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Recommended Practices
OCTOBER 1991, VOL 54, NO 4
AORN JOURNAL
Recommended Practices ASEPTICTECHNIQUE
T
he following recommended practices were developed by the AORN Recommended Practices Coordinating Committee and have been approved by the AORN Board of Directors. They were published as proposed recommended practices in the February 1991 AORN Journal for comment by members and others. These recommended practices are intended as achievable recommendations representing what i s believed to be an optimal level of practice. Policies and procedures will reflect variations in practice settings and/or clinical situations that determine the degree to which the recommended practices can be fulfilled. AORN recognizes the numerous different settings in which perioperative nurses practice. The recommended practices are intended as guidelines adaptable to various practice settings. These practice settings include traditional operating rooms, ambulatory surgery units, physicians’ offices, cardiac catheterization laboratories, endoscopy rooms, radiology departments, and all other areas where surgery may be performed. Purpose. Basic principles and practices provide guidelines for establishing and maintaining a sterile field. Anyone who is present in the operating room has a responsibility to provide and maintain a safe environment. Adherence to aseptic practices aids in fulfilling this responsibility. Aseptic practices are implemented preoperatively, intraoperatively, and postoperatively to minimize wound contamination.
Recommended Practice I Scrubbed persons should wear sterile gowns and gloves. Interpretive statement 1: Materials for gowns should be selected according to AORN “Recommended practices for evaluating protective barrier materials for surgical gowns and drapes.” Rationale: Surgical gowns should establish a barrier that minimizes the passage of microorganisms between nonsterile and sterile areas.’ Interpretive statement 2: Surgical hand scrubs performed before donning sterile gown and gloves should follow AORN “Recommended practices for surgical hand scrubs.” Rationale: Transfer of microorganisms is reduced by scrubbing hands and wearing sterile gloves. Interpretive statement 3: The srubbed person should don sterile gown and gloves from a sterile field other than the main instrument table. Rationale: This practice avoids c~ntamination.~ Interpretive statement 4: Sterile gowns should be considered sterile in front from the chest to the level of the sterile field, and the sleeves should be considered sterile from two inches above the elbow to the cuff. Rationale: The area of sterility in the front of the gown extends to the level of the sterile field because 819
AORN JOURNAL
most scrubbed personnel work adjacent to a sterile table. Because the arms of a scrubbed person must move across a sterile field, gown sleeves up to two inches above the elbow must remain steri1e.j Interpretive statement 5: The following surgical gown areas should be considered unsterile: neckline, shoulders, under the arms, back. and sleeve cuff. Rationale: The neckline. shoulders, under the arms, back, and cuffed portions of the sleeves are moisture collection and friction areas. Consequently, they are not effective microbial barriers.s The back of the gown cannot be under constant observation by the scrubbed person. Interpretive statement 6: Scrubbed people should inspect gloves for integrity after donning them. Rationale: Gloves should establish a barrier that minimizes the passage of microorganisms between nonsterile and sterile areas.6 Interpretive statement 7: Once the original gloves are donned, the gown cuffs should be considered contaminated. Rationale: As the scrubbed hand passes through the gown cuff, the cuff becomes contaminated.' Discussion: There are only two methods of changing contaminated gloves. The preferred method is for one member of the sterile team to glove the other. If this is not possible. the contaminated glove should be changed by the open-glove method. Wearing two pair of gloves (double gloving) may be indicated for some procedures in accordance with policies in the practice setting8
Recommended Practice II Sterile drapes should be used to establish a sterile field. Interpretive statement 1: Surgical drapes should be selected according to AORN "Recommended practices for evaluating protective barrier materials for sur820
OCTOBER I99 I , VOL 54, NO 4
gical gowns and drapes." Rationale: Surgical drapes establish a barrier that minimizes the passage of microorganisms between nonsterile and sterile areas9 Interpretive statement 2: Sterile drapes should be placed on the patient and on all furniture and equipment to be included in the sterile field. Rationale: Isolating the operative field with drapes assists in preventing contamination from other unprepared areas."' Interpretive statement 3: Sterile drapes should be handled as little as possible. Rationale: Rapid movement of sterile drapes creates air currents on which dust, lint, and droplet nuclei can migrate.'' Interpretive statement 4: During the draping process, draping material should be compact, held higher than the OR bed, and draped from the operative site to the periphery. Rationale: The movement of sterile drapes from clean areas to dirty areas helps prevent contamination of the sterile field." Interpretive statement 5: During draping, sterile gloves should be protected by cuffing the draping material over the hands. Rationale: The gloved hands should always be protected by cuffing the draping material back over the gloved hands to avoid c~ntamination.'~ Interpretive statement 6: Once the sterile drape is placed in position, it should not be moved. Rationale: Shifting or moving the sterile drape compromises the sterility of the field.I4
Recommended Practice III Items used within a sterile field should be sterile.
