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Surgical Aseptic Technique and Sterile Field
Recommendations for Asepsis for Invasive Surgical
Procedures Conducted Outside of Operating Rooms or in
Community-Based Healthcare Settings
Version Date (YYYY-MM-DD) Created 2013 - 01 - 31 Updated 2019 - 06 - 30
Version Date (YYYY-MM-DD) Created 2013 - 01 - 31 Updated 2019 - 06 - 30
Alberta Health Services Public Health and Infection Prevention and Control jointly updated these recommendations
which replaces the 2013 version Surgical Aseptic Technique and Sterile Field : Guideline for asepsis for invasive
surgical procedures conducted in Community-based Health Care Settings.
The surgical aseptic technique and sterile field recommendations provide information, support and evidence-based
practices to health care professionals performing invasive surgical procedures outside of operating rooms or in
community-based health care settings, such as dental clinics, podiatry clinics and medical clinics. Infection
prevention and control is a continually evolving discipline which is based on research and evidence-based practice.
Note : If specific program protocols vary from the general recommendations provided in these recommendation,
refer to, and follow department specific recommendations.
Not Acceptable / Not Sterile Acceptable / Sterile
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SURGICAL HAND ANTISEPSIS
- Objective of surgical hand antisepsis is to reduce the transient and resident flora. Skin can never be rendered sterile. It can be made surgically clean by reducing the number of organisms present with the mechanical action associated with scrubbing. Surgical hand antisepsis is only effective if all surfaces of the hand are exposed to the mechanical cleaning and chemical antisepsis.
- Process of removing as many microorganisms as possible from the hands and forearms by mechanical washing and chemical antisepsis before participating in a surgical procedure.
- Performed prior to donning sterile gloves or sterile gowns and gloves for surgical or other invasive procedures.
- Achieved with either an antimicrobial surgical scrub agent ( surgical hand scrub ) or an alcohol based antiseptic surgical hand rub ( surgical hand rub ) with documented persistent and cumulative activity. 1,
- Follow manufacturer’s instructions for use for the product for surgical hand antisepsis.
GENERAL CONSIDERATIONS
- Refer to the AHS Hand Hygiene Policy and Procedure or organization/department specific protocols for general hand hygiene information, including recommendations for fingernails, e.g., clean, short, natural nails
- Wash hands with soap and water if hands are visibly soiled or as required by the product manufacturer’s instruction for use.
- Remove all rings, wrist watches and bracelets prior to starting surgical hand antisepsis. (Figure 1)
- Don hair covers, protective eyewear and surgical mask prior to initiating the surgical hand antisepsis. (Figure 2)
- Keep hands above the level of the elbow so that water flows down during the surgical hand scrub and rinsing process. Avoid contact with the faucet or other potential contaminants. (Figure 3)
- Dry hands thoroughly using a sterile towel following a surgical hand scrub. Thorough drying is essential as moist surfaces allow pathogens to multiply.
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SURGICAL HANDRUB
https://www.who.int/infection-prevention/countries/surgical/NewSurgicalA3.pdf
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b. Time the application of the scrub solution according to the manufacturer’s written directions to allow adequate product contact with skin.
c. For each hand visualize each finger, thumb, hand and arm as having four sides. Wash all four sides effectively, keeping the hands elevated.
d. Avoid splashing surgical attire.
e. Discard used sponges.
f. Rinse hands and arms under running water in one direction from the fingertips to elbows as often as needed to remove soap. Take care to ensure fingers, hands and arms do not touch the faucet and the hands remain above the level of the elbows. If the water is controlled with hand control levers then the water is turned off by circulating personnel.
g. Ensure hands are held away from the body with hands and forearms held higher to prevent contamination by allowing the water to run from the clean to less clean area. Keep the surgical attire dry as the sterile gown cannot be donned over wet or damp attire without potential contamination of the gown by strike-through moisture.
h. Dry hands with a sterile towel.
- Don sterile gown and gloves. 1
HAND HYGIENE TIPS
- Keep nails natural, clean, short and healthy 3.
- Adhere to facility or organization policies on use of nail polish. Refer to the AHS Hand Hygiene Policy and Procedure or organization/department specific protocols for general hand hygiene information.
