Asepsis and Aseptic Practices in the Operating Room

by Cathy Osman, RN, BSN, CNOR

All surgical team
Preventing surgical site infection in the operating room is the primary goal of the surgical members must wear
team, and all activities performed by the team support this goal. Some of these activities scrub attire, sterile
include patient risk assessment, environmental cleaning, disinfection and sterilization of surgical gown, mask,
instrumentation, patient antibiotic prophylaxis, and the use of standard precautions. and gloves within the
However, operating room activities pertaining to asepsis and aseptic practices have the sterile field to establish
greatest direct impact upon the surgical team in helping to reduce the patient's risk to surgical bacterial barriers.
site infection.

The goal of asepsis is to prevent the contamination of the open surgical wound by isolating the operative site from the
surrounding nonsterile environment.1 The surgical team accomplishes this by creating and maintaining the sterile field
and by following aseptic principles aimed at preventing microorganisms from contaminating the surgical wound. 3

The standards and recommended practices, developed by the Association of periOperative Registered Nurses (AORN),
are guidelines to be used by the surgical team to achieve the optimal level of technical and aseptic practice when caring
for their patients in the perioperative setting. 3 These guidelines are not to be considered policies. They should be used
by institutions to provide direction and information on perioperative practice as they incorporate them into their own
policies and procedures.

The principles of aseptic technique play a vital role in accomplishing the goal of asepsis in the operating room
environment. It is the responsibility of each surgical staff member to understand the meaning of these principles and to
incorporate them into their everyday practice. The principles of aseptic technique include the following principles.

Principle #1
Scrubbed persons function within a sterile field. 2
The surgical team is made up of sterile and nonsterile members. Sterile members or "scrubbed" personnel work directly
in the surgical field while the nonsterile members work in the periphery of the sterile surgical field. All surgical team
members wear scrub attire. In addition to scrub attire, scrubbed persons must wear a sterile surgical gown, mask, and
gloves within the sterile field to establish bacterial barriers. 2,4 These barriers protect the patient from the transmission of
microorganisms from the surgical team.
Once the scrubbed person dons the sterile surgical gown, the gown's sterility is limited to the gown portions directly
viewed by the scrubbed person. These sterile areas include the gown front, from chest to the sterile field level, and the
sleeves from two inches above the elbow to the cuff. 2,4 The scrubbed personnel always perform a surgical hand scrub
prior to donning their sterile surgical gown and gloves.

Principle #2
Sterile drapes are used to create a sterile field. 2,5
Sterile surgical drapes establish an aseptic barrier minimizing the passage of microorganisms from nonsterile to sterile
areas.2 Sterile drapes should be placed on the patient, furniture, and equipment to be included in the sterile field,
leaving only the incisional site exposed.5 During the draping process, only scrubbed personnel should handle sterile
drapes. The drapes should be held higher than the operating room bed with the patient draped from the prepped
incisional site out to the periphery. 2 Once the sterile drape is positioned, it should not be moved or rearranged. 5 Keep in
mind that after the patient and operating room tables are draped, only the top surface of the draped area is considered
sterile.1

Principle #3
All items used within a sterile field must be sterile. 2,4
Under no circumstances should sterile and nonsterile items/areas be mixed since one contaminates the
other.4 Sterilization provides the highest level of assurance that all instruments, sutures, fluids, supplies, and drapes are
void of microorganisms.2 The sterility of a package is determined by events, not by time. To ensure sterility, all sterile
items need to be inspected for package integrity and sterilization process indicators, such as indicator tape and internal
chemical indicators, prior to introduction onto the sterile field. 2 If a package has been compromised, it should be
considered contaminated and not be used. 5
Fluid or air can contaminate a sterile package. When fluid penetrates a sterile package, fluid strikethrough occurs. The
fluid creates a vehicle in which migration of microorganisms reach the sterile item. When a sterile packaged item is
dropped on the floor, air penetrates the sterile package. The force that is created when the package contacts the floor
can cause the sterile barrier to be penetrated by forcing sterile air out and allowing contaminated air and particles into
the package.1,3