OCTOBER 1991, VOL 54, NO 4
Interpretive statement I : Packaging materials should meet the AORN “Recommended practices for selection and use of packaging materials.” Rationale: Packaging materials should ensure sterility of package contents until opened for use and should permit removal of contents without contamination. Interpretive statement 2: Methods of sterilization, storage, and handling of sterile items should meet AORN “Recommended practices for sterilization and disinfection.” Rationale: Sterilization provides the highest level of assurance that an object is void of viable microbes. Disinfection reduces the risk o f microbial contamination but without the same level of assurance.I6 Interpretive statement 3: All items presented to the sterile field should be checked for proper packaging, processing, moisture, seal integrity, package integrity, and the appearance of the sterilization indicator. Rationale: The inspection of packaging helps ensure that only sterile items are presented to the sterile field.”
Recommended Practice IV All items introduced onto a sterile field should be opened, dispensed, and transferred by methods that maintain sterility and integrity. Interpretive statement I : When opening wrapped supplies, unscrubbed personnel should open the wrapper flap farthest away from them first and the nearest wrapper flap last. Rationale: This method is used to prevent contamination by passing an unsterile arm over a sterile item.’* Interpretive statement 2: All wrapper edges should be secured when supplies are presented to the sterile field to
AORN JOURNAL
avoid contamination. Rationale: Secured wrapper edges prevent flipping the wrapper and contaminating the contents of the sterile field.I9 Interpretive statement 3: Sterile items should be presented to the scrubbed person or placed securely on the sterile field. Rationale: Items tossed onto a sterile field may roll off the edge and become contaminated or cause other items to be displaced.20 Interpretive statement 4: Sharp andlor heavy objects should be presented to the scrubbed person or opened on a separate surface. Rationale: Sharp and heavy objects may penetrate barriersZ1 Interpretive statement 5: When dispensing solutions to the sterile field the entire bottle contents should be poured into the receptacle or the remainder discarded, the solution receptacle should be placed near the edge of the table or held by the scrubbed person, and fluids should be poured slowly to avoid splashing. Rationale: Because the edge of a bottle cap is considered contaminated once the cap has been removed from the bottle, the sterility of the bottle contents cannot be ensured if the cap is replaced. Reuse of opened bottles may contaminate solutions due to drops contacting unsterile areas and then running back over sterile bottle lips. Placing the solution receptacle near the edge of the sterile table allows unscrubbed persons to pour fluids without contamination. Splashing can cause strike-through and contamination of the sterile field.22
Recommended Practice V A sterile field should be constantly monitored and maintained. 821
AORN JOURNAL
Interpretive statement I : Sterile fields should be prepared as close as possible to the time of use. Rationale: There is a direct correlation between the time the sterile field is established and the length of exposure to airborne contaminants.23 Interpretive statement 2: Sterile fields should not be covered. Rationale: It is very difficult to uncover the sterile field without contamination.’i Interpretive statement 3: Unguarded sterile fields should be considered contaminated. Rationale: Chances for contamination of an unguarded sterile field are numerous. Without direct observation, there is no way to ensure sterility.’s Interpretive statement 4: Every team member should observe for events which may contaminate the sterile field, and corrective action should be initiated. Rationale: The sterile field is monitored to assist in the maintenance of sterility. Application of the principles of aseptic technique depends primarily on the individual and his or her surgical conscience.’h Interpretive statement 5: Conversation should be minimal in the operating room. Rationale: Talking is kept to a minimum in the surgical area to reduce spread of droplets. Even though the surgical team members wear masks, excessive talking generates free moisture droplets that are forcefully dispersed into the surrounding air.?’ Interpretive statement 6: All cables, tubing, etc, for equipment should be secured to the sterile field with nonperforating devices. Rationale: A sterile barrier that has been perforated is considered contaminated.?* Interpretive statement 6: Nonsterile equipment brought into and/or 822
