Scrubbing , Gowning, Gloving and Draping

APN Cheng Mei Ling TMH (A&OT)

Content

•Surgical site infection (SSI)

•Source of contamination

•Scrubbing

•Gowning & Gloving & Draping

•Principle of Asepsis

Surgical site infection (SSI)

•An infection that occurs after surgery in the body site where the surgery was performed.

* Interventions in the pre-, intra-, and postoperative measures that can be undertaken to prevent or minimize the risk for developing SSIs.

Caple C, Woten M(2018)

Why?

Desired Outcome

To reduce the incidence and severity of SSIs, and thereby reduce the morbidity and mortality that can result from a serious SSI.

Caple C, Woten M(2018)

RISK IS A MYRIAD OF EVENT - SSI FISHBONE DIAGRAM (CHARLES E. EDMISTON , 2014)

WHO Global guideline for the prevention of SSI (2016)

SSI Prevention Bundle

HUMAN –BORNE SOURCES OF CONTAMINATIONSOURCES Action contribute to the prevalence

and dispersion of microorganisms

• Skin of patient, OR team, visitor

• Hair - staphylococci

• Nasopharynx - talking, coughing, sneezing

• Human error - break the aseptic technique

• Cross infection – every patient should be considered as a potential source of infection

- Minimize skin shedding – perform hand hygiene before entering OR/ clean OR attire/ cover cuts & abrasion

- Cover hair completely with clean cap

- Wear mask in restricted area and change if necessary

- Practice strict sterile, aseptic technique

- Standard precaution

NON-HUMAN FACTORS IN CONTAMINATIONNon Human factors Action contribute to the

prevalence and dispersion of microorganisms

Fomites- Contaminated particles present in the dust or inanimate surfaces

- Prompt disinfection of the contaminated environment - Separation of clean/ soiled items - Proper packing/ storage

Air - Effective ventilation system

HOW TO MAINTAIN ASEPSIS ?

SURGICAL HAND ANTISEPSIS

What is Surgical scrub?- A process of removing as many microorganisms as possible from the hands and arms by mechanical washing and chemical antisepsis before participating in a surgical procedure.

- Despite the mechanical action and the chemical antimicrobial component of the scrub process, skin is never sterile.

- The goal of perioperative hand antisepsis is not to render the hands sterile but to decrease the number of transient and resident flora on the hands and arms and to inhibit the growth of bacteria under the gloves during the procedure

(Caple C, Woten M, 2018)

TRANSIENT ORGANISM

-Micro organism attached to skin surfaceand acquired by direct contact

- Completely mechanically removed bythorough washing with soap and water

RESIDENT ORGANISMS -Microorganism below skin surface in

hair follicles, sebaceous and sweat glands. --More adherent and resistant to removal

• Their growth can be inhibited by chemical phase of the surgical hand- cleansing process

•Capable of causing infectione.g. Staphylococcus epidermidis

Hand Hygiene and Surgical Hand Antisepsis Four general types of hand hygiene that should be performed in the perioperative environment are :

1. Washing hands that are visibly soiled

2. Hand hygiene using alcohol-based products

3. Surgical hand scrubs, and

4. Surgical hand scrubs using an alcohol-based surgical hand rub product

(AORN, 2013)

FACTORS AFFECTING EFFECTIVENESS OF CLEANSING

-Hand conditions -Choice of antiseptic agent -Cleansing method -Duration for hand cleansing

Preparation of scrubbing-No skin abrasion

-Keep short fingernails

-No fingernail polish and artificial nails

-No jewelries

-Wear cap and mask

-Wear goggle or face shield

-Wear plastic apron if required

Surgical hand antiseptic products (recommended)Antimicrobial scrubbing

solutions: 1. Chlorhexidine 4 %

2. Providine Iodine 7.5%

Alcohol based handrub:- WHO Formula 1 or 2 Alcohol Rubs containing additive chlorhexidinegluconate 1 % solution and ethyl alcohol 61% w/w

Characteristics of antiseptic

• Antimicrobial action

• Persistent activity

• Safety

• Acceptance

Method of ScrubbingPRE -SCRUB

Method of Scrubbing• Standardized time or counted stroke method

- A 3 or 5-minute scrub should be timed to allow adequate product contact with skin, according to manufacturer’s written directions. (AORN,2013)

- Anatomical timed method: 2 minutes for Chlorhexidine 4% or 3 minutes for Providone iodine 7.5%, Counted stroke method: at least 5 strokes for each area when applied with Chlorhexidine 4%; at least 10 strokes for each area when applied with Povidone Iodine 7.5%. (Advanced Nursing Standard, 2017)

- From finger tips to elbow

• Pre-wash hands before surgical hand antisepsis to remove dirt and skin debris

• Apply adequate antiseptic scrub agent and ensure contact time is sufficient to be effective

• All surfaces are exposed to mechanical scrub and chemical antiseptic action

Method of Scrubbing• Studies suggest that neither a brush nor a sponge is necessary to

reduce bacterial counts on the hands of surgical personnel to acceptable levels, especially when alcohol-based products are used.