Principle #4
All items introduced onto a sterile field should be opened, dispensed, and transferred by methods that maintain sterility
and integrity.2,4
All sterile items should be dispensed to the sterile field by methods that preserve the integrity of the items and sterile
field.1 Nonsterile personnel, usually the circulating nurse, must use good judgement when dispensing sterile items onto
the sterile field either by presenting them directly to the scrubbed person or placing them securely on the sterile
field.1,2 Sterile items that are tossed onto the sterile field may displace other sterile items, penetrate the drape, or roll off
the sterile field causing contamination to occur. 1,2
When opening wrapped supplies, the nonsterile person should open the top wrapper flap away from them first, then
open the flaps to each side. The last wrapper flap is pulled toward the nonsterile person opening the package. 3 This
technique of opening a wrapped package ensures that the nonsterile person does not reach over the sterile item inside.
All wrapper edges should be secured to prevent flipping the wrapper and contaminating the contents of the sterile
package or field.2,5 After a wrapper has been opened, the inside of the wrapper and its contents are considered sterile
with the exception of the 1-inch outer edge of the wrapper. 1 This 1-inch outer edge of the wrapper is considered the
"margin of safety" between sterile and nonsterile. When a package is double wrapped, each institution's policies and
procedures determine if one or both wrappers are opened before presentation to the sterile field. 5
When opening a peel package, the nonsterile person opens the package by rolling the wrapper over his or her hands and
presenting the inner contents of the package to the scrubbed person. 5 The package and its contents must be presented
in such a way to prevent contamination of the sterile item or the scrubbed person. When determining package content
sterility, the inner edge of the heat seal is considered the line separating sterile from nonsterile.
When opening a solution container, the nonsterile person should lift the cap straight up and pour the contents of the
bottle into a sterile container. The sterile container is either held by the scrubbed person away from the sterile field or
placed near the edge of a sterile waterproof-draped table. Only the top rim of the bottle top and bottle contents are
considered sterile once the cap has been removed from the bottle. Therefore, when sterile fluids are dispensed, the
entire contents of the bottle must be poured or the fluid remaining in the bottle discarded. 1 When solutions are poured
onto the sterile field, they should be poured slowly to prevent contamination and fluid strikethrough from splashing. 2

Principle #5
A sterile field should be maintained and monitored constantly. 2,5
It is the responsibility of the operating room staff to monitor and maintain the sterile field. Sterility can never be
absolutely guaranteed, but surgical team members should make every reasonable effort to reduce the likelihood of
contamination and be vigilant to breaches in sterility. 2 When a breach of sterility occurs, team members must take
immediate and appropriate action to correct the break in technique to reduce further risk of contamination. Remember,
if there is doubt regarding an item's sterility, consider it not sterile. 3
The sterile field should be prepared as close as possible to the time of use. 2 The sterility of supplies used during a
surgical procedure can be affected by the events taking place within the operating room, and the length of time the
items have been exposed to the environment. 4 Once set up, the sterile field needs to be monitored constantly. When
the sterile field is left unattended, personnel, airborne contaminants, insects, and liquids can contaminate the sterile
field.2 Each facility should have policies and procedures that address these issues for the surgical team to follow.

Principle #6
All personnel moving within or around a sterile field should do so in a manner to maintain the sterile field. 2
Since the patient is the center of the sterile field, scrubbed personnel should remain close to this area without
wandering around the room. This movement can result in contamination of the sterile field. 2,4Scrubbed personnel should
move only from sterile areas to sterile areas. When scrubbed personnel change positions, they should maintain a safe
distance from each other and always pass each other by turning back-to-back or face-to-face. 2 This movement reduces
the risk of contamination by ensuring the scrub persons are passing either nonsterile to nonsterile or sterile to sterile.
Scrubbed personnel should remain in the position in which they began the surgery. For example, if the surgery begins
with the scrubbed person sitting and is completed with the scrubbed person standing, the portion of the gown that was
considered sterile is uncertain.5 Scrubbed personnel should keep their arms and hands within the sterile field at all times
to avoid any accidental contact with nonsterile items or areas. Scrubbed personnel must maintain a safe distance when
approaching nonsterile objects and personnel. This safe distance or "margin of safety" is important in identifying safe
boundaries between sterile and nonsterile areas.
Nonsterile personnel should always remain in nonsterile areas and contact only nonsterile items to prevent
contamination of the sterile field. It is important that the nonsterile personnel always face the sterile field on approach
and should never walk between two sterile fields. 2 This ensures that the sterile area is always being observed and
accidental contact is avoided. Just as the sterile scrubbed person must maintain a safe distance from nonsterile areas
and persons, nonsterile personnel must always be aware of and maintain a "margin of safety" when approaching sterile
fields and scrubbed personnel. And finally, when delivering sterile supplies to the sterile field, the nonsterile team
member must always maintain a " margin of safety" between themselves and the sterile field, never contacting or
reaching over any portion of the sterile area. 5 This "margin of safety" is generally identified as a minimum of 12 inches
(30 cm) or more.