OCTOBER 1991, VOL 54, NO 4
over the sterile field should be draped with a sterile material or covering. Rationale: Only sterile items should touch or extend over sterile surfaces.29
Recommended Practice V1 All personnel moving within or around a sterile field should do so in a manner to maintain the integrity of the sterile field. Interpretive statement I: Scrubbed people should remain close to the sterile field and should not leave the room. Rationale: Wandering around or leaving the room in sterile attire increases the potential for contamination.”’ Interpretive statement 2: Scrubbed surgical team members should move from sterile areas to sterile areas. If they must change positions, they should turn back to back or face to face while maintaining a safe distance between each other. Rationale: Scrubbed people move only in areas of similar preparation (ie, sterile to sterile) to prevent ~ontamination.~’ Interpretive statement 3: Scrubbed persons should keep arms and hands within the the sterile area at all time. Rationale: Contamination of hands and arms may occur when they are lowered below the level of the sterile field.32 Interpretive statement 4: Scrubbed persons should avoid changing levels and should be seated only when the entire surgical procedure will be performed at this level. Rationale: W h e n c h a n g i n g levels, exposure of t h e unsterile portion of the gown is likely.33 Interpretive statement 5: Unscrubbed people should face sterile areas on approach, should not walk between two sterile fields, and should maintain an awareness of the need for distance from the sterile field. Rationale:
OCTOBER 1991, VOL 54, NO 4
Establishing patterns of movement around the sterile field helps prevent accidental contamination. Accidental contamination can be prevented by keeping sterile areas in view during movement.34
Recommended Practice VII Policies and procedures for basic aseptic technique should be written, reviewed annually, and readily available within the practice setting. Discussion: These recommended practices should be used as guidelines for the development of policies and procedures within the practice setting. Policies and procedures establish authority, responsibility, and accountability and serve as operational guidelines. The AORN recommended practices that deal with basic aseptic technique should be consulted when developing those policies and procedures. Introduction and review of policies and procedures should be included in the orientation and ongoing education of personnel to assist in the development of knowledge, skills, and attitudes that affect patient care. Policies and procedures also assist in the development of quality assessment and improvement activities. Notes 1 . “Recommended practices for evaluating aseptic barrier materials for surgical gowns and drapes,” in AORN Standards and Recommended Practices for Perioperative Nursing (Denver: Association of Operating Room Nurses, Inc, 1991) 111: 6-1. 2. B P Simmons, “Guidelines for prevention of surgical wound infections,” Infection Control, Special Supplement 3 (MarcMApril 1982) 191. 3. J A Kneedler, G H Dodge, Perioperative Patient Care: The Nursing Perspective (Boston: Blackwell Scientific Publications, Inc, 1983) 41 9. 4. B J Gruendemann, M H Meeker, Alexander’s Care of the Patient in Surgery, second ed (St Louis: The C V Mosby Co, 1987) 58. 5. Ibid. 6. R E Condon, E J Quebbeman, “Preparing the operating room,” in American College of Surgeons: Care of the Surgical Patient, vol2, ed D W Wilmore et al, (New York: Scientific American, Inc, 1988) 9. 7. D M Fogg, “Resterilizing single-use items; technique for changing contaminated gloves; effec-
AORN JOURNAL
tiveness of sticky mats” (Clinical Issues) AORN Journal 48 (August 1988) 358. 8. J Gerberding et al, “Double gloving, barriers prevent blood exposure,” OR Manager 6 (August 1990) 4. 9. Condon, Quebbeman, American College of Surgeons: Care of the Surgical Patient, 9. 10. Kneedler, Dodge, Perioperative Patient Care: The Nursing Perspective, 432. 11. C W Walter, “Prevention and control of airborne infection in hospitals,” Annals of New York Academy of Sciences (1980) 325. 12. L J Atkinson, M L Kohn, Berry and Kohn’s Introduction to Operating Room Technique, sixth ed (New York City: McGraw-Hill Book Co, 1986) 317319. 13. B J Gruendemann et al, The Surgical Patient: Behavioral Concepts for the Operating Room Nurse, second ed (St Louis: The C V Mosby Co, 1977) 72. 