Ori Prereq 4 - ST

Aseptic Technique

• All items used in the sterile field must be sterile and inspected immediately before presentation to the sterile field (including package integrity and expiration date; if no expiration date, the package has "event-related sterility")
• Only sterile items should touch sterile surfaces
• All items introduced to a sterile field should be opened, dispensed, and transferred by methods that maintain item sterility and integrity; peel pouches should be presented to the scrubbed person to prevent contamination should the contents slide over the unsterile edge
• All items should be delivered to the surgical field in a manner that prevents non-sterile objects or people from extending over the sterile field
• Sterile field should be prepared as close as possible to time of use
• The sterility of an open sterile field is event-related and requires continuous visual observation
• Nonsterile personnel should face sterile fields on approach, should not walk between two sterile fields, and should be aware of the need for distance (at least 12 inches) from the sterile field
• Non-sterile equipment (i.e., Mayo stands, microscopes, C-Arms) should be covered with sterile barrier material(s) before being introduced to or brought over a sterile field

Sterility and Peel Packs

Sterility and Fluid Containers

Surgical Hand Scrubs

• Water-based
• Pick nails under running water
• Use the brush side of the scrub sponge only on nails/cuticles or visible soil
• Use the sponge side on skin — 3-minute scrub time is during this step only
• Waterless
• Wash hands, pick nails, and dry hands before the first application of the day
• Before subsequent applications, wash and dry hands if skin is soiled
• Apply product following manufacturer's instructions

***Sterillium should only be used if allergic to other products AND with approval from Occupational Health

Gowning & Gloving

• Gowning and gloving should be performed on a separate surface other than the back table
• Closed gloving is used for self gloving
• Double glove for all invasive procedures
• Gowns are sterile 2 inches below the neck hem down to the level of the waist/sterile field or back table and the gloves and arms to 2 inches above the elbows

Principles of Sterile Technique related to Scrubbed Personnel

Positioning

• Safety is the responsibility of every member of the surgical team
• Positioning devices and supplies should be gathered prior to induction
• To avoid injuring yourself or others, utilize appropriate transfer devices, use proper body mechanics/ergonomics, and request lifting help when necessary
• Ensure a safety strap is on the receiving bed, and lockthe OR bed and stretcher before transferring the patient
• Note pre-op skin condition for comparison to post-op skin condition — report any observations to the team
• Mepilex dressings, often applied in pre-op, protect against risk factors for developing pressure injuries

• Remember to provide care that respects your patient's privacy and preserves their dignity

• Close windows when the patient is exposed
• Cover the patient with linens as much as possible

Skin Prepping

• Having inspected the patient's skin, note presence of hair around the surgical site
• Only a non-sterile team member should perform skin prep (if a sterile team member preps, the gown and gloves must be changed before the procedure)
• To prepare for the prep:

• Remove jewelry/watch
• Don a scrub jacket to cover arms (which reduces skin shedding into sterile area)
• Perform hand hygiene

• During the prep:

• To prevent pooling of the antiseptic solution and protect sheets, electrodes, tourniquets, and positioning equipment, place drip paper before applying any prep solution
• For abdominal preps, clean the umbilicus using a cotton-tipped applicator dipped in prep solution first

• Before draping:

• Always remove drip papers
• Allow antiseptic to dry for the full time recommended in the manufacturer's instructions for use before draping

More about Betadine Preps

More about ChloraPrep Preps

Draping

• If the sterility of a drape is in question, consider it CONTAMINATED!

• When in doubt, throw it out!

Principles of Sterile Technique related to Sterile Field and Contamination

• Handle sterile drapes as little as possible and in a controlled manner
• After initially placing the drape on the site, do not move the drape
• Consider items which fall below the level of the sterile field to be contaminated
• Consider only the top surface of the sterile drape to be sterile (not the underside)
• Be sure that all instruments have been removed from the drapes before they are put in the garbage container

Energy Safety

• Electrosurgical unit (ESU)

• Confirm power settings with surgeon
• Allow prep solutions to completely dry before draping and avoid solution pooling
• Alcohol-based solutions requires a minimum 3-minute dry time
• Active electrode (pencil) must be stored in an insulated holster when not in use
• Adhesive pads
• Apply after positioning the patient
• Place over muscle mass and avoid implants and scars (including tattoos)
• Avoid gaps or moisture under the pad
• Megadyne Megasoft pads
• Do not use on patient's with electronic implants
• Do not use sheets between patient and pad