Principle #7
Policies and procedures for maintaining a sterile field should be written, reviewed annually, and readily available within
the practice setting.2
These recommended practices for aseptic technique should be used as guidelines for developing policies and procedures
within the practice setting.2 Introduction and review of policies and procedures should be included in the orientation and
ongoing education of all perioperative personnel. 2
Training of aseptic technique and practices requires experienced and skilled surgical team members to demonstrate
these skills to new and inexperienced personnel. New personnel should be assigned an experienced mentor who will be
a good role model and teacher providing leadership and education in perioperative practice.

Summary
All surgical team members must practice these principles of aseptic technique to help prevent the transfer of
microorganisms into the surgical wound during the perioperative period. It is the responsibility of the surgical team
members to develop a strong surgical conscience, adhering to the principles of asepsis and rectifying any improper
technique witnessed in the operating room. In addition to the principles of asepsis, proper surgical attire plays an
important role in the reduction of surgical site infections by reducing the amount of hair and skin contaminants reaching
the sterile field.
The goal of asepsis and aseptic technique is to prevent the transfer of microorganisms into the surgical wound.
Preventing surgical site contamination requires the efforts of all trained surgical team members to use their knowledge
and experience in aseptic practices to provide their patients with optimal care resulting in positive surgical outcomes.

A. Surgical Scrub Techniques

All sterile team members should perform the hand and arm scrub before entering the surgical suite. The basic principle of the scrub is
to wash the hands thoroughly, and then to wash from a clean area (the hand) to a less clean area (the arm). A systematic approach to
the scrub is an efficient way to ensure proper technique.

There are two methods of scrub procedure. One is a numbered stroke method, in which a certain number of brush strokes are
designated for each finger, palm, back of hand, and arm. The alternative method is the timed scrub, and each scrub should last from
three to five minutes, depending on facility protocol.

The procedure for the timed five minute scrub consists of:

 Remove all jewelry (rings, watches, bracelets).

 Wash hands and arms with anitmicrobial soap. Excessively hot water is harder on the skin, dries the skin, and is too
uncomfortable to wash with for the recommended amount of time. However, because cold water prevents soap from lathering
properly, soil and germs may not be washed away.
 Clean subungual areas with a nail file.
 Start timing. Scrub each side of each finger, between the fingers, and the back and front of the hand for two minutes.
 Proceed to scrub the arms, keeping the hand higher than the arm at all times. This prevents bacteria-laden soap and water
from contaminating the hand.
 Wash each side of the arm to three inches above the elbow for one minute.
 Repeat the process on the other hand and arm, keeping hands above elbows at all times. If the hand touches anything except
the brush at any time, the scrub must be lengthened by one minute for the area that has been contaminated.
 Rinse hands and arms by passing them through the water in one direction only, from fingertips to elbow. Do not move the arm
back and forth through the water.
 Proceed to the operating room suite holding hands above elbows.2
 If the hands and arms are grossly soiled, the scrub time should be lengthened. However, vigorous scrubbing that causes the
skin to become abraded should be avoided.
 At all times during the scrub procedure care should be taken not to splash water onto surgical attire.2
 Once in the operating room suite, hands and arms should be dried using a sterile towel and aseptic technique. You are now
ready to don your gown and sterile gloves.

When gowning oneself, grasp the gown firmly and bring it away from the table. It has already been folded so that the outside faces
away. Holding the gown at the shoulders, allow it to unfold gently. Do not shake the gown.

Place hands inside the armholes and guide each arm through the sleeves by raising and spreading the arms. Do not allow hands to
slide outside the gown cuff. The circulator will assist by pulling the gown up over the shoulders and tying it.

To glove, lay the glove palm down over the cuff of the gown. The fingers of the glove face toward you. Working through the gown
sleeve, grasp the cuff of the glove and bring it over the open cuff of the sleeve. Unroll the glove cuff so that it covers the sleeve cuff.
Proceed with the opposite hand, using the same technique. Never allow the bare hand to contact the gown cuff edge or outside of
glove.

The scrubbed technologist or nurse gowns the surgeon after he or she has performed the hand and arm scrub. After handing the
surgeon a towel for drying, the technologist or nurse allows the gown to unfold gently, making sure that there is enough room to prevent
contamination by nonsterile equipment. To glove another person, the rules of asepsis must be observed. One person's sterile hands
should not touch the nonsterile surface of the person being gloved.