14. Atkinson, Kohn, Berry and Kohn’s Introduction to Operating Room Technique, 3 17-319 15. “Recommended practices for selection and use of packaging materials,” in AORN Standards and Recommended Practices for Perioperative Nursing (Denver: Association of Operating Room Nurses, Inc, 1991) 111: 15-1. 16. “Recommended practices for sterilization and disinfection,” in AORN Standards and Recommended Practices for Perioperative Nursing (Denver: Association of Operating Room Nurses, Inc, 1991) 111: 17-1. 17. Kneedler, Dodge, Perioperative Patient Care: The Nursing Perspective, 41 1. 18. Ibid. 19. Ibid. 20. P Wells, Fundamentals of Aseptic Technique (Denver: Association of Operating Room Nurses, Inc, 1976) Film Instruction Guide, 8. 21. Ibid, 7-8. 22. Ibid, 5-6. 23. Kneedler, Dodge, Perioperative Patient Care: The Nursing Perspective, 41 2-413. 24. Wells, Fundamentals of Aseptic Technique, 9. 25. Ibid, 8-9. 26. Kneedler, Dodge, Perioperative Patient Care: The Nursing Perspective, 410. 27. Gruendemann et al, The Surgical Patient: Behavioral Concepts for the Operating Room Nurse, 73. 28. S Crow, Asepsis, the Right Touch: Something Old is Now New (Bossier City, La: The Everett Co, 1989) 84. 29. Gruendemann et al, The Surgical Patient: Behavioral Concepts for the Operating Room Nurse, 72. 30. Crow, Asepsis, the Right Touch: Something Old is Now New, 88-89. 3 1. ORNAC: Recommended Technical Standards823
AORN JOURNAL
Operatiiig Room N ~ r ~ s i n(Operating g Room Nurses Association of Canada. 1988) 22. 32. Crow, Asepsis, the Right Touch: Something Old i s Nou, Nett,, 84. 33. Kntxdler. Dodge. Prrioperati\,e Pntient Care:
The Niirsirig Per.specri\,e, 4 12. 34. Ibid.
Suggested reading Crow, S ..It’s second nature to me now ’’ Todm ‘s OR Nurtr 12 (October 1990)6-8 Crow, S. Taylor, E “Nurses’ compliance with asep-
OCTOBER 1991, VOL54, N O 4
tic technique.” AORN Journal 37 (May 1983) 1066-1072.
Gruendemann, B. “Surgical asepsis revisited.” Tuduy’s OR Nurse 12 (October 1990) 10-13. Laufman, H. “What’s happened to aseptic discipline i n the OR?” Today’s O R Nurse 12 (October 1990) 15-19. Maulden, B C. “Need for basic aseptic technique.” PointofView 19 (July 1, 1982) 10-11. Wells, P. “Teaching aseptic technique.” Today’s OR Nurse 6 (September 1983) 20-24, 57.
Use Tooth Whiteners With Caution
Men in Nursing Debunk Stereotypes
Tooth whiteners can give you a brighter smile, but caution should be exercised, according to an article in the April 1991 issue of the Mayo Clinic Health Letter. Several brands and types of tooth whiteners have come on the market in the past two years. These are more effective than toothpaste and simpler and less painful than the heat-activated hydrogen peroxide used to whiten teeth. Long-term effects, however, have not been determined completely . There are no reports yet on how long the whitening lasts. Whiteners are available in paste or gel forms, often with polishing creams. The cleansing action is a result of hydrogen peroxide and oxygen. According to the article, the American Dental Association (ADA) states that long-term use of hydrogen peroxide can damage chromosomes and may boost cancercausing effects of other substances. These chemicals also could cause infection or damage to the soft tissue or delay healing of already damaged tissue. The US Food and Drug Administration and the ADA have not approved or sanctioned the use of these new whitening products. The article notes that if you use tooth whiteners you should follow directions carefully and report any problems to your dentist.
Men choose nursing to provide a health service, work with people, and earn a living, according to an article in the April 1991 issue of The Journal ofhrursing Education. The article reports that most men in nursing are interested in job security, the sciences, and work in a humanistic field, and they desire personal and professional mobility. Male nurses scored high on normed empathy and social, esthetic, and theoretical interest scales. Other normed comparisons reveal that men in nursing are more emotionally stable, more outgoing, more abstract, yet more tenderminded than their male counterparts in other careers, according to the article. When compared to female nurses, male nurses reported a higher degree of tough-mindedness, and when compared to adult male norms, male nurses were more dominant and self-sufficient. The article reports that men in nursing believe they have been enriched by being able to express both masculine and feminine traits in their personal and professional lives. This better understanding of men who have made atypical career choices could help increase the number of career options available to young people today by alleviating the sexual segregation stereotypes from our society.