- Do not wear artificial nails or nail enhancements.
- Remove all hand and arm jewellery for invasive surgical procedures.
- Do not scrub if you have cuts, abrasions, weeping dermatitis or fresh tattoos on exposed skin.
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GOWNING AND GLOVING
- Following completion of the surgical hand antisepsis, it is important to correctly don a sterile surgical gown and sterile gloves.
- Gowns are only considered sterile in the front from the axilla (armpit) to the level of the sterile field and sleeves from 5cm (2inches) above the elbow to cuff. The neckline, shoulders, under arms, sleeve cuffs and the back are considered unsterile 4. (Figure 4)
GENERAL CONSIDERATIONS
- Gowns are donned before gloves.
- The scrubbed personnel gowns and gloves from a separate table or surface that is waist height, away from the main sterile field (to avoid any chance of contaminating the sterile field) using the “closed gloving” technique.
- The scrubbed personnel gowns and gloves the dentist/surgeon (and other sterile team members) using the assisted “open gloving” technique.
- Sterile gowns are:
a. Made of a material that is resistant to penetration of blood and other fluids.
b. Folded to allow the gown to remain sterile during donning and large enough to adequately cover the scrubbed personnel.
c. Gown cuffs are considered unsterile and are to be covered by sterile gloves because they:
i. tend to collect moisture, ii. are not an effective barrier and, iii. become contaminated when the scrubbed person’s hands pass through the cuff. 1
GOWNING AND CLOSED GLOVING
- Reach and lift the folded gown directly upward. Do not touch the wrapper and ensure the gown remains folded until after stepping back from the gown table into an unobstructed area. (Figure 5)
- Holding the folded gown like a book by its binding, carefully locate the neckline and armholes. (Figure 6) 6
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- Grasp the upper glove cuff with the cuffed non-dominant hand while holding the underside of the cuff with the cuffed dominant hand. Peel the cuff of the glove over the dominant cuffed hand, over the end of the sleeve. Hold the sleeve and glove cuff with the non-dominant hand and pull back the sleeve while wiggling the fingers of the dominant hand to extend them into the glove. The glove covers the entire gown cuff. (Figure 13)
- Using the gloved hand, pick up the remaining glove and place it with the palm of the glove against the palm of the non-dominant hand. Grasp the back of the cuff of the glove above the palm in the gloved hand and turned over the sleeve and hand. (Figure 14)
- The cuff of the glove is now over the gown cuff of the sleeve with the hand still in the sleeve.
- Grasp the top of the glove and underlying gown sleeve with the gloved hand and pull the sleeve allowing the glove to be pulled onto the non-dominant hand. (Figure 15)
- Grasp the tie and protector. Remove one tie from the protector. Hand the protector to the circulating personnel. Turn to wrap the back panel of the gown around the scrubbed personnel, covering the previously tied inner waist ties. Carefully pull the tie out of the protector held by the circulating personnel and tie to secure the gown. (Figure 16-18)^ The ties are not dropped below waist level before it is tied. If ties drop the circulating personnel ties the gown at the back. 5
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GOWNING AND OPEN GLOVING
- Sterile gowns for each member of the team are handed to the scrubbed personnel in a manner which maintains sterility. The gown is then placed on the sterile field.
- The scrubbed personnel picks up the gown and holds it away from the sterile field and allowing it to unfold with the inside of the gown held toward the individual being assisted with gowning and gloving. (Figure 19)^ The scrubbed personnel protects their gloved hands by holding the gown with a cuff over the glove and allows the individual being assisted to reach into the sleeves of the held gown. (Figure^ 20)^ The circulating personnel reaches to grasp the inside of the gown and carefully bring it up and over the shoulders being sure not to touch the outside of the front of the gown. The inside ties of the gown at the neck and waist are tied by the circulating personnel. The individual being gowned allows their hands to extend beyond the cuffs of the gown and ensure their hands remain above waist level not touching the gown.