 Pick up the right glove and place the palm away from you. Slide the fingers under the glove cuff and spread them so that a
wide opening is created. Keep thumbs under the cuff.
 The surgeon will thrust his or her hand into the glove. Do not release the glove yet.
 Gently release the cuff (do not allow the cuff to snap sharply) while unrolling it over the wrist. Proceed with the left glove, using
the same technique.

Formal guidelines and recommended practices for hand washing have been published by professional organizations (e.g., Association
for Professionals in Infection Control (APIC), Association of periOperative Registered Nurses, Inc. (AORN). AORN recommends the
use of a traditional standardized anatomical timed scrub or counted stroke method for surgical hand scrub and encourages institutions
to follow the scrub agent manufacturer's written recommendations when establishing policies and procedures for scrub times. On this
basis, for example, the typical scrub procedure for a PVPI-containing product based on manufacturer's labeling would require the use of
a scrub brush and two applications of five minutes each, whereas the typical procedure for a CHG-based product would require a three-
minute scrub followed by a three-minute wash. In actual practice, however, variations in surgical hand scrubbing times may be of
shorter duration than manufacturer's recommendations for a number of reasons:

 Staff time constraints.

 Desire to reduce poor hand health.
  Acceptance of data from other sources suggesting those scrub times shorter than those recommended by manufactures are
adequate.3

Hand condition is emerging as an increasingly important factor in personnel compliance and infection control. Frequent surgical
scrubbing can cause dermatitis of the hands and arms. Most antimicrobial agents are drying to the skin, especially when coupled with a
scrub brush.

Conclusion
No matter what agent is used, or which scrub technique you practice, there is only one goal: infection prevention. Effective surgical
scrubs are one of the most powerful strategies of infection prevention in the OR. Glove usage gives a false sense of security against
bacteria. Gloves provide an ideal environment for bacterial growth, moisture and warmth, which makes good hand-scrub techniques
and aseptic gowning and gloving an important part of the total infection prevention platform. It is important for healthcare management
to help the personnel understand the cause/effect cycle of surgical scrubs as they relate to infection prevention.

B. Sterile Surgical Gloves (GLOVING)

 Remember: hands are always held above the elbow

1. After hand washing procedure open the package of sterile gloves

o Place the package of gloves on a clean dry surface

 Remember: Any moisture could contaminate the gloves and make sure that the hands are held above the elbow

o Make sure that the gloves are positioned accordingly

o Some gloves are packed in an inner as well as an outer package.

 Remember : the non-working hand is always held above the elbow

o Open the outer package w/o contaminating the gloves or inner package
o Grasp the glove using the non-dominant hand, grab the cuff of the glove (on the palmar side)

o Put the first glove on the dominant hand

o Insert the dominant hand into the glove

o Touch only the inside of the cuff

o And pull the gloves on. Keep the thumb of the inserted hand against the palm of the hand during insertion

 Remember: non working hand is always held above the elbows

o Put the second glove on the non-dominant hand
o This time pick up the other glove with the sterile gloved hand, inserting the gloved fingers under the cuff.

o Pull on the second glove carefully, do not let the gloved hand touch the arm

o Adjust each glove carefully so that it fits smoothly, and carefully pull the cuffs up by sliding the sliding the fingers under the
cuff

o After use remove and dispose used gloves

2. Removal of Gloves

o Remove gloves by turning them inside out by not touching the clean parts of the hands.

3. Suggested technique

o Step 1- Plucking the palmar surface or anterior surface of the glove, it is done below the cuff of a contaminated glove

o Step 2- remove the contaminated glove, roll it inside out, put it on the remaining gloved hand

o Step 3- Insert the Index and middle finger inside the cuff of the second glove.

 Remember: touching the outside surface of the 2 nd soiled glove with a bare hand is avoided
 o Step 4- Pull the second glove off to the fingers by turning it inside out

o Step 5- Dispose the contaminated glove properly

C. DONNING OF FACIAL MASK

o Hold mask with color layer and ear loop fastener on the outside of the mask

o Position the mask below the face

o Secure the nose piece comfortably over the bridge of the nose

o Pull the mask down fanning / extend the mask under the chin

o Pull ear loops tight around the ears

o Confirm mask if it is secure around the ear and face

o A properly donned face mask

o Check the attire – from the head cap to mask up to the gown.

D. DONNING OF GLOVES
E. SERVING OF GLOVES AND GOWNS
F. CHARGING OF NEEDLES AND BLADES
G. PREPARING THE BACK