PROCEDURE GOALS AND OBJECTIVES
Goal: To provide clinicians with the knowledge and skills
necessary to perform clinical procedures using accepted sterile
technique.
Objectives: The student will be able to …
• Describe the indications and rationale for practicing sterile
technique.
• Identify and describe the history and development of the
concept of sterile technique.
• List the principles of sterile technique.
• Describe the essential steps performed in the surgical hand scrub.
• Describe the essential steps performed in preparing and
draping a sterile field.
• Describe the principles involved in the use of surgical caps,
masks, and gowns.
• Describe the principles involved in the use of standard
precautions.
Goal: To provide clinicians with the knowledge and skills
necessary to perform clinical procedures using accepted sterile
technique.
Objectives: The student will be able to …
• Describe the indications and rationale for practicing sterile
technique.
• Identify and describe the history and development of the
concept of sterile technique.
• List the principles of sterile technique.
• Describe the essential steps performed in the surgical hand scrub.
• Describe the essential steps performed in preparing and
draping a sterile field.
• Describe the principles involved in the use of surgical caps,
masks, and gowns.
• Describe the principles involved in the use of standard
precautions.
BACKGROUND AND HISTORY
The teachings of Hippocrates (460 BC) were instrumental in turning the art of
healing away from mystical rites to an approach that everyone could
understand and practice. He stressed cleanliness to avoid infection by using
boiling water and fire to clean instruments and by irrigating dirty wounds
with wine or boiled water (Adams, 1929). Louis Pasteur (1822-1895) developed
what would come to be known as the germ theory of disease. His experiments
revealed that microbes could be found in the air and on the surface of every
object (Dubos, 1950). He discovered that the number of microbes could be
reduced on surfaces by using heat or appropriate cleansing but that they
would still remain in the air. Joseph Lister (1827-1912) is considered the
father of sterile technique (Godlee, 1917). When Lister learned of Pasteur’s
work, he began to experiment with various methods of sterile technique in
surgery. He noted a significant decrease in postoperative infections after
using carbolic acid to sterilize both surgical wounds and his own hands and
by spraying the operative field. His antiseptic methods of performing surgery
were refined over the years and eventually incorporated into hospitals
worldwide.
The teachings of Hippocrates (460 BC) were instrumental in turning the art of
healing away from mystical rites to an approach that everyone could
understand and practice. He stressed cleanliness to avoid infection by using
boiling water and fire to clean instruments and by irrigating dirty wounds
with wine or boiled water (Adams, 1929). Louis Pasteur (1822-1895) developed
what would come to be known as the germ theory of disease. His experiments
revealed that microbes could be found in the air and on the surface of every
object (Dubos, 1950). He discovered that the number of microbes could be
reduced on surfaces by using heat or appropriate cleansing but that they
would still remain in the air. Joseph Lister (1827-1912) is considered the
father of sterile technique (Godlee, 1917). When Lister learned of Pasteur’s
work, he began to experiment with various methods of sterile technique in
surgery. He noted a significant decrease in postoperative infections after
using carbolic acid to sterilize both surgical wounds and his own hands and
by spraying the operative field. His antiseptic methods of performing surgery
were refined over the years and eventually incorporated into hospitals
worldwide.
PRINCIPLES OF STERILE TECHNIQUE
Sterile technique is the method by which contamination with microorganisms
is minimized. Adherence to protocol and strict techniques is required at all
times when caring for open wounds and performing invasive procedures. To
avoid infection, procedures should be performed within a sterile field from
which all living microbes have been excluded. Items entering the sterile field,
including instruments, sutures, and fluids, must be sterile. Although it is not
possible to sterilize the skin, it is possible to reduce significantly the number
of bacteria that is normally present on the skin. Before a procedure, personnel
must first perform a surgical hand scrub and then don sterile gloves, sterile
gown, and mask. The primary goal is to provide an environment for the
patient that promotes healing, prevents infections, and minimizes the length
of recovery time. Using the principles of sterile technique will help accomplish
that goal. The principles are as follows:
■ All items used within a sterile field must be sterile.
■ A sterile barrier that has been permeated must be considered
contaminated.
■ The edges of a sterile container are considered contaminated once the
package is opened.
■ Gowns are considered sterile in front from shoulder to waist level, and
the sleeves are considered sterile to 2 inches above the elbow.
■ Tables are sterile at table level only.