- Once the gown is on, the scrubbed personnel picks up the right glove and holds it with the cuff (to protect the gloved hands from touching the bare hand of the individual being assisted with gowning and gloving). The palm of the glove is turned toward the ungloved individual’s hand with the glove directly opposed to the thumb of the individual’s hand. Using fingers stretch the cuff to open the glove. (Figure 21)^ The individual being assisted with gloving will place their hand in the glove and the cuff will extend up the sleeve to cover the stockinette of the sleeve. (Figure 22)
- The scrubbed personnel repeats this process. With the second glove the individual being assisted can help to open the glove by placing the gloved hand under the cuff of the glove to increase the opening while inserting the ungloved hand. Again the cuff will be pulled up to cover the entire stockinette cuff of the sleeve.
- Once gloving is completed the wrap around tie can be handed to the scrubbed personnel to allow the gown to be closed^5. (Figure 23-24)
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ESTABLISHING THE STERILE FIELD
- Use sterile drapes to cover surfaces or operative fields and provide a barrier against micro-organisms, liquids, and particulate matter2.
- Surgical drapes are only sterile at table level. a. The drape below the working surface is not under direct vision of the surgical team and is not considered sterile. The edges of the table top serve as a demarcation line between sterile and non-sterile. b. Any item that falls below the table level is considered unsterile. This applies to the edges of the drape and portion of suction and irrigation tubing that is handed off the sterile field.
- If the drape does not cover the entire surface, a 1-inch margin around the edge of the drape is considered unsterile. (Figure 25)
- The edges of packages are considered unsterile. When opening packages for a sterile procedure prevent the wrapper from touching the sterile field or package contents. a. Control all flaps of non-woven wrap to prevent them from touching the sterile field. (Figure 26) b. The sterile boundary of a peel-open package is the inner edge. Peel pouches are peeled back not ripped or torn when opening. Do not push devices through the peel pouch. The inner edge of the seal is the demarcation for sterile and non-sterile. (Figure 27) c. Do not flip or drop items onto the sterile field. (Figure 28)
- Clean and dry flat surfaces before placing a sterile bundle or drape on them. (Rationale: moisture may cause strike-through and contaminate the sterile field. Dust may become airborne and land on the sterile field.)
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DISPENSING STERILE SUPPLIES
- Open supplies as close to possible to the surgical start time. ( Rationale : the potential for contamination increases with time and particles stirred up by movement of personnel which can settle on horizontal surfaces. 5 )
- Handle sterile supplies as little as possible. ( Rationale : increased handling increases the potential for contamination and prolongs set-up time.)
- Assess all items added to sterile field prior to opening for sterility by checking package integrity, and chemical indicators for a “pass” result.
- Open large bundles or packages on a flat surface. ( Rationale : large and/or heavy items are difficult to open aseptically while being held in the circulating personnel’s hand.)
- Maintain sterility and integrity of items introduced onto a sterile field as they are opened, dispensed, and transferred^1.
- Methods of transfer include, but are not limited to the following:
a. Place the item on the edge of the sterile instrument table with the inside of the wrapper covering your hand. Never reach over a sterile field and shake an item from its package. b. Expose the contents so the scrubbed personnel can remove the item from the wrapper or package using a forcep or by grasping the item. (Figure 29) c. Do not flip items onto the sterile field. ( Rationale : flipping creates air turbulence. It also creates the potential for contamination or damage. 5 ).
- Pour sterile solutions into a sterile receptacle. The scrubbed personnel holds the receptacle away from the table or places it on the edge of the draped surface eliminating the need for the circulating personnel to reach across the sterile field. (Figure 30, 31)
- Discard any remaining solution once the contents (sterile solution) of the bottle have been dispensed into the sterile receptacle. ( Rationale: re-application of caps is a questionable technique as the pour spout and cap may have been contaminated. The edge of a container is considered contaminated after the contents have been poured; therefore, the sterility of the contents cannot be ensured if the cap is replaced. 1 )
- Discard or dismantle supplies that have been opened once a patient has entered the operatory in the event the procedure is cancelled or if they are not used. ( Rationale : potential for cross-contamination will be prevented).
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STERILE TECHNIQUE WITHOUT CIRCULATING PERSONNEL
This section outlines basic sterile technique when performing a minor invasive procedure outside of operating rooms or in community based health care settings without the assistance of circulating (non-scrubbed) personnel, e.g., surgical removal of ingrown toenails, joint injections. It was adapted from Lippincott Procedures. 2018. Sterile Technique, Basic.