• One study (AORN J 2001;73:412) found a brushless application of a preparation of 1% CHG plus 61% ethanol yielded lower bacterial counts on the hands of participants than using a sponge/brush to apply 4% CHG.

• Brush is not recommended. (Advanced Nursing Standard, 2017)

Scrubbing Procedure1. Preliminary hand washing for 40 to 60 sec (pre-scrub)

2. Rinse under running water

3. Apply adequate antimicrobial agent from fingers to elbows (5-10ml), lather all areas completely

4. Scrub from fingers to elbows of each hand for 1 minute, total 2 minutes.

5. Rinse under running water. Always keep the hands higher than the elbows

6. Repeat steps 3 and 4 of each hand and arm for ½ minute and rinse, total 1 minute.

7. Dry from fingertips to elbows

8. Don gown and gloves with aseptic technique.

VIDEO FOR SURGICAL HAND ANTISEPSIS http://nursenet.home/sag/peri-op-anaes/Educational%20Material/Scrubbing%20video%20(Updated).wmv

SURGICAL ANTISEPSISHAND RUB • Apply alcohol-based product on dry

hand only

• Use sufficient amount of product to keep hands & forearm dry

• Dry thoroughly before donning sterile gown & glove

• Do not combine surgical hand antimicrobial agents with alcohol based surgical hand rub sequentially

SURGICAL ANTISEPSIS HAND RUB

PERIOPERATIVE PERSONNEL (AORN 2017)

• All the OR personnel should wear clean scrub attire/ head cover/ surgical mask when entering OR

• Perioperative personnel should perform hand hygiene before entering the OR where sterile supplies have been opened.

• Regular hand hygiene practices help to prevent transmission of infection

Purpose of Gowning, Gloving and Draping

• A sterile gown and gloves are worn to exclude skin as a possible contaminant and to create a barrier between the sterile and non-sterile areas. The gown protects the patient and the wearer from cross-contamination.

• Draping is the procedure of covering the patient and surrounding areas with a sterile barrier to create and maintain an adequate sterile field.

GOWN & DRAPE 1. Surgical gown and drapes should be evaluated according to the AORN “Recommended practices for the evaluation and selection of products used in perioperative practice setting” (2003, AORN)

- Safe construction, meet identified needs and promote patient safety.

- Reinforcements may consist of additional layers of the same material or layers of different material

2. Materials used for surgical gowns and drapes should be resistant to penetration by blood and other body fluids as necessitated by their intended use.

- Manufacturers data verifying materials used in gowns and drapes are protective barriers against the transfer of microorganisms, particulates and fluids.

3. Surgical gown and drapes should maintain their integrity and be durable-> resistant to tears, punctures and abrasions

- Reusable materials should be inspected visually to determine their integrity. Reusable textiles should be patched with heat sealed patches of the same quality material.

GOWN & DRAPE4. Material used for surgical gowns and drapes should be appropriate to the method of sterilization.

- Ethylene oxide, steam and radiation

- Reusable textile will lose their protective barrier quality after repeated processing. Manufacturers’ instructions for handling, suggested number of processings and the useful life of barrier materials should be provided and followed. (Tracking system)

5. Surgical gowns and drapes should resist combustion

- With accepted flammability standards

- Care should be taken when gowns and drapes are exposed to light and heat sources, electrosurgical devices, lasers and other power equipment.

6. Surgical gowns and drapes selected for use should have a favorable cost: benefit ratio

7. Policies and procedures for selecting and using surgical gowns and drapes should be developed

GOWN

-The front of the sterile gown should be considered sterile from the chest to the level of the sterile field

-The neckline, shoulders and axillary regions of the surgical gown should be considered as contaminated – area of friction and may not provide effective microbial barrier

-The back of the sterile gown considered as unsterile due to cannot constantly monitored

GOWN- Gown sleeve consider to be sterile from 2 inches above the elbow to the cuff, circumferentially

- Sleeve cuffs should be considered as contaminated when the hands pass through and beyond the cuff

- Sleeve cuff should be completely covered by sterile gloves and should not be exposed

