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APGOClinicalSkillsCurriculum

SterileTechnique

AssociationofProfessorsofGynecologyandObstetrics(APGO)UndergraduateMedicalEducationCommittee2008


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SterileTechnique:ScrubbingandGowningforSurgeryandPreparingandDrapingthePatient

TableofContentsIntendedLearningObjectives 3

Description 4

BestPractices 5

Checklist 13

PerformanceAssessment 14

PracticalTips 14

Resources 14

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IntendedLearningObjectivesThisclinicalskillsmoduleprovidesaframeworkforteachingtheimportanceof,andthe

principlesbehind,steriletechnique.Followingparticipationinthismodule,students

should:

1.Understandtherationalebehindtheimportanceofsteriletechnique

2.Scrubproperlyfordeliveriesandforsurgery

3.Gownandgloveproperlyforsurgery,withoutbreakingsteriletechnique

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Description[When]...itappearedthattheferments,properlysocalled,arelivingbeings,thatthegermsof

microscopicorganismsaboundonthesurfaceofallobjects,intheairandinwater;thatthetheory

ofspontaneousgenerationischimerical;thatwines,beer,vinegar,theblood,urineandallthe

fluidsof

the

body

undergo

none

of

their

usual

changes

in

pure

air,

both

Medicine

and

Surgery

receivedfreshstimulation. LouisPasteur

NotJustCleanSterile(oraseptic)techniqueisfirstandforemostinminimizingpossiblesourcesof

infection(nosocomialinfection=aninfectionacquiredwhilehospitalized).

Sterilemeansfreeofbugsthatcaninfectpeople.SterilitywillapplytoSELECTsurfaces

ofobjectsortosubstancesthatwillbeintroducedintoapatientsbody.Someobjectsjust

donot

have

the

potential

to

be

made

sterile.

Hands

can

be

made

very

clean,

but

not

sterile.Scrubsfromthelockerroomdispenserarenotsterile,noraresurgical

masks.Themessageis:Onlyspecific,deliberatelypreparedsurfacesorsubstancesare

consideredsterile.

Whatfollowsisthegeneralideabehindsterilefields:

1.Prepareandmaintainselectsurfacesassterile.

2.Minimizepotentialsourcesofcontaminationbysegregatingsterilesurfaces

fromnonsterileareas,evenverycleanareas!

Thespaceinwhichsterileobjectsmayinteractundisruptedbynonsterileobjectsisa

sterilefield.Animportantpointtobearinmindisthatapersonorthingwillhaveonlya

particularportionofitssurfacedesignatedassterileand,therefore,withinasterile

field.Everyothersurfaceisconsiderednonsterile,andanynonsterilesurfacemay

contaminateasterilesurface.

Sterilefieldsaredefinedbythesterilesurfacesoftwooperatingroom(OR)components.

Typically,onscrubbedsurgicalpersonnel(byscrubbed,meaninghandswashed

accordingtoORprotocol,donningsterilegown,sterilegloves),thesterilesurfacewould

extendapproximately

from

the

chest

to

the

waist

on

the

torso

and

from

elbows

to

the

tipsofglovedfingersontheupperlimb.Therestofthescrubbedpersonisnotsterile

andisapossiblesourceofcontaminationforthesterilearea.

Onapatient,onlythepreparedsurfaceofthebodyandthesteriledrapeareconsidered

withinthesterilefield.Notethatedgesofotherwisesterilesurfacesarenotsterile,since

theymustcontact(orappose)nonsterileobjects.So,thephysicaledgesofasteriledrape

oranysurfaceofthedrapebelowthespacedefinedbytheothersterileobjectsofthe

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fieldarenotconsideredsterile.

BestPracticesScrubbingInAtypicalORvisitmaybeasfollows:

1. Obtainscrubsandchanging

2.Washhandsorusingrapiddryingwaterfreewashespriortoexaminingortouching

anypatientsandpriortosurgery(oranypatientencounterwithyourhandsor

stethoscope)

3.

Obtain

and

don

a

surgical

hair

cap.

(All

hair

must

be

covered.

There

are

different

typesofcapsforlongerhairandforbeards).Shoecoversareusedatsome,butnotall,

institutions(TheseitemsaregenerallyfoundattheentrancetotheOR.)

