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Common Breaks in Sterile Technique: Clinical Perspectives and Perioperative Implications 3.4 WILLIAM R. HOPPER, MD, FAAOS; ROSE MOSS, RN, MN, CNOR ABSTRACT Prevention of health care-associated infections, specifically surgical site infections, is a fundamental responsibility of the perioperative team. Breaks in sterile technique can and do occur, even for the most conscientious perioperative practitioners. Surgical site infections are associated with unnecessary patient pain and suffering and increased lengths of hospital stay and health care costs. Prevention of surgical site infections, therefore, takes on great significance in today’s dynamic health care environment. Key responsibilities of perioperative nurses are to recognize and correct common breaks in sterile technique that are made in preparation for and during a surgical procedure and to implement methods to prevent future occurrences. AORN J 91 (March 2010) 350-364. © AORN, Inc, 2010 Key words: sterile technique, aseptic technique, asepsis, surgical site infections, health care-associated infections. P reventing infections in the surgical patient is a primary responsibility of every member of the perioperative team. One of the expected outcomes for surgical intervention is that the patient is free from signs and symptoms of infection.1 Health care-associated infection (ie, an infection that a patient acquires during the course of receiving treatment for other conditions in a indicates that continuing education contact hours are available for this activity. Earn the contact hours by reading this article, reviewing the purpose/goal and objectives, and completing the online Examination and Learner Evaluation at http://www.aorn.org/ce. The contact hours for this article expire March 31, 2013. health care setting) is one of the top 10 leading causes of death in the United States today.2 In a recent update, the Centers for Disease Control and Prevention estimated that health careassociated infections account for approximately 1.7 million infections and 99,000 associated deaths each year in US hospitals alone; of these infections, 22% are surgical site infections (SSIs).3 The economic burden of SSIs is significant. de Lissovoy et al,4 using data from the 2005 Healthcare Cost and Utilization Project National Inpatient Sample, identified SSIs in hospital discharge records for seven categories of surgical procedures performed: 350 AORN Journal ● March 2010 Vol 91 No 3 neurological; cardiovascular; © AORN, Inc, 2010 COMMON BREAKS IN STERILE TECHNIQUE colorectal; skin, subcutaneous tissue, and breast; gastrointestinal; orthopedic; and obstetric and gynecologic. The primary study outcomes were the rate of SSI by surgical procedure category and the effect of SSI on hospital length of stay and cost. The researchers identified 6,891 cases of SSI among the 723,490 surgical hospitalizations in the sample (ie, 1%). On average, an SSI increased length of stay by 9.7 days and increased costs by $20,842 per admission. The researchers then projected these results to the national level. National estimates of SSI would result in an additional 406,730 hospital days and hospital costs would exceed $900 million. An additional 91,613 patient readmissions for treating the SSIs would account for an estimated 521,933 extra days of care at a cost of approximately $674.4 million.4 For health care facilities, the escalating costs of treating SSIs were further affected in July 2008 when the Centers for Medicare & Medicaid Services announced new payment and coverage policies.5 A final acute care inpatient prospective payment system rule that updated Medicare payments to hospitals for fiscal year 2009 provided additional incentives for hospitals to improve the quality of care provided to patients with Medicare by including payment provisions to reduce preventable medical errors that occur in hospitals. If a condition is not present on admission but is subsequently acquired during the hospital stay, Medicare will no longer pay the additional cost of the hospitalization; furthermore, the patient is not responsible for the additional cost. Initially, hospitals were not reimbursed for infections associated with vascular catheters and coronary artery bypass graft surgery. As of October 1, 2008, hospitals are no longer reimbursed for SSIs after select elective procedures, including certain orthopedic surgeries and bariatric surgeries.5 The 2009 Joint Commission National Patient Safety Goals also www.aornjournal.org include requirements for reducing the risk of health care-associated infections, specifically SSIs, and state that best practices for preventing SSIs should be implemented.6 The sources of surgical site microbial contamination may be either resident flora (ie, endogenous microorganisms) or transient flora (ie, exogenous microorganisms). Resident flora are bacteria or microorganisms considered to be permanent residents of the skin and are not readily removed by hand washing.7 Transient flora are bacteria or microorganisms that colonize the superficial layers of the skin and are more easily removed by hand washing or use of a hand rub agent.7 Transient flora are easily transmitted to hands from patients and inanimate surfaces. Microbial contamination of the surgical site can cause an SSI. The risk of an SSI increases with the dose of bacterial contamination and the virulence of the bacteria.8 One potential cause of exogenous microbial contamination in the OR is a break in sterile technique. A key responsibility of perioperative nurses is to recognize and correct common breaks in sterile technique that are made in preparation for and during a surgical procedure and to implement methods to prevent future occurrences. CATEGORIES OF BREAKS IN STERILE TECHNIQUE Breaks in sterile technique can be divided into four types: Type 1—the break is recognized immediately. Type 2—the break is recognized shortly after it occurs. Type 3—the break is recognized later. Type 4 —the break is not recognized at all. Although quantifying type 4 breaks is not possible because they go unrecognized, it is intuitive to believe that some unrecognized breaks in sterile technique must occur. The list of recognized breaks is long; theoretically, it is possible to break sterile technique in an infinite number of ways. Certain breaks in AORN Journal 351 March 2010 Vol 91 No 3 HOPPER—MOSS the culprit, the scrub person would pass the needle off the sterile field in its needle holder, the circulating nurse would remove the scrubbed person’s glove, and the scrubbed person would don another glove. With the passage of time, the problem becomes more complex (ie, a type 2 break). Suppose that the individual has set the contaminated needle on a Mayo stand containing other instruments. For absolute containment to be achieved with a type 2 break, the entire Mayo stand must be taken down and all of the instruments resterilized or new ones obtained, which may or may Most Common Pathogens in HAIs not be practical or possible. According to an annual summary from the National Healthcare Invariably, the team pauses Safety Network on the frequency of selected antimicrobial resisto determine what else has tance patterns among pathogens causing device-associated and been contaminated. In these procedure-associated health care-associated infections (HAIs), the situations, the team does its 10 most common pathogens accounting for 84% of HAIs were best to cope with the contamination, but containment coagulase-negative staphylococci (15%), may not be possible (eg, Staphylococcus aureus (15%), during emergent surgery, for Enterococcus species (12%), an unstable patient). Candida species (11%), In a type 3 break, a Escherichia coli (10%), scrubbed team member looks Pseudomonas aeruginosa (8%), down and sees a hole in his Klebsiella pneumoniae (6%), or her glove. The individual Enterobacter species (5%), does not know where or Acinetobacter baumannii (3%), and 1 when the hole occurred and Klebsiella oxytoca (2%). cannot say whether anything As many as 16% of all HAIs were associated with the following else has been contaminated. multidrug-resistant pathogens: Potentially everything, in methicillin-resistant S aureus (8%), cluding the incision, could vancomycin-resistant Enterococcus faecium (4%), have been contaminated. carbapenem-resistant P aeruginosa (2%), This is an example of a extended-spectrum cephalosporin-resistant K pneumoniae (1%), break in sterile technique extended-spectrum cephalosporin-resistant E coli (0.5%), and that cannot be contained be carbapenem-resistant A baumannii, K pneumoniae, K oxytoca, cause this would require and E coli (0.5%).1 starting over completely: 1. Hidron AI, Edwards JR, Patel J, et al; National Healthcare Safety Network Team. irrigating the incision with NHSN update: antimicrobial-resistant pathogens associated with healthcare-associated infecantibiotic solution, repreptions: annual summary of data reported to the National Healthcare Safety Network at the Centers for Disease Control and Prevention, 2006-2007. Infect Control Hosp Epidemiol. ping, redraping, and begin2008;29(11):996-1011. ning again with all new sterile technique, however, occur repeatedly, such as stabbing oneself with a needle and thus potentially exposing oneself to bloodborne pathogens, having the suction or electrosurgical unit (ESU) active electrode fall over the side of the OR bed, or brushing one’s gown against an unsterile surface. Consider a classic example—the hole in the glove. If recognized immediately (ie, a type 1 break), containment (ie, solving the disruption of the sterile field and returning it to its former, uncontaminated