• X-ray

• Only physicians and imaging technologists operate radiation-emitting equipment

Energy Safety

• Lasers

• The nominal hazard zone (NHZ)
• The area where the level of direct, scattered, or reflected radiation during normal usage exceeds Maximum Permissible Exposure (MPE)
• This is the area in which increased control measures are required when a laser is in use – at VUMC, this is the entire OR suite!
• General Control measures:
• Appropriate laser signage and eyewear must be posted on allentrances of the OR suite

• Appropriate wavelength-specific eyewear must be worn by all people in the room – this is an OSHA requirement!
• Windows must be covered when using a laser that can transmit through glass
• Lasers must not be activated around flammable agents (including solutions that are alcohol- or petroleum-based and solutions delivered as an aerosol by a propellant)
• A wet towel near the surgical site and sterile water or saline readily available on the surgical field

Energy Safety

• Lasers (continued)

• Procedure-specific control measures:
• Instruments without a reflective finish (matte, anodized, etc.) must be used on cases which require instruments near the field during laser use
• For airway cases, anesthesia provider should use the minimum necessary oxygen required for a patient and a laser-specific endotracheal tube

• Other important points:
• In some locations, laser techs help implement control measures and complete Laser Log

• If appropriate for the laser being used, “test fire” or calibrate the laser before the patient enters the room
• Only physicians operate lasers in the OR

Fire Risk Score

• A fire risk assessment is completed in the eStar/Epic chart prior to the Time Out
• Some of the factors evaluated to get the fire risk score include the use of fiber optic light sources, burrs, saws, or drills, surgical site location, and use of alcohol-based prep solutions

Time Out

• Takes place in the procedure/operating room after the patient is prepped and draped
• All other activities are suspended, and EVERY MEMBER OF THE TEAM must participate in confirming the patient, procedure, and side/site marking (if necessary)
• Consent, chart, site marking, and surgeon confirmation must match
• The proceduralist in the OR for the timeout must be the one on the consent – or the Time Out cannot begin
• If any member of the team does not confirm an element of the Time Out
• The Time Out procedure is stopped

• The discrepancy must be reconciled (if necessary, the surgeon may need to break scrub, check chart, etc.)
• The Time Out process is restarted from the beginning

• More than one Time Out is required when two or more procedures are performed on the same patient by separate proceduralists or procedure teams
• A Time Out must be performed prior to the procedure that the team present will be performing

Section Complete!

References

[SOP] Photographing Pressure Injuries

[SOP] Periop: Pressure Injury Prevention

[Policy] Diagnostic Imaging X-Ray Safety

[Policy] Therapeutic Laser Maintenance

[SOP] Laser Safety

[Policy] Management of Surgical Smoke

[Policy] Fire Safety and Red Alert

[Policy] Universal Protocol - Identification of Correct Patient, Procedure, Site/Side (Time Out)

Procedure Requirements Reference List for Universal Protocol, Identification of Correct Patient, Procedure, Site, and Side (Time Out)

References

[SOP] Photographing Pressure Injuries

[SOP] Periop: Pressure Injury Prevention

[Policy] Diagnostic Imaging X-Ray Safety

[Policy] Therapeutic Laser Maintenance

[SOP] Laser Safety

[Policy] Management of Surgical Smoke

[Policy] Fire Safety and Red Alert

[Policy] Universal Protocol - Identification of Correct Patient, Procedure, Site/Side (Time Out)

Procedure Requirements Reference List for Universal Protocol, Identification of Correct Patient, Procedure, Site, and Side (Time Out)

Closed Gloving

Method of donning sterile gloves that requires the hands not pass through the cuff of the sterile gown before gloves cover the cuff

References

[SOP] Photographing Pressure Injuries

[SOP] Periop: Pressure Injury Prevention

[Policy] Diagnostic Imaging X-Ray Safety

[Policy] Therapeutic Laser Maintenance

[SOP] Laser Safety

[Policy] Management of Surgical Smoke

[Policy] Fire Safety and Red Alert

[Policy] Universal Protocol - Identification of Correct Patient, Procedure, Site/Side (Time Out)

Procedure Requirements Reference List for Universal Protocol, Identification of Correct Patient, Procedure, Site, and Side (Time Out)

References

[SOP] Photographing Pressure Injuries

[SOP] Periop: Pressure Injury Prevention

[Policy] Diagnostic Imaging X-Ray Safety

[Policy] Therapeutic Laser Maintenance

[SOP] Laser Safety

[Policy] Management of Surgical Smoke

[Policy] Fire Safety and Red Alert

[Policy] Universal Protocol - Identification of Correct Patient, Procedure, Site/Side (Time Out)

