FEATURE Back to A Fresh Look at Asepsis BASICS Alecia Cooper, RN, BS, MBA, CNOR 14 THE OR CONNECTION
PATIENT SAFETY A Back to Basics series should start with the principles of asepsis. What does asepsis mean? According to Alexander, asepsis means the absence of germs, infection, and septic matter, and it is directed toward cleanliness and the elimination of infectious agents; for perioperative personnel, aseptic principles and techniques are a cornerstone of infection control efforts. Aseptic techniques are the practices that restrict microorganisms in the environment and on equipment and supplies, and that prevent normal body flora from contaminating the surgical wound. 1 It is well established that surgery robs the patient of a significant barrier against infection and disease by interfering with the skin s surface. AORN states that all individuals involved in surgical interventions have a responsibility to provide and maintain a safe environment. Aseptic practices aid in fulfilling this responsibility. They are to be implemented preoperatively, intraoperatively, and postoperatively to minimize contamination. 2 Seven Principles of Asepsis Principle #1: Scrubbed persons function within a sterile field. Principle #2: Sterile drapes are used to create a sterile field. Principle #3: All items used within a sterile field must be sterile. Principle #4: All items introduced onto a sterile field should be opened, dispensed, and transferred by methods that maintain sterility and integrity. Principle #5: A sterile field should be maintained and monitored constantly. Principle #6: All personnel moving within or around a sterile field should do so in a manner to maintain the sterile field. Principle #7: Policies and procedures for maintaining a sterile field should be written, reviewed annually, and readily available within the practice setting. ALIGNING PRACTICE WITH POLICY TO IMPROVE PATIENT CARE 15
FEATURE Back to Basics: A Fresh Look at Asepsis Although the principles appear to be basic, logical, and intuitive, nonadherence to one or more is common for a multitude of reasons. Time factors, staffing issues, expectations from coworkers, pressure from surgeons or anesthesiologists, poor traffic control, and inefficient supply logistics are some of the most common influencers. Even fear of reprisal can interfere with the maintenance of a sterile field. Proper adherence to aseptic technique minimizes and often eliminates modes and sources of contamination. Consistent observance of the boundaries established in the principles by each member of the surgical team still provides the best way to ensure that aseptic technique is followed. How can we all be reminded to comply? Annual competency validation, posters, stickers, in-service training? Just what are the techniques, training, and reminders that work best in assuring compliance? Here are a few suggestions and tools that can help satisfy this basic need, simply and effectively. Annual Review. Annual review can take place in the form of a scheduled inservice to review principles, policies, and procedures. Consider developing skits and scenarios that depict proper and improper practices and techniques. These can be entertaining while pointing out the common breaches in aseptic technique that can and do occur in every facility. Traditional methods include modular study guides followed by a multiple-choice test. An excellent online resource can be found at www.engenderhealth.org. This Web site includes an Introduction to Aseptic Technique course and a test that can be easily administered on an annual basis. A sample Policy and Procedure document and sample Competency Statements are included on pages 78 and 80-81. Rigorous adherence to the principles of asepsis by all scrubbed personnel is the foundation of surgical site infection prevention. (CDC Guideline for Prevention of Surgical Site Infection, 1999) Skills Validation. Validation of competency follows training and is typically accomplished through clinical observations in the operating room setting by a trained observer, and through written tests that are conducted annually and recorded in the employee s permanent record. An alternative form of written validation or testing can be conducted using pictures and/or actual clinical staging. A sketch or picture of an OR setting that includes both obvious and subtle breaches in aseptic technique can be presented to a clinician, who would be asked to identify the breaches and correct the situation according to recommended practices and standards. Additionally, an OR simulation can be staged in a vacant operating room; clinicians would be asked to enter the room, identify and correct all breaches in aseptic technique, and document their findings on the testing form provided. Either of these tests could be graded and placed in a personnel record. See the sample test on page 79. Visual Reminders. Posters, signs, and stickers can serve as effective prompts when placed appropriately within the 16 THE OR CONNECTION