state) is possible. If a needle was 352 AORN Journal COMMON BREAKS IN STERILE TECHNIQUE instruments. Typically, this approach is not practical because the surgical procedure has started and time is of the essence, not just for cost reasons but for the patient’s safety as well. The team has noticed the unintended contamination, but it would not be in the patient’s best interest to start over. A better option for the patient might be to simply remove and replace any obviously contaminated items and supplies (eg, punctured gloves) and administer prophylactic antibiotics. COMMON BREAKS IN STERILE TECHNIQUE Common breaks in sterile technique include difficulties encountered with sterilization, setting up and opening the sterile field, scrubbing and drying hands, gowning, gloving, positioning, prepping, draping, the OR environment, and surgical technique. Breaks in sterile technique can and do occur, even for the best and most conscientious perioperative practitioners. Sterilization Preparation for a surgical procedure actually starts in the central processing department. Without sterilized instruments, there can be no sterile technique. Elaborate mechanisms, often only vaguely known to surgeons, are used to ensure quality control in the central processing department. Steam sterilization requires specific steam chamber temperatures and appropriate exposure times, and all parameters must be monitored regularly. Confirmation of sterilization parameters when using other methods (eg, lowtemperature hydrogen peroxide gas plasma, ethylene oxide, ozone) may be more complex compared with steam sterilization. There are numerous points in the decontamination and sterilization process where problems can occur. Despite advances in technology, disposable drapes and packaging remain water resistant rather than waterproof. Wet spots may occur from condensed steam that has soaked through a sterile package. These wet spots may wick contamination into the package. Perioperative personnel may not check sterility indicator tapes as re- www.aornjournal.org quired. These tapes turn a distinctive color and pattern when a defined level of exposure is reached. Knowledge is critical in the sterilization process. For instance, sterilization tape cannot be used again after it has gone through a sterilization cycle because it will have turned color, thus giving the impression that the item has been processed through a sterilization cycle when in fact it has not. Small holes or punctures may occur in the packaging that perioperative personnel may not notice even when they check the item. To ensure that items used in the sterile field are sterile, perioperative personnel preparing an OR for a procedure must inspect all items immediately before they are presented to the sterile field for proper packaging, correct processing, an intact seal, package container integrity, and inclusion of the proper sterilization indicator.9 The item should not be used if any of these problems are identified during the inspection process. Setting Up and Opening Assuming that the instruments are properly sterilized, the circulating nurse, scrub person, and other members of the perioperative team set up and open the instruments and supplies for the procedure. This process, although routine, may be fraught with opportunities for breaking sterile technique. The steps for preparing a sterile field require concentration and should never be hurried. All items introduced to the sterile field should be opened, dispensed, and transferred by methods that maintain both their sterility and integrity.9 The circulating nurse and scrub person are well versed in setting up and preparing a sterile field; they do this many times a day. In fact, they do it so often, it can become routine, and by sheer volume, some errors may seem inevitable. Not checking sterility indicators. All sterilized packages, regardless of size, should have sterility indicators on and in them. The color AORN Journal 353 March 2010 Vol 91 No 3 change is very easy to recognize. Overlooking this is very uncommon but can occur. The indicator should be visually inspected immediately to verify the appropriate color change for the selected sterilization process.9 Not noticing tears in sterile packaging. Recognizing holes or tears in sterile packaging may not be as easy as it sounds. Metal trays may tear their covers at corners, and it is time consuming to examine them all. Small holes may be missed, especially when the scrub person and circulating nurse are hurrying. All items presented to the sterile field should be inspected immediately before presentation. Not recognizing soaked-through spots. Most sterile packages are wrapped in waterresistant packaging material. Waterproof packaging material (ie, plastic) does not tolerate heat well. It is possible to have questionable wet spots in the packaging