- Follow routine practices including hand hygiene.
- Prepare a sterile field and then, using aseptic non-touch technique , set up the necessary supplies on the sterile field. See page 16 for information on dispensing sterile supplies.
- Don a cap and mask.
- Perform hand hygiene.
- Don a gown and gloves.
- If there is an existing dressing to be removed, gently remove the dressings and discard carefully in an impervious plastic garbage bag.
- Doff your gown and gloves.
- Perform hand hygiene.
- Don a sterile gown and sterile gloves. You will need a second person to tie the waist and neck of the sterile gown. See page 7 for information on gowning and closed gloving.
- Perform procedure.
- Dispose of all equipment in appropriate receptacles.
- Doff and discard your gloves and other personal protective equipment.
- Perform hand hygiene.
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DEFINITIONS
Aseptic non-touch technique means maintaining asepsis by not touching sterile equipment or areas with the intent of reducing the risk of transmission of infection to patients.
Circulating (non-scrubbed) personnel means staff that work in the periphery of the sterile field. Circulating personnel wear non-sterile scrubs and cover wear to perform duties such as delivering equipment and supplies to the surgical staff, documentation, and specimen handling.
Closed gloving technique means a gloving technique in which the hands are not extended from the sleeves and cuffs
when the gown is put on. Instead the hands are pushed through the cuff openings as the gloves are pulled into
place.
Doff means to take off (an article of clothing or wear).
Don means to put on (an article of clothing or wear).
Open gloving technique means a gloving technique in which the scrubbed person’s hands slide all the way through
the sleeves and cuffs when the gown is put on prior to donning gloves.
Product for surgical hand antisepsis means product used for surgical hand preparation with the following characteristics: 1) significantly reduces microorganisms on intact skin, 2) contains a non-irritating antimicrobial preparation with broad spectrum activity and 3) fast acting and persistent. The most commonly used soaps for surgical hand washing contain chlorhexidine or povidone-iodine. Alcohol based products for surgical hand rubs frequently have additional long acting compounds such as chlorhexidine gluconate or quaternary ammonium compounds.
Scrub (scrubbed) personnel means staff who work directly in the surgical field. Scrub personnel perform surgical hand antisepsis before donning a sterile gown and gloves. Duties may include establishing and maintaining the surgical field, assisting the surgical team by donning sterile masks, gloves and gowns and passing instruments during surgery.
Sterile field means the area around the site of incision into tissue or site of introduction of an instrument into an orifice that has been prepared for the use of sterile supplies and/or equipment.
Strike-through means an event whereby sterile drapes or packages become contaminated due to soaking through
or forcing through of moisture or air.
Version Date (YYYY-MM-DD) Created 2013 - 01 - 31 Updated 2019 - 06 - 30
REFERENCES
- Association of perioperative Registered Nurses. 2019. Perioperative standards and recommended practices. Available at: http://aornstandards.org
- Canadian Standards Association (CSA). 2018. Z314-18. Canadian Medical Device Reprocessing. Available at: http://shop.csa.ca/en/canada/sterilization/z314101-10/invt/27030452010. 3. Public Health Agency of Canada. 2012. Hand Hygiene Practices in Healthcare Settings. Available free of charge at: http://publications.gc.ca/site/eng/430135/publication.html.
- Operating Room Nurses Association of Canada (ORNAC). 2017. Standards, guidelines, and position statements for perioperative registered nurses. Available at: http://shop.csa.ca/invt/
- Phillips, N. 2017. Berry & Kohn’s operating room technique. (13th^ ed.) Toronto: Mosby.
- Alberta Health. 2011. Standards for Single-Use Medical Devices: As Applied to Critical and Semi-Critical Medical Devices. Available free of charge at: http://www.health.alberta.ca/documents/IPC-Medical-Device- Single-Use-2011.pdf
- Alberta Health. 2012. Standards for Cleaning, Disinfection and Sterilization of Reusable Medical Devices for Health Care Facilities and Settings. Available free of charge at: http://www.health.alberta.ca/documents/IPC- Medical-Device-Cleaning-2012.pdf
- Rothrock, J. 2019. Alexander’s care of the patient in surgery. (16th^ ed). Toronto: Mosby.
