Chapter 15 After studying this chapter, the learner will be able to: • Describe the transmission of microorganisms. • List several principles of standard precautions. • Discuss the obligation of the team to practice aseptic and sterile techniques. Dispersion of fine mist, droplets, or particulate matter into air (vt: aerosolize, to become airborne). Prevention of sepsis by the exclusion, destruction, or inhibition of growth or multiplication of microorganisms from body tissues and fluids. Inorganic chemical compounds that combat sepsis by inhibiting the growth of microorganisms without necessarily killing them. They are used on skin and tissue to arrest the growth of endogenous microorganisms (resident flora), and they must not destroy tissue. Absence of microorganisms that cause disease; freedom from infection; exclusion of microorganisms. Not the same as sterile. Methods by which contamination with microorganisms is prevented (alternate term: aseptic practice, to maintain asepsis). Material used to reduce or inhibit the migration or transmission of microorganisms in the environment. Barriers include attire of personnel, drapes over furniture and patients, packaging of supplies, and filters in ventilating system. Person who has potentially pathogenic microorganisms on or in his or her body and disperses them into the environment without becoming ill from the pathogen. Soiled or infected by microorganisms. Transmission of microorganisms from patient to patient and from inanimate objects to patients and vice versa. Cleaning and disinfecting or sterilizing processes carried out to make contaminated items safe to handle. Chemical or mechanical destruction of most pathogens rendering an object safe to handle. Inanimate object that may be contaminated with infectious organisms and that serves to transmit disease. Microbial burden cannot get any lower. Item is sterile to its highest degree. Special precautions taken to prevent the transmission of microorganisms from specific body substances. Producing or capable of producing disease. Microorganisms that cause infectious disease. They can invade healthy tissue through some power of their own or can injure tissue by a toxin they produce. Severe toxic febrile state resulting from infection with pyogenic microorganisms, with or without associated septicemia. An awareness of sterile, unsterile, clean, and contaminated areas and their proximity to each other. This includes the height of scrubbed team members in relation to each other and the sterile field. The circulating nurse must be aware of closeness to the sterile field and the appropriate means to control environmental contaminants. Procedures followed to protect personnel from contact with the blood and body fluids of all patients (formerly referred to as universal precautions). Free of living microorganisms, including all spores. Area around the site of incision into tissue or site of introduction of an instrument into a body orifice that has been prepared for the use of sterile supplies and equipment. This area includes all furniture covered with sterile drapes and all personnel who are properly attired in sterile garb. Methods by which contamination with microorganisms is prevented to maintain sterility throughout the surgical procedure. Terminal sterilization and disinfection Procedures carried out for the destruction of pathogens at the end of the surgical procedure in the OR or other areas of patient contact (e.g., postanesthesia care unit [PACU], intensive care unit [ICU], nursing unit). Inanimate object that has not been subjected to a sterilization process; the outside wrapping of a package containing a sterile item; a person who has not prepared to enter the sterile field (syn: nonsterile). The terms aseptic and sterile are not synonymous, although aspects of both are closely related.2,3 An object can be aseptic without being sterile. Asepsis literally means “without dirt,” and it implies the absence of pathogenic microorganisms that cause infection. Aseptic and sterile techniques are based on sound scientific principles and are carried out primarily to prevent the transmission of microorganisms that can cause infection. The degree of processing, whether disinfected or sterile, depends on the importance of the item’s use in patient care. • Critical. Any item entering the bloodstream, body tissues underlying the skin, and mucous membranes must be sterile (i.e., free of microorganisms, including endospores). These items are handled using sterile technique to maintain sterility. • Semicritical. Sterility is less critical for items that come into contact with intact skin or mucous membranes. These items are clean and safe to handle with bare hands (i.e., mechanically cleaned and disinfected to reduce microorganisms, but unsterile). Some items are disinfected immediately before use and are handled using aseptic technique to prevent contamination before use. Other items are terminally sterilized between uses on different patients, but sterility is not maintained during storage or use. • Noncritical. Items that will come into contact with only intact skin or mucous membranes in an area remote from the surgical site may be cleaned, terminally disinfected, and stored unsterile between patient uses. No special technique in handling is observed. It is essential that all members of the perioperative team know the common sources and mechanisms of contamination by microorganisms in the perioperative environment. The practices of sterile and aseptic techniques are the particular responsibility of everyone caring for the patient in the OR. All members of the OR team must be vigilant in safeguarding the sterility of the sterile field, because any contamination must be remedied immediately.4 • Aseptic technique is sometimes referred to