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AORN JOURNAL
Recommended Practices ASEPTICTECHNIQUE
T
he following recommended practices were developed by the AORN Recommended Practices Coordinating Committee and have been approved by the AORN Board of Directors. They were published as proposed recommended practices in the February 1991 AORN Journal for comment by members and others. These recommended practices are intended as achievable recommendations representing what i s believed to be an optimal level of practice. Policies and procedures will reflect variations in practice settings and/or clinical situations that determine the degree to which the recommended practices can be fulfilled. AORN recognizes the numerous different settings in which perioperative nurses practice. The recommended practices are intended as guidelines adaptable to various practice settings. These practice settings include traditional operating rooms, ambulatory surgery units, physicians’ offices, cardiac catheterization laboratories, endoscopy rooms, radiology departments, and all other areas where surgery may be performed. Purpose. Basic principles and practices provide guidelines for establishing and maintaining a sterile field. Anyone who is present in the operating room has a responsibility to provide and maintain a safe environment. Adherence to aseptic practices aids in fulfilling this responsibility. Aseptic practices are implemented preoperatively, intraoperatively, and postoperatively to minimize wound contamination.
Recommended Practice I Scrubbed persons should wear sterile gowns and gloves. Interpretive statement 1: Materials for gowns should be selected according to AORN “Recommended practices for evaluating protective barrier materials for surgical gowns and drapes.” Rationale: Surgical gowns should establish a barrier that minimizes the passage of microorganisms between nonsterile and sterile areas.’ Interpretive statement 2: Surgical hand scrubs performed before donning sterile gown and gloves should follow AORN “Recommended practices for surgical hand scrubs.” Rationale: Transfer of microorganisms is reduced by scrubbing hands and wearing sterile gloves. Interpretive statement 3: The srubbed person should don sterile gown and gloves from a sterile field other than the main instrument table. Rationale: This practice avoids c~ntamination.~ Interpretive statement 4: Sterile gowns should be considered sterile in front from the chest to the level of the sterile field, and the sleeves should be considered sterile from two inches above the elbow to the cuff. Rationale: The area of sterility in the front of the gown extends to the level of the sterile field because 819
AORN JOURNAL
most scrubbed personnel work adjacent to a sterile table. Because the arms of a scrubbed person must move across a sterile field, gown sleeves up to two inches above the elbow must remain steri1e.j Interpretive statement 5: The following surgical gown areas should be considered unsterile: neckline, shoulders, under the arms, back. and sleeve cuff. Rationale: The neckline. shoulders, under the arms, back, and cuffed portions of the sleeves are moisture collection and friction areas. Consequently, they are not effective microbial barriers.s The back of the gown cannot be under constant observation by the scrubbed person. Interpretive statement 6: Scrubbed people should inspect gloves for integrity after donning them. Rationale: Gloves should establish a barrier that minimizes the passage of microorganisms between nonsterile and sterile areas.6 Interpretive statement 7: Once the original gloves are donned, the gown cuffs should be considered contaminated. Rationale: As the scrubbed hand passes through the gown cuff, the cuff becomes contaminated.' Discussion: There are only two methods of changing contaminated gloves. The preferred method is for one member of the sterile team to glove the other. If this is not possible. the contaminated glove should be changed by the open-glove method. Wearing two pair of gloves (double gloving) may be indicated for some procedures in accordance with policies in the practice setting8
Recommended Practice II Sterile drapes should be used to establish a sterile field. Interpretive statement 1: Surgical drapes should be selected according to AORN "Recommended practices for evaluating protective barrier materials for sur820
OCTOBER I99 I , VOL 54, NO 4
gical gowns and drapes." Rationale: Surgical drapes establish a barrier that minimizes the passage of microorganisms between nonsterile and sterile areas9 Interpretive statement 2: Sterile drapes should be placed on the patient and on all furniture and equipment to be included in the sterile field. Rationale: Isolating the operative field with drapes assists in preventing contamination from other unprepared areas."' Interpretive statement 3: Sterile drapes should be handled as little as possible. Rationale: Rapid movement of sterile drapes creates air currents on which dust, lint, and droplet nuclei can migrate.'' Interpretive statement 4: During the draping process, draping material should be compact, held higher than the OR bed, and draped from the operative site to the periphery. Rationale: The movement of sterile drapes from clean areas to dirty areas helps prevent contamination of the sterile field." Interpretive statement 5: During draping, sterile gloves should be protected by cuffing the draping material over the hands. Rationale: The gloved hands should always be protected by cuffing the draping material back over the gloved hands to avoid c~ntamination.'~ Interpretive statement 6: Once the sterile drape is placed in position, it should not be moved. Rationale: Shifting or moving the sterile drape compromises the sterility of the field.I4
Recommended Practice III Items used within a sterile field should be sterile.