Procedure Requirements Reference List for Universal Protocol, Identification of Correct Patient, Procedure, Site, and Side (Time Out)

References

[SOP] Photographing Pressure Injuries

[SOP] Periop: Pressure Injury Prevention

[Policy] Diagnostic Imaging X-Ray Safety

[Policy] Therapeutic Laser Maintenance

[SOP] Laser Safety

[Policy] Management of Surgical Smoke

[Policy] Fire Safety and Red Alert

[Policy] Universal Protocol - Identification of Correct Patient, Procedure, Site/Side (Time Out)

Procedure Requirements Reference List for Universal Protocol, Identification of Correct Patient, Procedure, Site, and Side (Time Out)

Rationale

Skin is a source of bacteria and shedding; therefore, maintaining distance from the sterile field can decrease the potential for contamination

References

[SOP] Photographing Pressure Injuries

[SOP] Periop: Pressure Injury Prevention

[Policy] Diagnostic Imaging X-Ray Safety

[Policy] Therapeutic Laser Maintenance

[SOP] Laser Safety

[Policy] Management of Surgical Smoke

[Policy] Fire Safety and Red Alert

[Policy] Universal Protocol - Identification of Correct Patient, Procedure, Site/Side (Time Out)

Procedure Requirements Reference List for Universal Protocol, Identification of Correct Patient, Procedure, Site, and Side (Time Out)

Event-related sterility

Event-related sterility (ERS) means that the contents of a sterile package are considered sterile until and unless an event occurs which renders the items to be contaminated. Events include moisture penetration, tears/punctures in the wrapper, tearing of the seal, and airborne contamination.

Association of Surgical Technologists (AST)

Symbols on Packaging

You can look for symbols on packaging to find information like expiration date and sterility.

Use by date symbol = expiration date (not to be confused with the date of manufacture)

Principles of Sterile Technique

• All personnel moving within or around a sterile field should do so in a manner that maintains the sterile field (restricted movement)
• Self-donning sterile gown and gloves must be done on a separate surface than the back table to prevent the possibility of contaminating the instruments
• Scrubbed persons must function within a sterile field, remaining close to the sterile field (walking outside the sterile field’s periphery or leaving the OR in sterile attire increases the potential for contamination)
• Scrubbed personnel should move from sterile areas to sterile area to prevent contamination, and if changing positions, should turn back-to-back or face-to-face
• Gowns have established parameters of sterility; the sterile gown is considered sterile on front from the chest to the level of the sterile field and on gown sleeves from two inches above the elbow to the cuff, circumferentially (the neckline, shoulder, underarms, sleeve cuffs, and gown back are not considered sterile)
• Scrubbed personnel should always keep their arms and hands above the level of their waists and in front of the body, so the hands remain visible
• Arms should not be folded with the hands in the axilla as the potential for the gloves to become contaminated by perspiration is likely
• Scrubbed personnel should avoid changing levels and should be seated only when the entire surgical procedure will be performed at that level

Principles of Sterile Technique

• Corrective action should be taken immediately unless the patient’s safety is at risk — otherwise correct the break in sterile technique as soon as it is safe to do so
• Sterile gloves that become contaminated should be changed as soon as possible
• When a major break in technique occurs, remember to change the wound class and document accordingly
• A permeated barrier is contaminated
• Edges of sterile wrapper/container are unsterile
• Tables are sterile at table level only
• When in doubt, throw it out

Peel Packs

Peel pouches should be presented to the scrubbed person to prevent contamination should the contents slide over the unsterile edge

Betadine Preps

• With povidone scrub, use cotton-tipped applicator to clean umbilicus (if included in surgical area)
• Next, use foam sponge from incision site outward to the periphery; repeat with other sponges (for five minutes total)
• Use a sterile towel to blot the prepped area
• With povidone paint solution, repeat process using other cotton-tipped applicator and the “paintbrush” sponges (from incision site to periphery and not returning to an area previously painted)
• Do NOT blot the paint solution
• Remove drip papers and allow it to completely dry according to the IFU (2 minutes)

References

[SOP] Photographing Pressure Injuries

[SOP] Periop: Pressure Injury Prevention

[Policy] Diagnostic Imaging X-Ray Safety

[Policy] Therapeutic Laser Maintenance

[SOP] Laser Safety

[Policy] Management of Surgical Smoke

[Policy] Fire Safety and Red Alert

[Policy] Universal Protocol - Identification of Correct Patient, Procedure, Site/Side (Time Out)

