray for moisture. This is also an excellent time to find the inside indicator. If you cannot find an indicator, do not use the tray. Once the nurse verifies the instrument tray and you see an indicator, you can place the instruments on the back table.

Finally, open a gown and gloves for yourself on the mayo stand. The gown's wrapper is a small sterile field to open your gloves and towel. This is the  first stop after performing your surgical scrub and dry, gown, and glove.

Once all the necessary items are opened, it is time to complete the next step, the surgical hand scrub. Hand hygiene is the most essential item you can perform to prevent infections.

The surgical hand scrub can be accomplished in 1 of 2 ways: the 5-minute scrub or the counted brush stroke method.

Hand Washing

Hand washing is now considered an event-related practice performed before and after specific tasks. Handwashing should last 15 seconds up to a minute or more if the hands get dirty.[6][7][8][9]

• Ensure all jewelry is removed
• Wet hands and forearms and up 2 inches past the elbow
• Apply antiseptic soap. Start with rubbing hands together
• Interlace the fingers of each hand and rub repeatedly; this ensures all the space between each finger is cleaned
• Take the right hand, apply soap to the left forearm, and rub vigorously up to 2 inches above the elbow; ensure all sides are cleaned
• Repeat with left arm to right forearm
• Once all services have been cleaned, it is time to rinse
• Rinse with arms pointed down into the sink to assist with removing all soap and transient flora still left on surfaces.

Always perform a hand wash before performing a surgical scrub. The surgical scrub's purpose is to reduce microbes to the absolute minimum and is always completed right before gowning and gloving or any invasive procedure. It is impossible to sterilize a person's skin, but reducing the number of microbes to a minimum is paramount.

Before starting the scrub, ensure the scrub top is tucked into the scrub pants, and avoid splashing water on the scrubs. Bacteria can easily harbor in moist environments.

The Counted Scrub Method

• Remove all jewelry
• Perform hand washing as discussed
• Unwrap a sterile scrub brush and remove the nail cleaner. Hold the brush in 1 hand while cleaning the subungual area on each finger; perform this under running water. Discard the nail cleaner in the trash.
• You scrub 1 hand and then proceed to the other hand and arm
• Start the count stoke method by starting with the nails and cuticles, using a circular motion on the top of the nails for 30 strokes
• Each finger is divided into 4 sides; each side performs ten strokes for a total of 40 strokes for each finger
• Once the fingers are completed, proceed to the palm for 30 strokes and then the dorsal side of the hand for 30 strokes
• The forearm is next, and it is divided into 4 planes (planes are from the wrist to 2 inches above the elbow); each plane is scrubbed separately, performed in a circular motion for ten strokes each
• While cleaning this area, remember always to keep your hands higher than your elbows and keep your arms from touching your body.
• Do not rinse until you finish both hands and arms.
• Proceed to the next hand and forearm with the same brushstrokes you did for the first hand and arm.

Ensure you do not touch any surface already scrubbed; if you accidentally bump the sink or touch your skin where it is cleaned, you must wash that area for an extra minute.

After scrubbing both arms, rinse the hands and arms by passing through the running water in a 1-way direction. Once the arm has passed through the water, raise the arm to the same height as before with hands above the elbow to allow the water to drip down and off the elbow. This is to let the water go from the cleanest to the least clean area. If you need to pass through again with the same hand and arm, it is OK to do so to ensure all soap residuals are removed. Repeat for the other hand and arm.

Once the scrub is complete, you cannot touch any nonsterile surface; if you do, you must re-scrub. Proceed to where the gown and gloves were opened by holding arms above the elbows and arms away from scrubs.

The Timed Scrub

• Remove all jewelry
• Perform hand washing as discussed
• Unwrap a sterile scrub brush and remove the nail cleaner. Hold the brush with 1 hand while cleaning the subungual area on each finger; perform this under running water. Discard the nail cleaner in the trash.
• You scrub on 1 hand and arm, then proceed to the other hand and arm
• Start the timed method by starting with the nails and cuticles, then move to the fingers; 2 minutes for the entire hand
• Once the nails and fingers are completed, proceed to the palm and dorsal sides of the hand for 1 minute total
• The forearm is next, and it is divided into 4 planes (planes are from the wrist to 2 inches above the elbow); each plane is scrubbed separately, performed in a circular motion for 1 minute for all 4 planes
• While cleaning this area, remember to keep your hands higher than the elbows at all times and keep your arms from touching your body
• Do not rinse until you finish both hands and arms
• Proceed to the next hand and forearm with the exact timing you did for the first hand and arm.
• Ensure you do not touch any surface already scrubbed; if you accidentally bump the sink or touch your skin where it is cleaned, you must wash that area for an extra minute.

After scrubbing both arms, rinse the hands and arms by passing through the running water in a 1-way direction. Once the arm has passed through the water, raise the arm to the same height as before with hands above the elbow to allow the water to drip down and off the elbow. This is to let the water go from the cleanest to the least clean area. If you need to pass through again with the same hand and arm, it is OK to do so to ensure all soap residuals are removed. Repeat for the other hand and arm. Once the scrub is complete, you cannot touch any non-sterile surface; if you do, you must re-scrub.

Proceed to where the gown and gloves were opened by holding arms above the elbows and arms away from scrubs.

Complications

Breaks in aseptic techniques or contamination of sterile fields or supplies cause complications.

Clinical Significance

Using a sterile technique reduces the microbial count, which creates a sterile field and prevents infection.

Enhancing Healthcare Team Outcomes

All healthcare workers, including nurses who assist physicians and surgeons, should be fully aware of the importance of sterile techniques. Breaks in the method can lead to infections in the patient, leading to higher healthcare costs. An infectious disease team should routinely audit all physicians and nurses involved in sterile procedures to ensure proper protocol is followed.[10]