material. If there is any possibility that moisture is present, the items should be considered unsterile, should not be used, and should be returned for reprocessing. Contaminating the sterile field, instruments, or supplies. Perioperative textbooks emphasize this caveat: unsterile individuals must not touch or reach over a sterile field or allow any unsterile item to contaminate the field.10 All items should be delivered to the sterile field in a manner that prevents nonsterile objects or personnel from extending over the sterile field.9 If care is not taken, it is possible to touch the inside of a package while opening it. It is also possible for the outside of the package to touch the inside, sterile portion. Use of covered metal containers has helped minimize chances for contamination. The instruments are lifted out of the containers by recessed metal trays with hinged handles. A good rule when handing an item directly to a scrubbed person is to have both the opener (eg, circulating nurse) and receiver (eg, scrub person) concentrate on the act together, watching carefully to observe for inadvertent breaks in technique. 354 AORN Journal HOPPER—MOSS Charnley11 recommends using as few sets of instruments as possible to minimize the risk of contamination when opening a sterile field and to avoid clutter, which increases the chance of breaking sterile technique. Few surgeons have followed his example.11 Some larger procedures require opening of a large number of trays, many of which are only needed for an instrument or two. Some facilities have worked to consolidate sets and supply packaging. Some instruments can be packaged individually to minimize the number of sets being opened for one or two instruments, but this still requires opening numerous individual instruments. Obtaining consensus among surgeons regarding what is needed in an instrument set or procedure pack is not always easy. Having preassembled supply packs saves time in picking the case and opening for the procedure and minimizes the opportunity for contamination. If the contents of the pack are not selected carefully, however, supplies can be wasted. Improperly delivering solutions. Delivering solutions to the sterile field may not be easy. When solutions, such as normal saline irrigation, must be dispensed onto the sterile field, the scrub person should place the labeled solution receptacle near the edge of the sterile field to permit the circulating nurse to pour the solution without contaminating the sterile field, or the scrub person should hold the labeled solution receptacle while the circulating nurse pours the entire contents of the container slowly to avoid splashing.9 Any remaining fluid should be discarded because the edge of the container is considered contaminated after the contents have been poured. Medications should be delivered to the sterile field in an aseptic manner. The circulating nurse should not remove the vial stoppers to pour the medication into a labeled receptacle on the sterile field. For example, bupivacaine hydrochloride can come in a flip-top bottle. It is easy to contaminate the medication if the circulating nurse attempts to flip off the top with a fingertip and pour the COMMON BREAKS IN STERILE TECHNIQUE solution from the other side. This technique risks the finger touching the edge of the bottle and the solution becoming contaminated as it is poured over the edge. Instead, the circulating nurse should use a sterile transfer device (eg, sterile vial spike, filter straw, plastic catheter).9 Improperly moving tables. The risk exists that unsterile scrub attire can touch sterile drapes on tables and stands. Tables are sterile only at table level; only the top surface of a draped table is considered sterile.10 The circulating nurse must always move draped tables by grasping them well below the sterile drape. The scrub person should not move tables by grabbing around the top and underside of the tabletop with gloved hands. If the scrub person needs to move the table, he or she should push on the top of the table with gloved hands. Leaving sterile supplies open too long. Situations have occurred in which the instruments and supplies for a procedure have been opened and set up but the procedure is delayed, for example, because of the need to repeat a test or because the surgeon is unavoidably delayed. Whatever the reason, instruments and supplies are left out. In the past, sterile drapes were used to cover tables in these situations, but this practice has been abandoned because of the risk of contaminating the sterile items when placing and removing the sterile drape. In particular, removing the drape could result in a part of the drape that was below the table level being drawn above the table level or air currents drawing microorganisms from a nonsterile area to the sterile field.9 The