Sterile Field: Part II

Creating &  Maintaining a Sterile Field for Surgical Instruments: Part II In Part I of this blog it was pointed out that creating and maintaining a sterile field for surgical instruments during a case helps to minimize the risk of a surgical infection caused by a contaminated instrument. To achieve this goal the surgical team members must adhere to the principles of aseptic technique and utilize those principles on every surgical procedure. As noted in Part I of this blog, the following recommendations are from the Association of Surgical Technologists (AST) and they are designed to help create and maintain the sterile field in the perioperative setting. ¹ Continuing where Part I left off, we see in AST Standard of Practice III, Section D, that aseptic technique must be strictly adhered to by the surgical team members when opening sterile instrument sets, packages and peel packs. Specifically:

4. Peel packs that contain a heavy or difficult item(s), (e.g. pliers, multiple clamps) should not be opened and flipped onto the sterile field. The item could puncture the sterile cover. The item should be opened into a basin on a ring stand or preferably a non-scrubbed person should open the peel pack and pass the sterile item(s) using aseptic technique to the CST in the first scrub role.
5. Items should be opened in a grouping manner the same way on all cases to establish a logical, sequential, and efficient routine for creating the sterile field.
   1. The grouping of items minimizes movement and contributes to the efficiency of the set up. 
   2. Items opened in a grouping manner allows the CST to easily identify and locate similar items (e.g. all of the drapes are opened in the same area of the back table.)
   3. Sharps should be grouped on one corner of the back table and other items should not be opened near the sharps.  This aids in minimizing the risk of an accidental sharps injury during the set up.
   4. Items such as drapes should be opened in reverse order of use (e.g., the last drape to be used will be opened first so it will be on the bottom and the first drape will on top).  This minimizes movement and contributes to efficiency.
6. Rigid instrument containers should be inspected prior to opening.
7. The filter and/or valve system should be inspected to confirm they are intact.
8. The tray locking mechanisms should be checked for integrity, and checked to make sure the chemical indicator on the seal lock changed color to confirm that the container was exposed to a sterilization process.
9. If the container does not meet these inspection criteria, it must be considered contaminated and not used.
10. The lid should be lifted upward, with taking a step back and away from the container to prevent contamination.
11. Containers that have a gasket should be checked to make sure the gasket is intact. If the gasket is not intact, the set should be considered contaminated.
12. If a sterile package is dropped, the package may be considered safe for immediate use if wrapped in impervious packaging, the area of contact is dry, and the integrity of the packaging is maintained. The package should not be placed back in sterile storage and must be immediately opened and placed on the sterile field. Sterile packages wrapped in reusable woven fabric packaging that have been dropped should not be opened, and the items should not be transferred to the sterile field; reusable fabric packaging allows air to implode into the package when it lands on the area of contact.²  

As was pointed out in an earlier blog, the sterility of a packaged sterile item is event-related (i.e. being dropped) and should not be used in a surgical case if anything happens to the package. Ensuring the sterility of a surgical instrument starts with proper handling immediately after use on a patient and continuing right through the moment the instrument comes into contact with a new patient in the OR. This includes proper decontamination and thorough cleaning to remove all of the accumulated bioburden prior to sterilization. Regardless of how many times you run an instrument through the sterilization cycle, if it is contaminated with residual bioburden, it will not be sterile and will not be safe for use on a patient. The only way to ensure clean, sterile, moisture-free instruments for every patient, every time, is to only use instruments whose cleaning IFUs have been validated using AAMI and FDA recommended validation protocols. 1 AST Standards of Practice for Creating the Sterile Field 2 AST Recommended Standard of Practice for Sterile Wrapped Items Dropped on Floor