surgical suite. Because these tools will be viewed by the public, they should look as professional as possible; they should also be durable enough to withstand normal wear and tear. Also, be aware that adhesives and other fasteners can damage walls, surfaces, and charts. It is important to follow facility protocols regarding the use of visual reminders. Some facilities are adding specially designed stickers to the outside of commonly used supplies within the OR to remind personnel of important procedures and processes. Educational materials on hand washing and aseptic technique that can be printed and posted in your facility are available at www.engenderhealth.org/ip/miw/index.html. Clinical Documentation. A separate form or checklist including the principles of asepsis can be incorporated into the perioperative record. Adherence to aseptic technique can be documented by having the nursing circulators sign the perioperative record. A sample patient record from AORN includes an outcome statement in the Postprocedure Assessment and Evaluation section stating, Patient s surgery performed using aseptic technique and in a manner to prevent cross-contamination. This not only serves as a consistent and frequent reminder to adhere to these principles, but also provides a review each time the circulator performs his or her duties. Most often, a separate form is not needed unless there have been unrelenting issues with following the principles of asepsis without improvement over time in a given facility. Typically, the incorporation of a checklist, signature, or outcome statement attesting to adherence of the principles is sufficient. Review of Departmental Infection Rates. Surgical infection rates are continuously being monitored, reviewed, and recorded by infection control clinicians and should be shared with the clinical staff within the surgical department on a routine basis. The decision to share this data with staff may be controversial for fear that the data would be misinterpreted. Through trending and coding of sensitive data, both by specialty and discipline, satisfactory methods of data analysis and presentation can be developed, making it possible to share information that will improve overall patient care. Improvements in surgical infection rates can help validate the use of aseptic technique. References: 1. Meeker, M.H., Rothrock, J.C. Alexander s Care of the Patient in Surgery. Mosby, St. Louis, 1995. 2. Association of Perioperative Registered Nurses. 2005 Standards, Recommended Practices and Guidelines. Denver, CO, 2005. This sample patient record from AORN includes the following outcome statement to help document adherence to aseptic technique: "Patient's surgery performed using aseptic technique and in a manner to prevent cross-contamination." Alecia Cooper, currently a clinical service consultant, has been an RN for 26 years. She has worked in the field of surgical services for the past 21 years in various capacities ranging from staff nurse to administrative director. ALIGNING PRACTICE WITH POLICY TO IMPROVE PATIENT CARE 17
1. 2. 1. 2. 3. 6. 7. 8. CROSSWORD PUZZLE: ASEPTIC TECHNIQUE 5. 10. 4. 5. 7. 18 THE OR CONNECTION 3. 9. 10. 11. 8. 9. 6. 4. Down: 1. Typically accomplished through clinical observation and written tests. (2 words) 2. and regarding asepsis should be written, reviewed annually, and readily available within the practice setting. 3. Routine departmental review of surgical infection is a very important way to reinforce surgical asepsis. 4. Sterile are used to create a sterile field. 5. states that all individuals involved in surgical interventions have a responsibility to provide and maintain a safe environment. 6. Clinical for following aseptic technique may be in the form of a checklist or be incorporated in the medical record. 7. For perioperative personnel aseptic principles and techniques are a cornerstone of control efforts. 8. All moving within or around a sterile field should do so in a manner to maintain the sterile field. 9. Consider developing that depict proper and improper practices and techniques for annual review of aseptic principles. 10. Often solutions to common compliance issues surrounding asepsis can improve patient care. 11. Annual can be accomplished by inservice, review of policies and procedures, and review of aseptic principles. Across: 1. means the absence of germs, infection, and septic matter. 2. Prior to placement of surgical gowns and drapes, patients skin must be prepared with To receive one hour of CE hospital-approved antiseptic skin. credit, enter your answers 3. Surgical infections can occur when aseptic techniques are not adhered to. online at www.medline.com! 4. Scrubbed personnel function within a field. 5. items used within a sterile field must be sterile. 6. A quick and easy prompt when placed appropriately within the surgical suite. (2 words) 7. A sterile field should be maintained and monitored. 8. Practice that restricts microorganisms in the environment and on equipment and supplies, and prevents normal body flora from contaminating the surgical wound, is defined as. 9. Nursing documentation that aseptic technique adhered to should be incorporated into the perioperative record according to AORN. 10. training modules are a simple and effective method to provide annual review of aseptic technique in the perioperative setting.