How to Handle 3 Sterile Conscience Dilemmas
Dan Mayworm, Contributing Editor
Handling dropped items
A sterile item falls on the floor. What do you do? An OR staff person would probably take one of the following three options.
Option 1: Resterilize it. If the item is a facility wrapped and sterilized product, a staff person may feel that the only conscientious thing to do would be to send it back through decontam and resterilize it.
Option 2: Throw it away. If the item is a pre-sterilized disposable product and can't be re-sterilized, the staff person may feel that the only possible choice would be to throw it away (or send it to a third world country).
Option 3: Put it back. In many cases, the staff person may simply look around to see if anyone is watching, swipe it against a pant leg, and put the item back on the shelf.
Which option is correct? The answer is 1, 2, or 3, depending on the circumstances. The problem with a hard and fast rule such as, you must re-sterilize any sterile item that falls on the floor, is that it doesn't take into consideration the wide range of circumstances that could be involved. For example, suppose you EtO gas or gas plasma sterilize cotton balls because you want to keep them on a crash cart where the package is subjected to various sources of potential contamination. You package the cotton balls in a plastic package that is impervious to bacterial contamination. The package falls on the floor. Are the cotton balls still sterile? Of course they are. Do you need to wipe off the package before you put it back on the shelf? That depends on what it fell into (whatever you do, don't ever wipe off the package with anything that's wet, such as alcohol).
The circumstances are different if you drop a 16-lb tray loaded with delicate eye surgical instruments wrapped in 140 TC linen. Common sense says to open the package, see if the wrap or any of the instruments have been damaged, and then re-wrap and resterilize. Do you need to send the tray back through decontam? I wouldn't. The purpose of decontamination is to remove gross soil from used items. Items that have fallen on the floor are still safe to handle, and unless they fell into a grossly contaminated environment, there is no need to subject them to another session in decontam.
These are two extremes, and there are a host of circumstances that fall in between these extremes. To make sure you are handling these sterile conscience dilemmas correctly and with consistency, assign one person the responsibility of making these decisions. This person should understand sterilization theory thoroughlyenough to make the correct decision based on the circumstances, not on any hard and fast rules. This person should also educate all personnel who handle sterile items so that they will eventually be able to make their own informed decisions.
Managing single-use, disposable products that fall on the floor is much simpler. Train the staff to examine the protective packaging for any damage. If there is no damage, just return the item to the shelf. If there is obvious damage to the package or to the item, consider returning the item to the manufacturer or to a third party reprocessor that will guarantee the product.
Maintaining the sterile field
There is a lot of mysticism regarding "the sterile field." The sterile field is only truly sterile for those few moments when the sterile drapes are opened to form the field. Then, depending upon the amount of activity in the room, the time the sterile field is open to the environment, and the relative cleanliness of the room environment, the sterile field becomes increasingly unsterile. Realize that the front of the gown is only marginally cleaner than the back of the gown, and the edges of the drapes are no less sterile seven inches down from the top than three inches.
The idea that putting a non-sterile item into the sterile field immediately causes the entire field to become non-sterile has no scientific basis and is simply not true. Again, use common sense. Dropping a bloody instrument into a ring of sterile instruments will undoubtedly contaminate them. However, placing a container of sterile instruments onto the far side of the back table will not contaminate other instruments on the table unless it comes in contact with them, even though the outside of the container itself is not sterile. Do the "bugs" jump or crawl from the non-sterile item to the sterile items? Of course not. Furthermore, having the container conveniently at hand may enhance the surgeon's ability to expedite the procedure, reducing the amount of time the patient is open to infectious agents.
I am not trying to completely destroy the concept of maintaining an area around the patient that is as environmentally safe as possible. That always has been good surgical practice. The only time it is not good practice is when the safety of the patient is put at risk because someone touched someone in the wrong place, causing the procedure to be delayed while the surgeon or scrub nurse re-gowns. You need not abandon sterile field protocols, but be sure to use them with discretion.
Opening a double wrapped sterile package:
Ever since I can remember, a controversy has existed regarding who should open the inner wrap in a double-wrapped sterile package. For many years, it was common practice for the circulating nurse to open the outer wrap and the scrub nurse to open the inner wrap so that the "dirty" nurse did not handle the sterile inner wrap and possibly contaminate it by touching the inner wrap contents. Keeping the contents wrapped in the inner wrap until they were used was also thought to be a good idea, especially if the staff set up the ORs well ahead of time.
In 1971, however, the CDC published a shelf life article1 that showed that a double 140TC wrap would keep the contents sterile anywhere from 21 to 30 days, but a single wrap only kept the contents sterile for three days. Enterprising OR nurses then took the next step and determined that if a single wrap (such as the outer wrap in a double wrap) only stayed sterile for three days then the outer layer of the inner wrap would probably not be sterile after three days and should not be touched by the scrub nurse. They thus instituted a new practice: The circulator would open both the inner and the outer wraps and present the contents aseptically onto the sterile field or into the scrub's hands.
The last time I took a survey of standard OR practice I found a 50/50 split between these two ways of presenting sterile items into the sterile field. Which one is correct?
To answer that question we need to first eliminate a variable-the use of 140TC linen as a sterile wrap. This product is an insufficient bacteria barrier and becomes less effective with each successive laundering; most recognized authorities have discredited it. So you should not even be using it.
If you are using a brand-name disposable wrap or a more tightly woven reusable material designed to be used as a wrap, you don't have to be concerned with the sterility of the outside of the inner wrap-these wraps are woven tightly enough and are moisture-resistant enough to resist contamination. It's good practice, in fact preferable, to have the circulator open the outer wrap and the scrub open the inner wrap. This way, the contents of the package are protected until they are needed, which is especially important in long procedures.
If you want to speed up the process of both wrapping and opening you can use a double wrap singly rather than sequentially. Simply make a single wrap using two layers of wrapping material. This saves labor costs, but your staff needs to be properly trained on how to present items aseptically into the sterile field.
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