current recommendation, therefore, is that sterile fields should not be covered;9 this raises the question, how long is it safe to leave the setup open? There is no specified amount of time that a setup can remain open and unused and still be considered sterile; the sterility of an open field is event related, and the field requires continuous visual observation.9 www.aornjournal.org Surgical Hand Antisepsis “The skin can never be rendered sterile, but it can be made surgically clean by reducing the number of microorganisms.”10(p79) Transient and some resident bacteria can be removed by effective surgical hand antisepsis. Anecdotal evidence suggests that enforcement of hand antisepsis rules may be lax in some surgical suites. Perioperative personnel are on an honor system, but perceived lack of time may adversely affect individual hand antisepsis practices. The facility should implement a hand antisepsis policy that includes removing rings, watches, and bracelets; keeping fingernails short, clean, and healthy; not wearing artificial nails; donning a mask before scrubbing; prewashing the hands and forearms with soap and running water immediately before performing the surgical hand scrub if hands are visibly soiled; and cleaning the subungual areas of both hands under running water using a disposable nail cleaner.7 A three- to five-minute, standardized, anatomic, timed method7 for surgical hand antisepsis using an antimicrobial scrub solution that has met US Food and Drug Administration requirements for surgical hand antisepsis should be used to reduce microbial bioburden.7 Alcohol-based solutions (eg, alcohol-based surgical hand rubs) reduce bacterial count on hands more rapidly than do antimicrobial soaps or detergents. A standardized protocol for their use should follow the manufacturer’s written instructions.7 When drying scrubbed hands and forearms, the top half of the towel is held securely with one hand and the opposite fingers and hand are thoroughly blotted dry before moving to the forearm; the lower end of the towel is then grasped with the dried hand and the same procedure is used to dry the second hand and forearm.10 The towel should not touch the scrub suit. AORN Journal 355 March 2010 Vol 91 No 3 Gowning Gowning should occur on a separate table. The front of a sterile gown is considered sterile from the chest to the level of the sterile field.9 Therefore, only the inner side of a sterile gown can be touched when picking it up, usually at the neck. As a result of the way gowns are folded, a fingertip inadvertently can HOPPER—MOSS graze the front of the gown if the fingertip strays from the inside of the gown. Another aseptic break in gowning another person can occur when a scrub person grazes the surgeon’s shoulders with the gloved fingertips as the gown is “cinched up.” The white cuffs at the wrists of the gown are made of soft, permeable material that is not waterproof. The sleeve cuffs are considered unsterile Gowning and Draping Materials when the scrubbed person’s hands pass beyond the cuff The best materials for gloves, gowns, and drapes remains a conand also because they tend troversial subject. Disposable gowns and drapes have proven their to collect moisture and are worth because washable, reusable fabric or linens of the past cannot an effective bacterial not remain waterproof. Some facilities still use washable linens, barrier.9,10 If the surgical however, and reusable fabrics that are breathable and waterproof gloves do not cover the continue to evolve, including polyester microfibers and porous cuffs, contamination may forms of polytetrafluoroethylene bonded between two layers of occur from inside out or lightweight polyester. Cost is a significant factor, especially in from outside in. This is esdeveloping countries, but the cost of washing, sterilizing, storing, pecially dangerous when the and replacing linens must also be considered. Disposables may clinician’s hands are deep in replace reusables over time, even in underdeveloped countries, the patient’s body, such as although dealing with hospital waste has become a pressing issue. in the abdominal cavity. The disposable gowns and drapes of today provide an effective fluid-proof sterile barrier.1 The shiny, plastic, adhesive-bordered Gloving drapes, laparotomy drapes, and extremity drapes have been emThere are three methods of braced in the surgical environment. See-through, adhesive plastic gloving: open, closed, and drapes (eg, antiabsorbent adhesive drapes, incise drapes) have beassisted.10 The open method come popular in many draping situations, although sometimes they is fraught with potential for are not practical (ie, in hand and foot surgery). These drapes may aseptic breaks, for obvious or may not be impregnated with an antimicrobial agent in the adreasons. It is difficult not to hesive.1 When selecting