OCTOBER 1991, VOL 54, NO 4
Interpretive statement I : Packaging materials should meet the AORN “Recommended practices for selection and use of packaging materials.” Rationale: Packaging materials should ensure sterility of package contents until opened for use and should permit removal of contents without contamination. Interpretive statement 2: Methods of sterilization, storage, and handling of sterile items should meet AORN “Recommended practices for sterilization and disinfection.” Rationale: Sterilization provides the highest level of assurance that an object is void of viable microbes. Disinfection reduces the risk o f microbial contamination but without the same level of assurance.I6 Interpretive statement 3: All items presented to the sterile field should be checked for proper packaging, processing, moisture, seal integrity, package integrity, and the appearance of the sterilization indicator. Rationale: The inspection of packaging helps ensure that only sterile items are presented to the sterile field.”
Recommended Practice IV All items introduced onto a sterile field should be opened, dispensed, and transferred by methods that maintain sterility and integrity. Interpretive statement I : When opening wrapped supplies, unscrubbed personnel should open the wrapper flap farthest away from them first and the nearest wrapper flap last. Rationale: This method is used to prevent contamination by passing an unsterile arm over a sterile item.’* Interpretive statement 2: All wrapper edges should be secured when supplies are presented to the sterile field to
AORN JOURNAL
avoid contamination. Rationale: Secured wrapper edges prevent flipping the wrapper and contaminating the contents of the sterile field.I9 Interpretive statement 3: Sterile items should be presented to the scrubbed person or placed securely on the sterile field. Rationale: Items tossed onto a sterile field may roll off the edge and become contaminated or cause other items to be displaced.20 Interpretive statement 4: Sharp andlor heavy objects should be presented to the scrubbed person or opened on a separate surface. Rationale: Sharp and heavy objects may penetrate barriersZ1 Interpretive statement 5: When dispensing solutions to the sterile field the entire bottle contents should be poured into the receptacle or the remainder discarded, the solution receptacle should be placed near the edge of the table or held by the scrubbed person, and fluids should be poured slowly to avoid splashing. Rationale: Because the edge of a bottle cap is considered contaminated once the cap has been removed from the bottle, the sterility of the bottle contents cannot be ensured if the cap is replaced. Reuse of opened bottles may contaminate solutions due to drops contacting unsterile areas and then running back over sterile bottle lips. Placing the solution receptacle near the edge of the sterile table allows unscrubbed persons to pour fluids without contamination. Splashing can cause strike-through and contamination of the sterile field.22
Recommended Practice V A sterile field should be constantly monitored and maintained. 821
AORN JOURNAL
Interpretive statement I : Sterile fields should be prepared as close as possible to the time of use. Rationale: There is a direct correlation between the time the sterile field is established and the length of exposure to airborne contaminants.23 Interpretive statement 2: Sterile fields should not be covered. Rationale: It is very difficult to uncover the sterile field without contamination.’i Interpretive statement 3: Unguarded sterile fields should be considered contaminated. Rationale: Chances for contamination of an unguarded sterile field are numerous. Without direct observation, there is no way to ensure sterility.’s Interpretive statement 4: Every team member should observe for events which may contaminate the sterile field, and corrective action should be initiated. Rationale: The sterile field is monitored to assist in the maintenance of sterility. Application of the principles of aseptic technique depends primarily on the individual and his or her surgical conscience.’h Interpretive statement 5: Conversation should be minimal in the operating room. Rationale: Talking is kept to a minimum in the surgical area to reduce spread of droplets. Even though the surgical team members wear masks, excessive talking generates free moisture droplets that are forcefully dispersed into the surrounding air.?’ Interpretive statement 6: All cables, tubing, etc, for equipment should be secured to the sterile field with nonperforating devices. Rationale: A sterile barrier that has been perforated is considered contaminated.?* Interpretive statement 6: Nonsterile equipment brought into and/or 822