Sterile technique is the method by which contamination with microorganisms
is minimized. Adherence to protocol and strict techniques is required at all
times when caring for open wounds and performing invasive procedures. To
avoid infection, procedures should be performed within a sterile field from
which all living microbes have been excluded. Items entering the sterile field,
including instruments, sutures, and fluids, must be sterile. Although it is not
possible to sterilize the skin, it is possible to reduce significantly the number
of bacteria that is normally present on the skin. Before a procedure, personnel
must first perform a surgical hand scrub and then don sterile gloves, sterile
gown, and mask. The primary goal is to provide an environment for the
patient that promotes healing, prevents infections, and minimizes the length
of recovery time. Using the principles of sterile technique will help accomplish
that goal. The principles are as follows:
■ All items used within a sterile field must be sterile.
■ A sterile barrier that has been permeated must be considered
contaminated.
■ The edges of a sterile container are considered contaminated once the
package is opened.
■ Gowns are considered sterile in front from shoulder to waist level, and
the sleeves are considered sterile to 2 inches above the elbow.
■ Tables are sterile at table level only.
■ Sterile persons and items touch only sterile areas; unsterile persons and
items touch only unsterile areas.
■ Movement within or around a sterile field must not contaminate the field.
■ All items and areas of doubtful sterility are considered contaminated.
items touch only unsterile areas.
■ Movement within or around a sterile field must not contaminate the field.
■ All items and areas of doubtful sterility are considered contaminated.
SURGICAL HAND SCRUB
The surgical hand scrub has its own traditions and rituals dating back to the
use of chlorinated lime by Semmelweis, who in 1846 recognized the role of
contagions on doctors’ hands in the spread of puerperal fever, and the use of
carbolic acid by Lister to soak his instruments and hands (Lister, 1867). The
goal of the surgical hand scrub is to remove dirt and debris and to reduce
bacterial flora. An ideal surgical hand scrub should provide the following
antimicrobial effects:
■ Immediate reduction in the resident bacterial flora
■ Sustained effect to maintain a reduced bacterial count under surgical
gloves
■ Cumulative effect with each additional application of the antiseptic
■ Persistent effect providing progressive reduction of bacteria with
additional applications
The traditional 10-minute surgical scrub, using a stiff brush and harsh
chemicals, does not meet the criteria for satisfactory antimicrobial action
(an immediate reduction in microbial count that is sustained, cumulative,
and persistent) and is associated with a number of difficulties and problems,
chiefly a high incidence of irritation and dermatitis that can paradoxically
result in an increased microbial population on the hands (Larson, 1986).
Modifications have been made to the traditional surgical hand scrub to
increase its beneficial effects and to decrease its harmful effects.
The duration of the recommended scrub time has been decreased so that
a 2-minute scrub time is now considered by some to be optimal (Wheelock,
1997). Some authors have recommended eliminating the scrub brush, to
decrease abrasion of the hands (Gruendemann, 2001). New antiseptics,
emollients, and humectants have been developed to minimize skin dryness
and dermatitis resulting from the surgical hand scrub. New procedures and
products for hand hygiene and the surgical hand scrub have been
consolidated into a publication that was issued by the Centers for Disease
Control and Prevention (CDC) in 2002. These guidelines are comprehensive,
providing an analysis of the science of hand hygiene and specific recommendations
for surgical hand antisepsis (CDC, 2002):
The surgical hand scrub has its own traditions and rituals dating back to the
use of chlorinated lime by Semmelweis, who in 1846 recognized the role of
contagions on doctors’ hands in the spread of puerperal fever, and the use of
carbolic acid by Lister to soak his instruments and hands (Lister, 1867). The
goal of the surgical hand scrub is to remove dirt and debris and to reduce
bacterial flora. An ideal surgical hand scrub should provide the following
antimicrobial effects:
■ Immediate reduction in the resident bacterial flora
■ Sustained effect to maintain a reduced bacterial count under surgical
gloves
■ Cumulative effect with each additional application of the antiseptic
■ Persistent effect providing progressive reduction of bacteria with
additional applications
The traditional 10-minute surgical scrub, using a stiff brush and harsh
chemicals, does not meet the criteria for satisfactory antimicrobial action
(an immediate reduction in microbial count that is sustained, cumulative,
and persistent) and is associated with a number of difficulties and problems,
chiefly a high incidence of irritation and dermatitis that can paradoxically
result in an increased microbial population on the hands (Larson, 1986).
Modifications have been made to the traditional surgical hand scrub to
increase its beneficial effects and to decrease its harmful effects.
