Asepsis vs ritualism

AORN e d u c d o n

Asepsis vs ritualism What is the difference between asepsis and ritualism in the operating room?

To see the relationship between asepsis and ritualism, I& us look at the definitions of the words. Asepsis is defined as "absence of septic matter or freedom from infection."' This term is used to describe a number of procedures intended to reduce infection. When we use the term aseptic technique, we are referring not only to instruments and the hands of the surgeon, but also to the entire operating room cmd even the air filling the room. All d these should either be free from all living organisms or surgically clean. When we look up ritualism, Webster tells us it is "conducting a devotional service established by tradition; adherence to or observance of a1 ritual; or excessive devotion to prescribed forms."2 Although the two seem quite different by definition, there is a marked relationship of ritualism and aseptic practice. Is it possible that rituals have been taken from altars of worship and have become firmly established in operating rooms? Is it possible that practices of asepsis, which once had

bases to which we firmly adhered, have lost their foundations? Is it possible that we have become lax in our adherence to aseptic techniques? Modern aseptic technique is vitally important to the recovery of the patient. We are so technically advanced in this country that we have made it to the moon and back many times, but we have not done as well in our efforts for the surgical patient. A recent article reports cross-infection, which costs an additional $4,000 per infected patient and ties up acute care beds, affects nearly six million patients each year. 'We could eliminate 50% of these case5 by maintaining a clean, bacteriologically controlled environment."3 Apathy, carelessness, and indifference are more than dangerous; they are lethal. These are strong words; they are meant to be. Asepsis i s not one person's responsibility; it involves more than the operating room supervisor, scrub nurse and surgeon. Until automation can totally replace the human element in the operating room, every penon who works in our hospitals has a moral obligation to

contribute to the safety and health of our patients.

This surgeon behaved ritualistically. He

l e t us look carefully at some OR practices. Which ones still have sound bases? Which

would not go out of surgery without covering his scrub suit, yet he defies good asepsis by disregarding practices based on sound

ones are now rituals that have lost their point? Which ones have a meaning for the future?

principles. Are our rules based on sound asepsis or are they rituals which can be disregarded at someone's whim?

We say everyone who comes into the OR suite must be properly attired with cap,

For example, regarding the subject of masks, what about the people who wear masks improperly? They wear them under the nose or gaping at both cheeks. Or they

mask, and a clean scrub suit.

I say clean,

because if you have worked with residents and interns who have been on call the night before, many of them "forgot" to change their scrub suits after having slept in them. They need reminding. Everyone seems to wear masks, special shoes or bootieseveryone except perhaps the man with the mop who should wear them. We also say

wear cloth masks, or masks dangling around the neck, and then put them up again for use. They wear masks during the operation, but take them down in the room where many operations will follow. To be effective, a mask must fit the face well enough to prevent the escape of air so that

the hair has to be covered. Nurses are told this and comply, and we remind the

the air can only pass through the filtering system of the mask, and should be used

surgeons to cover their hair and beards. Then we look up at the head of the table at the anesthesiologist and see six or seven inches of hair sticking out from under the

only as long as it is effective. Masks should be changed between cases and sometimes during the case, depending on the length of the case and how much talking i s going

cap.

on.

The surgeon i s doing his ritual of scrubbing, he i s scrubbing by the clock-the mechanics of over and under his finger nails. However, there i s one thing wrong; his wedding ring i s on his finger.

Shoe covering i s another area of concern. Everyone must have special OR shoes or covering for shoes before entering the OR. I would say everyone must wear conductive shoe covering in the OR, for the OR supervisors have threatened and pleaded in vain with too many surgeons to get their shoes cleaned and washed. It i s a fact that many OR shoes harbor more bacteria than street shoes. I've learned to appreciate the Japanese custom of removing shoes at the door before entering their homes. I am not advocating that we adopt this tradition in the OR, but we can learn from, and appreciate, the Asian idea of the difference between clean and not clean, and insist that shoes be covered or cleaned before entering the operating room.

No one, we say, would enter today's OR without a mask on. Maybe back in lister's time we would see such practice, but not in 1973. We are so careful about masks that the problem doesn't even exist now. Don't you believe it! Not long ago I witnessed the chief of surgery in a prominent city hospital walk into the OR suite while the patient was still on the table being operated on. He did not have a mask on, nor did he wear a cap. He was also wearing a white coat, since he had been up on the floor. Yet he walked into the OR dressed in this fashion. This patient developed a postoperative infection. Who was to blame? O r can we say it was an act of God?

You are all aware that some wound infections are endogenous, that is, caused by bacteria the patient brings with him to &+o

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the operating room. Here is something that was brought to my attention not too long ago and I would like to share with you. As nurses we have heard since the beginning of our training-do not neglect oral hygiene. Everyone has a certain amount of peridontal disease; and gingivitis in most patients is a rich source of bacteria. While the patient i s being intubated, and with the manipulation of anesthesia tubes during surgery, organisms are showered into the blood stream and bacteremia results. Oral hygiene is important, and the patient's mouth should be as healthy as possible before surgery. The function can be delegated to the surgical ward, but the OR nursing staff i s directly or indirectly responsible for seeing that the patient is totally prepared for surgery. How many of us are aware that we have a responsibility for quality of asepsis in the materials which come to us prepackaged? We have gone to disposable prepackaged items such as catheters, Penrose drains, and dressings. Many of the sterile items come in peel packages. The idea is great, but how often have you opened a peel-down package and have had the paper tear across the package or off to the side? This means you either discard what you are opening and try another package, or you compromise, using gyrations and gymnastics in attempts to extract the sterile item from this package. We pay a dear price for these disposable prepackaged items. And the dear price may include not only the dollars and cents, but also the patient's safety. Why are we so reticient in demanding proper, acceptable packaging? Or is this one of our acceptable rituals? If we de-

manded that the manufacturers change, or

if we stop buying their product, we would soon have acceptable sterile packaging, whether it be a tear-apart, ripapart, or pop-apart closures.

Remember asepsis did not simply happen, it came about because it was demanded. It has progressed from lister's time through a continuous evolution. It i s our responsibility to keep this evolution from regressing, and to bring our asepsis up-to-date with our current knowledge of technology.

I have reviewed a few principles of aseptic technique. By no means have I attempted to cover all the principles of asepsis. An attempt has been made to get you to look at the aseptic technique you are now practicing. Are your techniques based on sound principles? Or are you performing rituals, devotional services long established by tradition, but without value to modern asepsis? Aseptic technique i s not static, it is changing all the time as different methods and materials become available. Study your own situation, determine what is best for you, back it up by data. Then you will be replacing rituals with asepsis.

Rose Marie McWilliams, RN Assistant director of education FOOTNOTES I. F A Davis, Tuber's Encyclopedia M e d i c a l Dictionary, ( 1 9 7 3 ) , A128.

2. Webster's Seventh N e w Collegiate Dictionary (Springfield: G & C Merriam Co, 1971), p 743. 3. Bertha Yanis Litsky, "Simple Steps to OR Asepsis," M e d i c a l Surgical Review, ( April-May, I97 I ) , 20-24.

Mosf blind can see Despite the general connotation of blindness as a total absence of vision, the American Foundation for the Blind reports that almost 60% of the severely impaired have useful vision, however limited.

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