Procedure Requirements Reference List for Universal Protocol, Identification of Correct Patient, Procedure, Site, and Side (Time Out)

References

[SOP] Photographing Pressure Injuries

[SOP] Periop: Pressure Injury Prevention

[Policy] Diagnostic Imaging X-Ray Safety

[Policy] Therapeutic Laser Maintenance

[SOP] Laser Safety

[Policy] Management of Surgical Smoke

[Policy] Fire Safety and Red Alert

[Policy] Universal Protocol - Identification of Correct Patient, Procedure, Site/Side (Time Out)

Procedure Requirements Reference List for Universal Protocol, Identification of Correct Patient, Procedure, Site, and Side (Time Out)

References

[SOP] Photographing Pressure Injuries

[SOP] Periop: Pressure Injury Prevention

[Policy] Diagnostic Imaging X-Ray Safety

[Policy] Therapeutic Laser Maintenance

[SOP] Laser Safety

[Policy] Management of Surgical Smoke

[Policy] Fire Safety and Red Alert

[Policy] Universal Protocol - Identification of Correct Patient, Procedure, Site/Side (Time Out)

Procedure Requirements Reference List for Universal Protocol, Identification of Correct Patient, Procedure, Site, and Side (Time Out)

ChloraPrep Preps

• Not used on mucosa
• Recommended to open to the sterile field to avoid contamination from small packaging
• Dip cotton-tipped applicators in prep solution and clean umbilicus (if included in the surgical area)
• In dry areas, scrub incision site vigorously for 30 seconds before moving outward to the periphery (in moist areas, scrub incision site for 2 minutes)
• Move in a back-and-forth motion outward from incision area to periphery
• Do NOT blot or wipe away the solution; remove drip papers and allow it to completely dry according to the manufacturer’s instructions for use (3 minutes for non-hairy sites and up to 1 hour for hairy sites)

How Mepilex Addresses Risk Factors

• Specifically designed to protect against the extrinsic forces of pressure, shear, and friction (significant contributors to pressure injury)
• Manage microclimate by effectively handling wound exudate
• Seals the wound edges to prevent exudate from leaking onto the surrounding skin, minimizing the risk of maceration
• Ensures that the dressing can be removed atraumatically, minimizing pain and trauma to the wound and surrounding skin
• Can be applied prophylactically to patients at risk of pressure ulcers, particularly those with reduced mobility or immobility
• Designed to protect fragile or compromised skin

References

[SOP] Photographing Pressure Injuries

[SOP] Periop: Pressure Injury Prevention

[Policy] Diagnostic Imaging X-Ray Safety

[Policy] Therapeutic Laser Maintenance

[SOP] Laser Safety

[Policy] Management of Surgical Smoke

[Policy] Fire Safety and Red Alert

[Policy] Universal Protocol - Identification of Correct Patient, Procedure, Site/Side (Time Out)

Procedure Requirements Reference List for Universal Protocol, Identification of Correct Patient, Procedure, Site, and Side (Time Out)

Containers with Sterile Fluids

• When solutions are dispensed, the receiving container should be placed near the edge of the sterile table and the entire contents of the container should be poured slowly to avoid splashing
• Any remaining fluids should be discarded as the edge of the container is considered contaminated after the contents have been poured (the sterility of the contents cannot be ensured if the cap is replaced)

Chart View of Fire Risk Score

References

[SOP] Photographing Pressure Injuries

[SOP] Periop: Pressure Injury Prevention

[Policy] Diagnostic Imaging X-Ray Safety

[Policy] Therapeutic Laser Maintenance

[SOP] Laser Safety

[Policy] Management of Surgical Smoke

[Policy] Fire Safety and Red Alert

[Policy] Universal Protocol - Identification of Correct Patient, Procedure, Site/Side (Time Out)

Procedure Requirements Reference List for Universal Protocol, Identification of Correct Patient, Procedure, Site, and Side (Time Out)

References

[SOP] Photographing Pressure Injuries

[SOP] Periop: Pressure Injury Prevention

[Policy] Diagnostic Imaging X-Ray Safety

[Policy] Therapeutic Laser Maintenance

[SOP] Laser Safety

[Policy] Management of Surgical Smoke

[Policy] Fire Safety and Red Alert

[Policy] Universal Protocol - Identification of Correct Patient, Procedure, Site/Side (Time Out)

Procedure Requirements Reference List for Universal Protocol, Identification of Correct Patient, Procedure, Site, and Side (Time Out)

Chart View of Time Out