The duration of the recommended scrub time has been decreased so that
a 2-minute scrub time is now considered by some to be optimal (Wheelock,
1997). Some authors have recommended eliminating the scrub brush, to
decrease abrasion of the hands (Gruendemann, 2001). New antiseptics,
emollients, and humectants have been developed to minimize skin dryness
and dermatitis resulting from the surgical hand scrub. New procedures and
products for hand hygiene and the surgical hand scrub have been
consolidated into a publication that was issued by the Centers for Disease
Control and Prevention (CDC) in 2002. These guidelines are comprehensive,
providing an analysis of the science of hand hygiene and specific recommendations
for surgical hand antisepsis (CDC, 2002):
SURGICAL HAND ANTISEPSIS
1. Remove rings, watches, and bracelets before beginning the “surgical
hand scrub” (i.e., a process to remove or destroy transient microorganisms
and reduce resident flora).
2. Remove debris from underneath fingernails using a nail cleaner under
running water.
3. “Surgical hand antisepsis” (i.e., a process for removal or destruction of
transient microorganisms) using either an antimicrobial soap or an
alcohol-based hand rub with persistent activity is recommended before
donning sterile gloves when performing surgical procedures.
4. When performing surgical hand antisepsis using an antimicrobial soap,
scrub hands and forearms for the length of time recommended by the
manufacturer, usually 2 to 6 minutes. Long scrub times (e.g., 10 minutes)
are not necessary.
5. When using an alcohol-based surgical hand scrub product with
persistent activity, follow the manufacturer’s instructions. Before
applying the alcohol solution, prewash hands and forearms with a
nonantimicrobial soap and dry hands and forearms completely. After
application of the alcohol-based product as recommended, allow hands
and forearms to dry thoroughly before donning sterile gloves.
Materials Utilized for Hand Scrub
hand scrub” (i.e., a process to remove or destroy transient microorganisms
and reduce resident flora).
2. Remove debris from underneath fingernails using a nail cleaner under
running water.
3. “Surgical hand antisepsis” (i.e., a process for removal or destruction of
transient microorganisms) using either an antimicrobial soap or an
alcohol-based hand rub with persistent activity is recommended before
donning sterile gloves when performing surgical procedures.
4. When performing surgical hand antisepsis using an antimicrobial soap,
scrub hands and forearms for the length of time recommended by the
manufacturer, usually 2 to 6 minutes. Long scrub times (e.g., 10 minutes)
are not necessary.
5. When using an alcohol-based surgical hand scrub product with
persistent activity, follow the manufacturer’s instructions. Before
applying the alcohol solution, prewash hands and forearms with a
nonantimicrobial soap and dry hands and forearms completely. After
application of the alcohol-based product as recommended, allow hands
and forearms to dry thoroughly before donning sterile gloves.
Materials Utilized for Hand Scrub
■ Chlorhexidine gluconate or povidone-iodine solutions are rapid-acting,
broad-spectrum antimicrobials that are effective against gram-positive
and gram-negative microorganisms. Each is prepared in combination
with a detergent to give a cleansing action along with the antimicrobial
effect.
■ Sterile disposable scrub brushes impregnated with chlorhexidine
gluconate, povidone-iodine, or other CDC-approved products (CDC,
2002).
broad-spectrum antimicrobials that are effective against gram-positive
and gram-negative microorganisms. Each is prepared in combination
with a detergent to give a cleansing action along with the antimicrobial
effect.
■ Sterile disposable scrub brushes impregnated with chlorhexidine
gluconate, povidone-iodine, or other CDC-approved products (CDC,
2002).
REFERENCES
Adams F: The Genuine Works of Hippocrates. New York, W. Wood, 1929.
Centers for Disease Control and Prevention: Guideline for hand hygiene
in health-care settings. MMWR Recomm Rep 51(RR-16):1-45, 2002.
Centers for Disease Control and Prevention: Recommendations for
prevention of HIV transmission in health-care settings. MMWR Morb
Mortal Wkly Rep 36(suppl 2):1S-18S, 1987.
Dubos R: Louis Pasteur: Free Lance of Science. Boston, Little, Brown,
1950.
Godlee RJ: Lord Lister. London, Macmillan, 1917.
Gruendemann BJ: Is it time for brushless scrubbing with an alcoholbased
agent? AORN J 74:859-873, 2001.
Larson E: Physiologic and microbiologic changes in skin related to
frequent handwashing. Infect Control Hosp Epidemiol 7:59-63, 1986.
Lister J: On a new method of treating compound fractures, abscess, etc.
with observations on the conditions of suppuration. Lancet 1:326,
357, 507, 1867.
Wheelock SM: Effect of surgical hand scrub time on subsequent
bacterial growth. AORN J 65:1087-1098, 1997.
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