Operating Room Back to Basics

Operating Room Back to Basics

Wills Eye Hospital Operating room April 2026

Surgical Conscience

• What is it?
• Advocating and defending perioperative safety protocols regardless of consequences and cost.
• Surgical conscience (SC) begins with the knowledge of aseptic technique, infection control, and safety.
• SC is supported by constant awareness of self and surroundings to maintain sterile integrity
• Critical skill that involves “The courage to make ethical and moral decisions that benefit the patient”.

Before Preparing the Sterile Field

• Wear clean surgical attire and surgical head covering when entering an OR
• Wear a clean surgical mask that completely covers the mouth, nose, and chin when opened sterile supplies are present
• A clean surgical mask is required for each patient; change your mask after each case.

Donning Gowns and Gloves

• Select a surgical gown that provides adequate barrier protection as determined by the:team members role, procedure type, anticipated blood loss, anticipated volume of irrigation, length of procedure, and probability of handling hazardous medications.

• Select a gown that wraps around the body and completely covers wearer’s back.

• Perform surgical antisepsis before putting on a surgical gown and gloves.

Donning Gowns and Gloves

• Prevent contamination when donning a sterile gown by:

• Following the manufacturer’s IFU’s
• Placing and opening the gown away from sterile field
• Avoid putting sterile gloves on top of the open surgical gown
• Only touching the inside of the gown when putting it on
• Only touching the sterile glove wrapper after the gown has been put on
• Wear two pairs of sterile gloves and use a perforation indicator system when scrubbed into the sterile field
• Cover the surgical gown cuffs with the sterile gloves

Donning Gowns and Gloves

• Change surgical gloves:

• Every 60 to 150 minutes

• When known or suspected contamination occurs
• When a defect or perforation is identified or suspected
• After touching: (a surgical helmet/visor/optic eyepieces on a microscope)
• Avoid using penetrable materials (sterile towels) to manipulate or hold unsterile items such as a cell phone

Preparing the Sterile Field and Draping

• Prepare the sterile field as close as possible to the time of the procedure

• Do not move the sterile field to another room once it is set up

• Keep sterile fields and instrumentation separate for procedures that involve more than one wound classification (clean, clean-contaminated, contaminated, dirty)

• Prepare sterile fields according to the health care organization’s process when using isolation technique

• Place sterile drapes as close as possible to the time of the procedure and in accordance with the manufacturer’s IFU

Preparing the Sterile Field and Draping

• Avoid leaning over or reaching across an unsterile area when placing surgical drapes

• Shield sterile gloved hands by cuffing the sterile drape

• Avoid moving drapes once they are placed

• Use a non-perforating device when securing surgical equipment (tubing, cords) to the drape

• Consider any item that falls below the level of sterile field to be contaminated

Opening and Handling Sterile Items

• Inspect the packaging of sterile items for:

• Sterility of the contents as noted on the packaging

• Package and product integrity

• The expiration date when applicable

• Chemical indicator changes (color change)

• Present sterile items directly to the scrubbed person or place them securely on the sterile field

• Present heavy or sharp items directly to the scrubbed person or place them on a separate surface

• Inspect rigid sterilization containers for intact, secure latch filters; intact external locks, valves, and tamper-evident devices; and correct color change to external chemical indicators

Opening and Handling Sterile Items

• Examine wrapped sterile packages for intact tape and the correct color change for the external chemical indicator before opening

• Examine paper-plastic pouches (peel pouches) for intact seals and chemical indicators

• Prevent items from sliding over unsterile edges of the pouch by pulling back on the flaps without touching the inside of the package

• Inspect instruments for retained bioburden and debris after they are opened to the sterile field

• Consider instruments to be contaminated if debris, moisture, or damage is present

• When a contaminated instrument is discovered, consider the entire instrument set to be contaminated

Opening and Handling Sterile Items

• Medication Preparation:

• Disinfect medication vial stoppers with alcohol and allow the stopper to dry before each entry, including the initial entry after removal of the cap or cover.

• Use a new sterile access device each time medication is withdrawn from a vial, preferably with a needleless method or use of a blunt needle.

• Transfer medications and solutions to the sterile field by:

• Opening them as close as possible to the time of use

• Transferring them in a slow, controlled manner using a sterile transfer device (sterile vial spike, sterile blunt needle, sterile syringe) and in accordance with the manufacturer’s IFU

• Only removing the medication vial stopper if it is designed for removal

• Pouring them in a container that is near the sterile table’s edge or held by the scrubbed person (Irrigation)

• Pouring them only once (Irrigation)
• Minimize splashing or spilling of medications and solutions and the need to reach over the sterile field.

• Reduces the risk of contaminating the medication or solution, the sterile field, and the surgical site

Limiting Movement Around Sterile Field

• Keep the number of personnel in the OR to a minimum

• Keep doors to the OR closed as much as possible

• Decrease movement around the sterile field

• Limit non essential conversations

Limit Movement Around Sterile Field

• Scrubbed team members:

• Stay close to sterile field and touch only sterile items

• Keep hands above waist level

• Limit the number and speed of movements

• Do not fold arms and place hands in the axilla

• Avoid changing levels

• Avoid turning back to sterile field

• Turn back to back or face to face during position changes

• Unscrubbed team members:

• Limit the number and speed of movements

• Face sterile field when approaching it

• Avoid walking between sterile fields or scrubbed team members

• Stay as far from the sterile field and scrubbed team members as possible

Maintaining the Sterile Field

• Refer to the organization’s standard procedure regarding circumstances that might necessitate the sterile field being covered, how it is covered, and the length of time it should be covered

• Monitor the sterile field for contamination, and correct breaks and potential breaks in sterile technique immediately.

• Consider instruments and devices to be contaminated when they are:

• Processed assembled or clamped closed

• Found to have retained organic material (eg, blood, hair, tissue) or other debris (eg, bone cement, grease, mineral deposits)

• Used on infected tissue

• Used inside the bowel or on the bowel lumen

• Used to resect metastatic tumors

• Involved in a glove tear or perforation

Maintaining the Sterile Field

• Monitor the sterile field for contamination, and correct breaks and potential breaks in sterile technique immediately

• When bins with sterile water are used for instrument soaking:

• Separate bin from other items on sterile field

• Do not use the water for patient irrigation

• Do not return instruments from the basin to sterile field

• Do not use water for any other purpose

Surgical Wound Classification

• Determine the surgical wound classification for the procedure during the postprocedural debriefing

• Document the surgical wound classification in the patient’s EMR

• Document major breaks in sterile technique and report incident per facility policy/procedure

• Assigned based on presence of infection or contamination in the wound

• The four surgical wound classifications the National Healthcare Safety Network Recognizes:
• Clean

• Clean-Contaminated

• Contaminated

• Dirty/Infected

Specimen Collection

• Specimens should be protected and secured on the sterile field to maintain the integrity of the specimen.

• Specimen should be passed off the sterile field as soon as possible.

• Specimens and containers removed from the surgical field should be handled using standard precautions.

• Syringes used for specimen collection and containment should be capped without needles.

• Cases where there is a high probability of a specimen open a sterile specimen cup and or telfa to the sterile field in the beginning of the case.

References

• 2024 August AORN Journal
• Guideline Quick View: Sterile Technique
• Karch, J. (2023, September 21). Pathology Specimens . Philadelphia; Wills Eye Hospital

• The Importance of Having a Surgical Conscience, AORN, 2023