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APGOClinicalSkillsCurriculum
SterileTechnique
AssociationofProfessorsofGynecologyandObstetrics(APGO)UndergraduateMedicalEducationCommittee2008
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SterileTechnique:ScrubbingandGowningforSurgeryandPreparingandDrapingthePatient
TableofContentsIntendedLearningObjectives 3
Description 4
BestPractices 5
Checklist 13
PerformanceAssessment 14
PracticalTips 14
Resources 14
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IntendedLearningObjectivesThisclinicalskillsmoduleprovidesaframeworkforteachingtheimportanceof,andthe
principlesbehind,steriletechnique.Followingparticipationinthismodule,students
should:
1.Understandtherationalebehindtheimportanceofsteriletechnique
2.Scrubproperlyfordeliveriesandforsurgery
3.Gownandgloveproperlyforsurgery,withoutbreakingsteriletechnique
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Description[When]...itappearedthattheferments,properlysocalled,arelivingbeings,thatthegermsof
microscopicorganismsaboundonthesurfaceofallobjects,intheairandinwater;thatthetheory
ofspontaneousgenerationischimerical;thatwines,beer,vinegar,theblood,urineandallthe
fluidsof
the
body
undergo
none
of
their
usual
changes
in
pure
air,
both
Medicine
and
Surgery
receivedfreshstimulation. LouisPasteur
NotJustCleanSterile(oraseptic)techniqueisfirstandforemostinminimizingpossiblesourcesof
infection(nosocomialinfection=aninfectionacquiredwhilehospitalized).
Sterilemeansfreeofbugsthatcaninfectpeople.SterilitywillapplytoSELECTsurfaces
ofobjectsortosubstancesthatwillbeintroducedintoapatientsbody.Someobjectsjust
donot
have
the
potential
to
be
made
sterile.
Hands
can
be
made
very
clean,
but
not
sterile.Scrubsfromthelockerroomdispenserarenotsterile,noraresurgical
masks.Themessageis:Onlyspecific,deliberatelypreparedsurfacesorsubstancesare
consideredsterile.
Whatfollowsisthegeneralideabehindsterilefields:
1.Prepareandmaintainselectsurfacesassterile.
2.Minimizepotentialsourcesofcontaminationbysegregatingsterilesurfaces
fromnonsterileareas,evenverycleanareas!
Thespaceinwhichsterileobjectsmayinteractundisruptedbynonsterileobjectsisa
sterilefield.Animportantpointtobearinmindisthatapersonorthingwillhaveonlya
particularportionofitssurfacedesignatedassterileand,therefore,withinasterile
field.Everyothersurfaceisconsiderednonsterile,andanynonsterilesurfacemay
contaminateasterilesurface.
Sterilefieldsaredefinedbythesterilesurfacesoftwooperatingroom(OR)components.
Typically,onscrubbedsurgicalpersonnel(byscrubbed,meaninghandswashed
accordingtoORprotocol,donningsterilegown,sterilegloves),thesterilesurfacewould
extendapproximately
from
the
chest
to
the
waist
on
the
torso
and
from
elbows
to
the
tipsofglovedfingersontheupperlimb.Therestofthescrubbedpersonisnotsterile
andisapossiblesourceofcontaminationforthesterilearea.
Onapatient,onlythepreparedsurfaceofthebodyandthesteriledrapeareconsidered
withinthesterilefield.Notethatedgesofotherwisesterilesurfacesarenotsterile,since
theymustcontact(orappose)nonsterileobjects.So,thephysicaledgesofasteriledrape
oranysurfaceofthedrapebelowthespacedefinedbytheothersterileobjectsofthe
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fieldarenotconsideredsterile.
BestPracticesScrubbingInAtypicalORvisitmaybeasfollows:
1. Obtainscrubsandchanging
2.Washhandsorusingrapiddryingwaterfreewashespriortoexaminingortouching
anypatientsandpriortosurgery(oranypatientencounterwithyourhandsor
stethoscope)
3.
Obtain
and
don
a
surgical
hair
cap.
(All
hair
must
be
covered.
There
are
different
typesofcapsforlongerhairandforbeards).Shoecoversareusedatsome,butnotall,
institutions(TheseitemsaregenerallyfoundattheentrancetotheOR.)