4. Obtainanddonasurgicalmaskatthescrubstation;removehandjewelry,suchas

ringsandwatches

5. Entertheoperatingroom.Bealerttothescrubnurse,andavoidanysterileareas

6. Performanydutieswithnonsterileobjects(includingpatientpreparation)

7. Scrubbingin

Generally,scrubbinginmeansasequenceofprocedureswhereinoneattainsasterilesurface,including:1. Surgicalhandscrub

2. Gowning(puttingonsterile,surgicalgown)

3. Gloving(puttingonsterile,surgicalgloves)

ThesurgicalhandscrubisperformedoutsidetheORatthescrubstation.Once

completed,onemustcarefullyreentertheORforgowning,usuallywiththeassistance

ofthescrubnurse,andgloving.

Finally,oncegownedandgloved,apersonsmovementsmusttakeintoconsideration

thesterilefields.Typically,whenmoving,handsshouldbekeptdirectlyinfrontofthe

chest,butclearofthefaceorothernonsterileareas.WhenpassingORpersonnelornon

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sterilethings,onesbackshouldbedirectedtowardthenonsterilesurfacesoftheseOR

obstacles.Oncepartofthesterilefield,thesterilesurfacemustfacethepreparedsurface

ofthepatientorothersterilesurfaces.

Reviewthepictures,below,foravisualunderstandingofthisprocess:

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ChecklistWellDone

NeedsImprovement

NotDone

CannotRecall

ScrubbingforsurgeryCorrectlydonsthesurgicalcapand

mask

Correctlyopensthepacketof

surgicalscrubsoap

Turnsonthewatercorrectlyand

adjustthetemperaturetoa

comfortablelevel

Correctlycleansbeneathfingernails

Scrubshandsandforearmscorrectly

Keepshandsandforearmselevated

andavoidscontaminationswhileenteringdoortoOR

GowningforsurgeryAcceptsthedryingtowelproperly,

withoutcontaminatingitagainsthis

orherbody

Drieshandsproperly,usinga

separatesterileareaofthetowelfor

eachhand

Properlydisposesoftheusedtowel

ReceivesthesurgicalgownproperlyDonsgloveswithoutcontaminating

gownorgloves

Turnsproperlytocloseofftheback

ofthegown

PreparinganddrapingthepatientDescribesthepropersolutionsfor

preparationofthesurgicalfield

Describesthepropermethodfor

scrubbingthesurgicalfield

Properlypositionsthesurgicaldrapes

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PerformanceAssessmentThereareanumberofoptionsofhowtobestassessstudentsabilitywithsterile

technique:

1.Demonstrationofthetechniques,followedbystudentpracticewiththechecklist,above,usedtodemonstratecompetence.

2.Preparationanddrapingofthepatientcanbepracticedonasimulatedpatient

oramannequin.Ifthosearenotavailable,thiscanalsobedoneonaflattable

coveredwithadrape.

3.AnOSCEusingthechecklist,above,canalsobeused

PracticalTipsThereareanumberofvideosorDVDsavailablethatmanymedicalschoolsand

hospitalsuseforfurtherunderstandingthisprocess.Ifstudentsfeeltheyneedmorehelp,

theyshouldaskiftheseareavailableattheirinstitution.Manyinstitutionswill

automaticallyshowthem,orstudentswillbegivenapracticesessionbyanexperienced

ORnurse.

ThefirsttimeintheORcanbeananxietyprovokingexperience,becauseofthestudents

fearofmakinganerror.Ifstudentsmakeamistake,theyshouldunderstandthat

teachershave

been

in

the

same

situation,

and

students

should

understand

that

they

are

learning.Physicianeducatorswillnotletamistakeharmthepatient,andanerrorwill

notruinastudentscareer.

Resources1.QuotefromPasteursspeech,GermTheoryanditsApplicationstoMedicineand

Surgery,madetotheFrenchAcademyofSciences,April29th,1878.ComptesRendus

delAcademiedesSciences,LXXXVI,pp.103743(translationbyH.C.Ernst).

2.Meeker,MandRothrockJ.Alexanderscareofthepatientinsurgery,14thed.Mosby,

Inc.1999.

3.Fortunato,N.BerryandKohnsoperatingroomtechnique,9thed.,Mosby,Inc.2000.

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4.Maxwell,CandGirotti,M.Steriletechnique,TheCabellSociety,Universityof

VirginiaSchoolofMedicineWebsite,

http://www.healthsystem.virginia.edu/internet/som/

5.CouncilonResidentEducationinObstetricsandGynecology.Surgicalcurriculumfor

residentsinobstetricsandgynecology,CREOGWebsite,2002,http://www.acog.org/departments/dept_web.cfm?recno=1.

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