APGO Clinical Skills Curriculum
Association of Professors of Gynecology and Obstetrics (APGO) Undergraduate Medical Education Committee ©2008
Sterile Technique: Scrubbing and Gowning for Surgery and Preparing and Draping the Patient
Table of Contents Intended Learning Objectives Description Best Practices Checklist Performance Assessment Practical Tips Resources
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Intended Learning Objectives This clinical skills module provides a framework for teaching the importance of, and the principles behind, sterile technique. Following participation in this module, students should: 1. Understand the rationale behind the importance of sterile technique 2. Scrub properly for deliveries and for surgery 3. Gown and glove properly for surgery, without breaking sterile technique
Description [When]...it appeared that the ferments, properly so‐called, are living beings, that the germs of microscopic organisms abound on the surface of all objects, in the air and in water; that the theory of spontaneous generation is chimerical; that wines, beer, vinegar, the blood, urine and all the fluids of the body undergo none of their usual changes in pure air, both Medicine and Surgery received fresh stimulation. – Louis Pasteur Not Just Clean Sterile (or ‘aseptic’) technique is first and foremost in minimizing possible sources of infection (nosocomial infection = an infection acquired while hospitalized). Sterile means free of bugs that can infect people. Sterility will apply to SELECT surfaces of objects or to substances that will be introduced into a patient’s body. Some objects just do not have the potential to be made sterile. Hands can be made very clean, but not sterile. “Scrubs” from the locker room dispenser are not sterile, nor are surgical masks. The message is: Only specific, deliberately prepared surfaces or substances are considered sterile. What follows is the general idea behind sterile fields: 1. Prepare and maintain select surfaces as sterile. 2. Minimize potential sources of contamination by segregating sterile surfaces from non‐sterile areas, even very clean areas! The space in which sterile objects may interact – undisrupted by non‐sterile objects – is a sterile field. An important point to bear in mind is that a person or thing will have only a particular portion of its surface designated as sterile and, therefore, within a sterile field. Every other surface is considered non‐sterile, and any non‐sterile surface may contaminate a sterile surface. Sterile fields are defined by the sterile surfaces of two operating room (OR) components. Typically, on scrubbed surgical personnel (by “scrubbed,” meaning hands washed according to OR protocol, donning sterile gown, sterile gloves), the sterile surface would extend approximately from the chest to the waist on the torso and from elbows to the tips of gloved fingers on the upper limb. The rest of the scrubbed person is not sterile and is a possible source of contamination for the sterile area. On a patient, only the prepared surface of the body and the sterile drape are considered within the sterile field. Note that edges of otherwise sterile surfaces are not sterile, since they must contact (or appose) non‐sterile objects. So, the physical edges of a sterile drape – or any surface of the drape below the space defined by the other sterile objects of the
field – are not considered sterile. Best Practices Scrubbing In A typical OR visit may be as follows: 1. Obtain scrubs and changing 2. Wash hands or using rapid drying water‐free washes prior to examining or touching any patients and prior to surgery (or any patient encounter with your hands or stethoscope) 3. Obtain and don a surgical hair cap. (All hair must be covered. There are different types of caps for longer hair and for beards). Shoe covers are used at some, but not all, institutions (These items are generally found at the entrance to the OR.) 4. Obtain and don a surgical mask at the scrub station; remove hand jewelry, such as rings and watches 5. Enter the operating room. Be alert to the scrub nurse, and avoid any sterile areas 6. Perform any duties with non‐sterile objects (including patient preparation) 7. Scrubbing in Generally, scrubbing in means a sequence of procedures wherein one attains a sterile surface, including: 1. Surgical hand scrub 2. Gowning (putting on sterile, surgical gown) 3. Gloving (putting on sterile, surgical gloves) The surgical hand scrub is performed outside the OR at the scrub station. Once completed, one must carefully reenter the OR for gowning, usually with the assistance of the scrub nurse, and gloving. Finally, once gowned and gloved, a person’s movements must take into consideration the sterile fields. Typically, when moving, hands should be kept directly in front of the chest, but clear of the face or other non‐sterile areas. When passing OR personnel or non‐
sterile things, one’s back should be directed toward the non‐sterile surfaces of these OR obstacles. Once part of the sterile field, the sterile surface must face the prepared surface of the patient or other sterile surfaces. Review the pictures, below, for a visual understanding of this process:
Checklist Scrubbing for surgery Correctly dons the surgical cap and mask Correctly opens the packet of surgical scrub soap Turns on the water correctly and adjust the temperature to a comfortable level Correctly cleans beneath fingernails Scrubs hands and forearms correctly Keeps hands and forearms elevated and avoids contaminations while entering door to OR Gowning for surgery Accepts the drying towel properly, without contaminating it against his or her body Dries hands properly, using a separate sterile area of the towel for each hand Properly disposes of the used towel Receives the surgical gown properly Dons gloves without contaminating gown or gloves Turns properly to close off the back of the gown Preparing and draping the patient Describes the proper solutions for preparation of the surgical field Describes the proper method for scrubbing the surgical field Properly positions the surgical drapes
Performance Assessment There are a number of options of how to best assess students ability with sterile technique: 1. Demonstration of the techniques, followed by student practice with the checklist, above, used to demonstrate competence. 2. Preparation and draping of the patient can be practiced on a simulated patient or a mannequin. If those are not available, this can also be done on a flat table covered with a drape. 3. An OSCE using the checklist, above, can also be used Practical Tips There are a number of videos or DVDs available that many medical schools and hospitals use for further understanding this process. If students feel they need more help, they should ask if these are available at their institution. Many institutions will automatically show them, or students will be given a practice session by an experienced OR nurse. The first time in the OR can be an anxiety provoking experience, because of the student’s fear of making an error. If students make a mistake, they should understand that teachers have been in the same situation, and students should understand that they are learning. Physician‐educators will not let a mistake harm the patient, and an error will not ruin a student’s career. Resources 1. Quote from Pasteur’s speech, “Germ Theory and its Applications to Medicine and Surgery,” made to the French Academy of Sciences, April 29th, 1878. Comptes Rendus de lʹAcademie des Sciences, LXXXVI, pp. 1037‐43 (translation by H.C. Ernst). 2. Meeker, M and Rothrock J. Alexander’s care of the patient in surgery, 14th ed. Mosby, Inc. 1999. 3. Fortunato, N. Berry and Kohn’s operating room technique, 9th ed., Mosby, Inc. 2000.
4. Maxwell, C and Girotti, M. Sterile technique, The Cabell Society, University of Virginia School of Medicine Web site, http://www.healthsystem.virginia.edu/internet/som/ 5. Council on Resident Education in Obstetrics and Gynecology. Surgical curriculum for residents in obstetrics and gynecology, CREOG Web site, 2002, http://www.acog.org/departments/dept_web.cfm?recno=1.