4. Obtainanddonasurgicalmaskatthescrubstation;removehandjewelry,suchas
ringsandwatches
5. Entertheoperatingroom.Bealerttothescrubnurse,andavoidanysterileareas
6. Performanydutieswithnonsterileobjects(includingpatientpreparation)
7. Scrubbingin
Generally,scrubbinginmeansasequenceofprocedureswhereinoneattainsasterilesurface,including:1. Surgicalhandscrub
2. Gowning(puttingonsterile,surgicalgown)
3. Gloving(puttingonsterile,surgicalgloves)
ThesurgicalhandscrubisperformedoutsidetheORatthescrubstation.Once
completed,onemustcarefullyreentertheORforgowning,usuallywiththeassistance
ofthescrubnurse,andgloving.
Finally,oncegownedandgloved,apersonsmovementsmusttakeintoconsideration
thesterilefields.Typically,whenmoving,handsshouldbekeptdirectlyinfrontofthe
chest,butclearofthefaceorothernonsterileareas.WhenpassingORpersonnelornon
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sterilethings,onesbackshouldbedirectedtowardthenonsterilesurfacesoftheseOR
obstacles.Oncepartofthesterilefield,thesterilesurfacemustfacethepreparedsurface
ofthepatientorothersterilesurfaces.
Reviewthepictures,below,foravisualunderstandingofthisprocess:
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ChecklistWellDone
NeedsImprovement
NotDone
CannotRecall
ScrubbingforsurgeryCorrectlydonsthesurgicalcapand
mask
Correctlyopensthepacketof
surgicalscrubsoap
Turnsonthewatercorrectlyand
adjustthetemperaturetoa
comfortablelevel
Correctlycleansbeneathfingernails
Scrubshandsandforearmscorrectly
Keepshandsandforearmselevated
andavoidscontaminationswhileenteringdoortoOR
GowningforsurgeryAcceptsthedryingtowelproperly,
withoutcontaminatingitagainsthis
orherbody
Drieshandsproperly,usinga
separatesterileareaofthetowelfor
eachhand
Properlydisposesoftheusedtowel
ReceivesthesurgicalgownproperlyDonsgloveswithoutcontaminating
gownorgloves
Turnsproperlytocloseofftheback
ofthegown
PreparinganddrapingthepatientDescribesthepropersolutionsfor
preparationofthesurgicalfield
Describesthepropermethodfor
scrubbingthesurgicalfield
Properlypositionsthesurgicaldrapes
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PerformanceAssessmentThereareanumberofoptionsofhowtobestassessstudentsabilitywithsterile
technique:
1.Demonstrationofthetechniques,followedbystudentpracticewiththechecklist,above,usedtodemonstratecompetence.
2.Preparationanddrapingofthepatientcanbepracticedonasimulatedpatient
oramannequin.Ifthosearenotavailable,thiscanalsobedoneonaflattable
coveredwithadrape.
3.AnOSCEusingthechecklist,above,canalsobeused
PracticalTipsThereareanumberofvideosorDVDsavailablethatmanymedicalschoolsand
hospitalsuseforfurtherunderstandingthisprocess.Ifstudentsfeeltheyneedmorehelp,
theyshouldaskiftheseareavailableattheirinstitution.Manyinstitutionswill
automaticallyshowthem,orstudentswillbegivenapracticesessionbyanexperienced
ORnurse.
ThefirsttimeintheORcanbeananxietyprovokingexperience,becauseofthestudents
fearofmakinganerror.Ifstudentsmakeamistake,theyshouldunderstandthat
teachershave
been
in
the
same
situation,
and
students
should
understand
that
they
are
learning.Physicianeducatorswillnotletamistakeharmthepatient,andanerrorwill
notruinastudentscareer.
Resources1.QuotefromPasteursspeech,GermTheoryanditsApplicationstoMedicineand
Surgery,madetotheFrenchAcademyofSciences,April29th,1878.ComptesRendus
delAcademiedesSciences,LXXXVI,pp.103743(translationbyH.C.Ernst).
2.Meeker,MandRothrockJ.Alexanderscareofthepatientinsurgery,14thed.Mosby,
Inc.1999.
3.Fortunato,N.BerryandKohnsoperatingroomtechnique,9thed.,Mosby,Inc.2000.
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4.Maxwell,CandGirotti,M.Steriletechnique,TheCabellSociety,Universityof
VirginiaSchoolofMedicineWebsite,
http://www.healthsystem.virginia.edu/internet/som/
5.CouncilonResidentEducationinObstetricsandGynecology.Surgicalcurriculumfor
residentsinobstetricsandgynecology,CREOGWebsite,2002,http://www.acog.org/departments/dept_web.cfm?recno=1.