OCTOBER 1991, VOL 54, NO 4
over the sterile field should be draped with a sterile material or covering. Rationale: Only sterile items should touch or extend over sterile surfaces.29
Recommended Practice V1 All personnel moving within or around a sterile field should do so in a manner to maintain the integrity of the sterile field. Interpretive statement I: Scrubbed people should remain close to the sterile field and should not leave the room. Rationale: Wandering around or leaving the room in sterile attire increases the potential for contamination.”’ Interpretive statement 2: Scrubbed surgical team members should move from sterile areas to sterile areas. If they must change positions, they should turn back to back or face to face while maintaining a safe distance between each other. Rationale: Scrubbed people move only in areas of similar preparation (ie, sterile to sterile) to prevent ~ontamination.~’ Interpretive statement 3: Scrubbed persons should keep arms and hands within the the sterile area at all time. Rationale: Contamination of hands and arms may occur when they are lowered below the level of the sterile field.32 Interpretive statement 4: Scrubbed persons should avoid changing levels and should be seated only when the entire surgical procedure will be performed at this level. Rationale: W h e n c h a n g i n g levels, exposure of t h e unsterile portion of the gown is likely.33 Interpretive statement 5: Unscrubbed people should face sterile areas on approach, should not walk between two sterile fields, and should maintain an awareness of the need for distance from the sterile field. Rationale:
OCTOBER 1991, VOL 54, NO 4
Establishing patterns of movement around the sterile field helps prevent accidental contamination. Accidental contamination can be prevented by keeping sterile areas in view during movement.34
Recommended Practice VII Policies and procedures for basic aseptic technique should be written, reviewed annually, and readily available within the practice setting. Discussion: These recommended practices should be used as guidelines for the development of policies and procedures within the practice setting. Policies and procedures establish authority, responsibility, and accountability and serve as operational guidelines. The AORN recommended practices that deal with basic aseptic technique should be consulted when developing those policies and procedures. Introduction and review of policies and procedures should be included in the orientation and ongoing education of personnel to assist in the development of knowledge, skills, and attitudes that affect patient care. Policies and procedures also assist in the development of quality assessment and improvement activities. Notes 1 . “Recommended practices for evaluating aseptic barrier materials for surgical gowns and drapes,” in AORN Standards and Recommended Practices for Perioperative Nursing (Denver: Association of Operating Room Nurses, Inc, 1991) 111: 6-1. 2. B P Simmons, “Guidelines for prevention of surgical wound infections,” Infection Control, Special Supplement 3 (MarcMApril 1982) 191. 3. J A Kneedler, G H Dodge, Perioperative Patient Care: The Nursing Perspective (Boston: Blackwell Scientific Publications, Inc, 1983) 41 9. 4. B J Gruendemann, M H Meeker, Alexander’s Care of the Patient in Surgery, second ed (St Louis: The C V Mosby Co, 1987) 58. 5. Ibid. 6. R E Condon, E J Quebbeman, “Preparing the operating room,” in American College of Surgeons: Care of the Surgical Patient, vol2, ed D W Wilmore et al, (New York: Scientific American, Inc, 1988) 9. 7. D M Fogg, “Resterilizing single-use items; technique for changing contaminated gloves; effec-
AORN JOURNAL
tiveness of sticky mats” (Clinical Issues) AORN Journal 48 (August 1988) 358. 8. J Gerberding et al, “Double gloving, barriers prevent blood exposure,” OR Manager 6 (August 1990) 4. 9. Condon, Quebbeman, American College of Surgeons: Care of the Surgical Patient, 9. 10. Kneedler, Dodge, Perioperative Patient Care: The Nursing Perspective, 432. 11. C W Walter, “Prevention and control of airborne infection in hospitals,” Annals of New York Academy of Sciences (1980) 325. 12. L J Atkinson, M L Kohn, Berry and Kohn’s Introduction to Operating Room Technique, sixth ed (New York City: McGraw-Hill Book Co, 1986) 317319. 13. B J Gruendemann et al, The Surgical Patient: Behavioral Concepts for the Operating Room Nurse, second ed (St Louis: The C V Mosby Co, 1977) 72. 