as clean technique. • Items have been cleaned and decontaminated so they are safe to handle with clean bare hands. • Items in use in patient care are handled with exam gloves for the protection of both the caregiver and the patient. • Items have been cleaned, decontaminated, disinfected, or terminally sterilized without a wrapper, and stored in a clean dry place. • Items may start out sterile, but are not maintained or used under sterile conditions. Skin preps may be packaged sterile, but skin cannot be sterilized. The process is aseptic. • Contamination is contained. Extraneous contamination is avoided. • Items are set up on clean towels or drapes and used with exam gloves. • Items are not sterile or maintained sterile during use. Extraneous contamination is avoided. • Disposable items are not cleaned and reused for another patient. • Items are classified as semicritical or noncritical by Spaulding’s classification of the importance of patient care items. • Items can be used outside the confines of the restricted area. • Items are used on intact skin or mucous membranes. • Items are not used when the patient’s vascular system will be entered. • Items are used only in a sterile field in the restricted area. • Items are used by sterile team members wearing appropriate sterile attire. • Items are used in areas of the patient’s body where the site has been prepped. • Items may be used in invasive surgery. • Items may be used in body areas with nonintact skin and membranes and may enter the patient’s vascular system. • Items are classified as critical according to Spaulding’s level of importance of patient care items. • Items have been cleaned, decontaminated, and packaged before sterilization. • Items processed by sterilization remain wrapped and are stored wrapped until use by a sterile team member. • Items are for individual patient use only. Reusable items can be reprocessed and resterilized for use with another patient. Disposable items are discarded after use. If opened and unused, disposable items are discarded. • Items that become contaminated are discarded and replaced immediately. There are many sources of contamination in the OR environment. Transmission-based precautions should be implemented in the perioperative environment and in any area with the potential to transmit potentially pathogenic microorganisms. Transmission-based precautions are described in Box 15-1. Perioperative personnel are concerned primarily with protecting the environment of the OR suite because surgical procedures should be performed under optimal conditions. • OR ventilation, humidity, and temperature controls • Decontamination, disinfection, and sterilization methods • Improved barriers, such as impervious drapes between sterile, clean, and contaminated surfaces • Surgical technique and tissue handling Despite advances, surgical-site infections (SSIs) continue to cause significant morbidity and mortality in surgical patients. Emergence of resistant microorganisms is complicated by patients with comorbid disease and the increasing numbers of implants and transplants. Microbiologic considerations and specific microorganisms that concern the perioperative team are described in Chapter 14. The following are vital points for all personnel entering the OR: • Bathe daily with soap that contains an antibacterial agent. • Wash hands before entering the OR suite and after every patient contact to prevent infection and cross-infection. This handwashing technique involves vigorously rubbing together all surfaces of well-lathered, soapy hands, followed by rinsing under a stream of water. • Don clean OR attire for each entry into the OR suite. Unsterile team members should wear long sleeves. • Cover any cuts and abrasions. Open wounds on the skin are portals for infection, and infected wounds can disseminate microorganisms. • Wear gloves when handling blood, body fluids, or tissue specimens, and wash hands after removing sterile and unsterile gloves. In maintaining an aseptic environment, the following key points should be considered: • Prompt disinfection and decontamination of used equipment and reusable supplies. • Prompt disinfection of OR surfaces (e.g., disinfecting furniture and floors, disposing of waste and laundry). • Separation of clean and soiled items. Sterile storage areas are physically separated from decontamination areas. • Proper packaging and storing of supplies. External shipping cartons should be removed before bringing supplies beyond the unrestricted area in the OR suite. Insects and rodents can gain entrance to the suite in corrugated cartons. • Placement of dust covers over sterile items during transport and while in prolonged storage. Approximately 35% of all health care–acquired S. aureus infections develop in surgical patients. They may occur as complications of surgical or other procedures performed on uninfected patients. They may occur also as complicating infections in organs unrelated to the surgical procedure that occur with or as a result of postoperative care. The majority of health care–acquired infections (HAIs) are related to instrumentation of the urinary and respiratory tracts. Microbial colonization is the primary component of HAI. The potential for SSIs can be conceptualized in the following equation1:
Principles of aseptic and sterile techniques
What is the difference between aseptic and sterile techniques?
Spaulding’s levels of importance of patient care items
Aseptic technique
Sterile technique
Transmission of microorganisms
Human-borne sources of contamination
Skin
Nonhuman factors in contamination
Fomites
Sources of infection
Health care–acquired infection
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Principles of aseptic and sterile techniques
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