Gowning and Gloving

General considerations

• Donning sterile gowns and gloves in a separate area – prevent contamination of the main instrument table by droplets of water or skin antiseptic solution from the scrub team’s wet hand

• Perioperative team members should perform surgical hand scrub before donning sterile gowns and gloves

• Scrub team’s hand should keep dry before donning the sterile gowns & gloves

• Splashing water on scrub attire during the surgical scrub should be avoided

• Only the inside of sterile gown should be touched when it is picked up for donning by the scrubbed personnel

Double gloving• Double gloves is recommended during surgical &

other invasive procedures with potential for exposure to infectious materials. (AORN, 2013)

• Perforation indication system should be used

A perforation indicator system uses a colored pair of gloves worn beneath a standard pair of gloves. Wearing dark-colored gloves under light-colored gloves helps surgeons and surgical team members more readily notice glove perforations and change gloves more easily than if they're wearing 2 pairs of the same-colored gloves.

GLOVES

-Scrubbed team members should inspect gloves for integrity after donning, before contact with the sterile field, and throughout use.

-Change the gloves if:

1)Contamination

2)Visible defect of perforation

3)Adjusting microscope optic eyepieces

4)Gloves begin to swell. expand, and become loose on one hands as a result of the material’s absorption of fluids and fats

5)Every 90 to 150 minutes (2013, AORN)

Glove

Various types of sterile gloves

- Latex

- Latex free

- Powder free

VIDEO FOR GOWNING & GLOVING

https://www.youtube.com/watch?v=VY7tgbbg6-E

DRAPE (2003, AORN) • Blood and fluid resistant to keep drapes dry and

prevent migration of microorganism. Material should be impermeable to moist.

• Resistant to tear, puncture, or abrasion that cause fiber breakdown.

• Lint-free to reduce airborne contaminants and shedding into the surgical site.

• Antistatic to eliminate risk of a spark from static electricity. (National Fire Protection Association).

• Sufficient porous to eliminate heat buildup so as to maintain an isothermic enviromment for patient’s body temperature.

• Drapable to fit around contours of patient, furniture, and equipment.

DRAPE • Free from toxic ingredients

• Dull to minimize colour distortion from reflected light.

• Flame-resistant to self-extinguish rapidly on removal of an ignition source.

RULES OF DRAPING - Drapes should be placed on the patient and all surfaces within the sterile field

- Perioperative team should place the sterile drape on non sterile furniture/ equipment in manner that prevents contamination

- Draping should be done from area around the incision towards the periphery

- Any non-sterile equipment brought into the sterile field should be draped with sterile barrier materials

- Once a drape is in position, it is not to be repositioned

- A drape is considered contaminated if it falls below waist level during handling

- When a drape is secured with towel clips, the clips and towel should not be allowed to remove until the end of the procedure

- Equipment or accessories that cannot be sterilized should be inserted into sterile covers when brought into the sterile field

RULES OF DRAPING - Drapes should be handles as little as possible

- Drapes should not be shaken

-During draping, sterile gloves should be protected by cuffing the draping material over the hands.

- The drape is held between the shoulder and waist level of a scrubbed person while draping

- Sufficient space should be allowed for draping to minimize risk of contamination by surrounding objects

- The sterile field should be prepared as close to the time of use. Potential for contamination from particles in air increases with time.

PRINCIPLE OF ASEPSIS AORN 2012; BERRY & KOHN’S 2013

- Sterile personnel are scrubbed, gowned & gloved

- Sterile personnel touch only sterile items/ area

- Sterile drapes should be used to establish a sterile field

- Only sterile items are used within sterile field

- All items introduced to a sterile field should be opened, dispensed & transferred by methods that maintain items sterility

- A sterile field should be maintained & monitored constantly. Personnel moving within or around a sterile field should do so in a manner that maintains the sterile field

- The sterile field is created as close as possible to the time of use

PRINCIPLE OF ASEPSIS Scrubbed Persons function within a sterile field

- Separated the sterile & Non sterile team

- Scrubbed up personnel work only on sterile field, non sterile team work periphery of the sterile field

- All surgical team members wear surgical attire

- All scrubbed persons should wear sterile gown/ gloves, & mask to establish bacteria barriers in order to prevent transmission of microorganism from sterile team to patient

PRINCIPLE OF ASEPSIS Sterile Drapes are used to create sterile field

Sterile surgical drapes establish an aseptic barrier minimizing the passage of microorganisms from non sterile area to sterile area

Sterile drapes should be placed on patient/ equipment which included in sterile field, leaving the incisional site exposed

Only scrubbed personnel should handle the sterile drapes

PRINCIPLE OF ASEPSIS Sterile drapes are used to create sterile field

- Once the sterile drape is positioned, it should not be moved or rearranged

- Patient should be draped from prepped incisional site out to the periphery

- After the patient and working table are draped, only the top of surface of the draped area is considered sterile

PRINCIPLE OF ASEPSIS All Items used within a sterile field must be sterile

- Sterilization provides the highest level of assurance that sterile items are free of microorganism.