14. Atkinson, Kohn, Berry and Kohn’s Introduction to Operating Room Technique, 3 17-319 15. “Recommended practices for selection and use of packaging materials,” in AORN Standards and Recommended Practices for Perioperative Nursing (Denver: Association of Operating Room Nurses, Inc, 1991) 111: 15-1. 16. “Recommended practices for sterilization and disinfection,” in AORN Standards and Recommended Practices for Perioperative Nursing (Denver: Association of Operating Room Nurses, Inc, 1991) 111: 17-1. 17. Kneedler, Dodge, Perioperative Patient Care: The Nursing Perspective, 41 1. 18. Ibid. 19. Ibid. 20. P Wells, Fundamentals of Aseptic Technique (Denver: Association of Operating Room Nurses, Inc, 1976) Film Instruction Guide, 8. 21. Ibid, 7-8. 22. Ibid, 5-6. 23. Kneedler, Dodge, Perioperative Patient Care: The Nursing Perspective, 41 2-413. 24. Wells, Fundamentals of Aseptic Technique, 9. 25. Ibid, 8-9. 26. Kneedler, Dodge, Perioperative Patient Care: The Nursing Perspective, 410. 27. Gruendemann et al, The Surgical Patient: Behavioral Concepts for the Operating Room Nurse, 73. 28. S Crow, Asepsis, the Right Touch: Something Old is Now New (Bossier City, La: The Everett Co, 1989) 84. 29. Gruendemann et al, The Surgical Patient: Behavioral Concepts for the Operating Room Nurse, 72. 30. Crow, Asepsis, the Right Touch: Something Old is Now New, 88-89. 3 1. ORNAC: Recommended Technical Standards823
AORN JOURNAL
Operatiiig Room N ~ r ~ s i n(Operating g Room Nurses Association of Canada. 1988) 22. 32. Crow, Asepsis, the Right Touch: Something Old i s Nou, Nett,, 84. 33. Kntxdler. Dodge. Prrioperati\,e Pntient Care:
The Niirsirig Per.specri\,e, 4 12. 34. Ibid.
Suggested reading Crow, S ..It’s second nature to me now ’’ Todm ‘s OR Nurtr 12 (October 1990)6-8 Crow, S. Taylor, E “Nurses’ compliance with asep-
OCTOBER 1991, VOL54, N O 4
tic technique.” AORN Journal 37 (May 1983) 1066-1072.
Gruendemann, B. “Surgical asepsis revisited.” Tuduy’s OR Nurse 12 (October 1990) 10-13. Laufman, H. “What’s happened to aseptic discipline i n the OR?” Today’s O R Nurse 12 (October 1990) 15-19. Maulden, B C. “Need for basic aseptic technique.” PointofView 19 (July 1, 1982) 10-11. Wells, P. “Teaching aseptic technique.” Today’s OR Nurse 6 (September 1983) 20-24, 57.
Use Tooth Whiteners With Caution
Men in Nursing Debunk Stereotypes
Tooth whiteners can give you a brighter smile, but caution should be exercised, according to an article in the April 1991 issue of the Mayo Clinic Health Letter. Several brands and types of tooth whiteners have come on the market in the past two years. These are more effective than toothpaste and simpler and less painful than the heat-activated hydrogen peroxide used to whiten teeth. Long-term effects, however, have not been determined completely . There are no reports yet on how long the whitening lasts. Whiteners are available in paste or gel forms, often with polishing creams. The cleansing action is a result of hydrogen peroxide and oxygen. According to the article, the American Dental Association (ADA) states that long-term use of hydrogen peroxide can damage chromosomes and may boost cancercausing effects of other substances. These chemicals also could cause infection or damage to the soft tissue or delay healing of already damaged tissue. The US Food and Drug Administration and the ADA have not approved or sanctioned the use of these new whitening products. The article notes that if you use tooth whiteners you should follow directions carefully and report any problems to your dentist.
Men choose nursing to provide a health service, work with people, and earn a living, according to an article in the April 1991 issue of The Journal ofhrursing Education. The article reports that most men in nursing are interested in job security, the sciences, and work in a humanistic field, and they desire personal and professional mobility. Male nurses scored high on normed empathy and social, esthetic, and theoretical interest scales. Other normed comparisons reveal that men in nursing are more emotionally stable, more outgoing, more abstract, yet more tenderminded than their male counterparts in other careers, according to the article. When compared to female nurses, male nurses reported a higher degree of tough-mindedness, and when compared to adult male norms, male nurses were more dominant and self-sufficient. The article reports that men in nursing believe they have been enriched by being able to express both masculine and feminine traits in their personal and professional lives. This better understanding of men who have made atypical career choices could help increase the number of career options available to young people today by alleviating the sexual segregation stereotypes from our society.
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