- The sterility of package is determined by events, not by time.

- All sterile item should be inspected for package integrity and sterilization process (sterilization indicator) prior to the introduction onto the sterile field

PRINCIPLE OF ASEPSIS All items used within a sterile field must be sterile

- If a package has been compromised, it should be considered contaminated and not be used.

- Fluid & air can contaminate a sterile package, if it penetrates a sterile package, it should be considered contaminated and not be used.

PRINCIPLE OF ASEPSIS All items introduced onto a sterile filed should be opened, dispensed, and transferred by methods that maintain sterility & integrity

- The circulating nurse should be careful when dispensing sterile item onto the sterile field

- Sterile items that are tossed onto the sterile field may displace other sterile items, penetrate the drapes, or roll off the sterile field causing contamination to occur

PRINCIPLE OF ASEPSIS When opening wrapped supplies……..

The ‘Non sterile’ person opens the package by rolling the wrapper over his/her hands & presenting the inner contents of the package to the scrubbed person.

The package and its contents must be presented in such a way to prevent contamination of the sterile item or the scrubbed person.

PRINCIPLE OF ASEPSIS When opening wrapped supplies……..

- When determining package content sterility, the inner edge of the heat seal is considered the line separating sterile from non-sterile.

PRINCIPLE OF ASEPSIS When opening solution container……..

- The non sterile person should lift the cap straight up and pour the content into the sterile container

- A safe distance should be maintained between the bottle and the sterile field

PRINCIPLE OF ASEPSIS When opening solution container……..

- The sterile container is either held by the scrubbed person away from the sterile field or placed near the edge of sterile drape.

- Only the top rim of the bottle & the contents are considered - Avoid splashing while pouring liquid……..

- Pour slowly to prevent contamination and fluid strike through from splashing cap has been removed from the bottle

PRINCIPLE OF ASEPSIS

A sterile field should be maintained and monitored constantly

• Responsibility of all OR staff

• Make every reasonable effort to minimize the risk of contamination

• When a breach of sterility occurs, take immediate & appropriate actions to correct the break.

• If there is doubt regarding an item’s sterility, consider it is not sterile

PRINCIPLE OF ASEPSIS All personnel moving within or around a sterile field should do so in a manner to maintain the sterile field

- Scrubbed personnel should move only from sterile area to sterile area

- When scrubbed personnel change positions, they should maintain a safe distance from each other & always pass each other by turning:

Back to back (non sterile to non sterile) or

Face to face (sterile to sterile)

PRINCIPLE OF ASEPSIS The sterile field should be prepared as close as possible to the time of use

- The sterility of supplies used during a surgical procedure can be affected by:

• Events taking place within the operating theatre or

• Length of time items exposed to the environment

• Once set up, the sterile field needs to be monitored constantly.

• When the sterile field is left unattended, personnel, airborne contaminants, insects, & liquids can contaminate the sterile field

RULES TO FOLLOW • Scrubbed personnel should remain in the

position in which they began the surgery

• Scrubbed personnel should keep their arms & hands within the sterile field to avoid any accidental contamination

• Scrubbed personnel must maintain a safe distance when approaching non-sterile objects or personnel

• Non-sterile personnel always face the sterile field on approach & never walk between two sterile fields. This ensure that the sterile area is always being observed and accidental contact is avoided.

MARGIN OF SAFETY• Non-sterile personnel must maintain

a “Margin of safety” between themselves and the sterile field

• Never contacting or reaching over any portion of the sterile area. This “Margin of safety” is generally identified as a minimum of 12 inches (30cm) or more

POINTS TO NOTE IN MAINTAINING THE STERILE FIELD• Scrubbed personnel should kept

hands above the waist and insight at all times

• The Sterile area are:

• 1. Front of the gown from the table level or sterile field to two inches below the neck

• 2. The sleeves from 2 inches above the elbow to the cuff

• 3. The surgical gloves

POINTS TO NOTE IN MAINTAINING THE STERILE FIELD • Underarm/ back of the gown

are considered non sterile

• If any part of the sterile gown being contaminated, change immediately

• Once the gloves are donned, the gown cuffs could be contaminated because the scrubbed hand passed through them

ADVANCED NURSING STANDARDS FOR PATIENT CARE MAINTENANCE OF STERILE FIELD HAHO-COC-NS-NUR-015-07-V01 (SPECIALTY ADVISORY GROUP)

• Standard statement

Patient’s risk for Surgical Site Infection is

minimized with the practice of aseptic

techniques during operative procedure

PROCESS STANDARD

• Proper scrub attire (sterile gown/ glove no contamination)

• Scrubbed personnel function within sterile field (keep hands in front of chest, below shoulders and above waist level)

• Correct draping method (No shift/ create sterile field from surgical site to periphery, from above downward)

• All items used in sterile field are sterile (wrapper opening/ integrity of sterile pack/ sterilization status)

• Maintain and monitor the sterile field constantly (keep at least 30cm distance from sterile field/ facing to the sterile field/ avoid walking between 2 sterile area)

• Initiate corrective action(s) when break in aseptic technique occur

ADVANCED NURSING STANDARDS FOR PATIENT CARE SURGICAL HAND ANTISEPSIS, GOWNING & GLOVING FOR OPERATIVE PROCEDURES HAHO-COC-NS-NUR-015-17-V02 (SPECIALTY ADVISORY GROUP)

Patient safety is maintained with proper surgical hand antisepsis, gowning & gloving of the perioperative procedure(s)

PROCESS STANDARDS * Ensure all members of surgical team are dressed appropriately in perioperative attire & PPE prior to commencement of surgical hand antisepsis

• Ensure recommended surgical hand antiseptic products are used

• Perform surgical antisepsis in accordance to individual protocol or method as recommended by the manufacturer

• Ensure donning of gown & gloves are performed under aseptic technique

• Initiate appropriate action(s) when contamination occur

REFERENCES

• AORN Recommended Practices Committee. Association of Operating Room Nurses, AORN Journal 83.2 (Feb 2006): 402-4, 407-10, 413-6

• Centre for Health Protection (2009). Recommendations on Prevention of Surgical Site Infection, Hong Kong: Centre for Health Protection.

• Guidelines for Perioperative practice, 2017, AORN

• Guidelines for Specialty Nursing Services – Perioperative Care 2015, SAG (Peri-op/Anaes), HAHO

• Harnoss JC, Partecke LI, Heidecke CD, Hubner NO, Kramer A, Assardian O. Concentration of bacteria passing through puncture holes in surgical gloves. AM J Infection control. 2010; 38(2)11(12):825-832. IIB

•

• Recommendations on Prevention of surgical site infection (2009), Scientific committee on Infection Control,CHP

REFERENCES

1. Phillips, N. (2017). Berry & Kohn’s Operating Room Technique (13th ed). St Louis, MO: Elsevier Health Sciences.

2. Caple C, Woten M. (2018). Hand Hygiene: Surgical Scrub- Performing. CINAHL Nursing Guide, Database: Nursing reference Center Plus. EBSCO Publishing.

3. World Health Organization. (2016).Global guideline for the prevention of surgical site infection. Geneva, Switzerland: World Health Organization.

4. Association for Perioperative Practice (AfPP). (2017). A guide to surgical asepsis. Retrieved April 30, 2018, from http://www.afpp.org.uk/careers/Standards-Guidance

5. Advanced Nursing Standards for Patient Care- Surgical Hand Antisepsis, Gowning & Gloving for Operative Procedures 2017, SAG (Peri-op/Anaes), HAHO

6. AORN Recommended Practices Committee. Association of Operating Room Nurses, AORN J 2001;73:412

7. Video for surgical hand antisepsis, 2020, Retrieved from http://nursenet.home/sag/peri-op anaes/Educational%20Material/Scrubbing%20video%20(Updated).wmv

8. Recommended practices for hand hygiene. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc: 2013: 63-74

9. Association of PeriOperative Registered Nurses, 2017; Gibbons et al., 2017.

10. AORN Recommended Practices for Selection and Use of Surgical Gowns and Drapes. AORN J 2003; 77: 206-213

REFERENCES

11. Tammy Childs, Use of Double Gloving to Reduce Surgical Personnel's Risk of Exposure to Bloodborne Pathogens: An Integrative Review, AORN Journal, 10.1016/j.aorn.2013.10.004, 98, 6, (585-596.e6), (2013).

12. Phillips, N. F. (2013). Berry & Kohn’s Operating Room Technique,12th ED. “Surgical Asepsis and Sterile Technique”. Missouri: Mosby

13. https://www.youtube.com/watch?v=VY7tgbbg6-E

HR App Nursing App