surgical drapes, personnel should consult touch any part of the skin to practice standards, guidelines, and recommended practices, such as the sterile glove exterior; AORN’s “Recommended practices for selection and use of surgitherefore, this method should cal gowns and drapes”2 and the Association for the Advancement be performed with care. It is of Medical Instrumentation guideline Liquid Barrier Performance not acceptable to tolerate and Classification of Protective Apparel and Drapes Intended for poor open gloving technique; Use in Health Care Facilities.3 rather, it is better to start 1. Mews P. Establish and maintain the sterile field. In: Phippen M, Ulmer B, Wells M, over. The open method is eds. Competency for Safe Patient Care During Operative and Invasive Procedures. Denver, used for many minor proceCO: Competency and Credentialing Institute; 2009:272. 2. Recommended practices for selection and use of surgical gowns and drapes. Periopdures, from emergency deerative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2010:127-131. partment suturing to admin3. ANSI/AAMI PB70 Liquid Barrier Performance and Classification of Protective Apparel and Drapes Intended for Use in Health Care Facilities. Arlington, VA: Association istering spinal anesthesia, for the Advancement of Medical Instrumentation; 2003. but it can be used during a 356 AORN Journal COMMON BREAKS IN STERILE TECHNIQUE surgical procedure when the scrub person discovers a hole in the glove. He or she may change the glove by having the circulating nurse pull it off and then proceed to put on a new glove using the open method. It would be better to be regloved using the assisted method, but the scrub person may not wish to or be able to disturb the team. The closed method is better, but not perfect. The scrub person uses the cuff of the gown or the gown itself to perform a modified open technique. When the scrubbed person’s hands protrude through the sleeve cuffs, the cuffs should be considered contaminated.9 The assisted method is the usual way to glove the surgeon and his or her assistants. Although it is the safest, it also can be complex. As the scrub person spreads the glove apart, the surgeon’s skin or hair may touch the glove exterior as the hand enters the glove. The key is for the scrub person to spread the glove as widely and as circumferentially as possible. Neither the scrub person nor the surgeon should hesitate to mention if a possible break in technique is suspected. Sterile gloves that become contaminated in any manner should be changed as soon as possible.9 Scrubbed personnel should inspect gloves for integrity after donning them.9 When a hole in a glove is identified, the surgical team should attempt to isolate all equipment suspected of being contaminated. Irrigating the incision and applying additional drapes should be considered. Double gloving is increasingly popular. Many surgeons wear two gloves to apply the drapes, discard the outer pair of gloves after draping the surgical site but before beginning the procedure, and then don new outer gloves after draping. Tactile sensation may be diminished, but the trade-off is that a small hole in the outer glove may not penetrate through the inner glove. The Centers for Disease Control and Prevention, the American College of Surgeons, and the American Academy of Orthopaedic Surgeons support the practice of double gloving during invasive procedures.8,12,13 Another possible break can occur when turning www.aornjournal.org the gown after gowning and gloving. The scrub person may turn his or her gown with another scrubbed person or turn it with a nonscrubbed person (eg, the circulating nurse). If the scrub person turns with a nonscrubbed person, the scrub person hands the tie for turning to the nonscrubbed person; care must be taken to prevent the tie from striking the nonscrubbed person’s bare hand as it traverses the cardboard tab. This break in technique may go unnoticed, especially if it occurs quickly or if staff members are hurrying. One solution is to insist on turning with a scrubbed person; however, often this is not possible for the scrub person because no one else is scrubbed in at the time. Positioning the Patient Some of the positions required for optimal surgical exposure may make draping the patient awkward. Typically, this is not a problem with abdominal surgery or other procedures performed in the supine position. Positioning should always be accomplished with draping in mind; any awkwardness in draping increases the chance of a break in technique. The portion of the sterile surgical drape that establishes the sterile field should not be moved after it has been placed; moving the sterile drape may compromise the sterility of the field.9 Performing the Surgical Skin Prep Skin cannot be sterilized; it is merely disinfected. The goal of performing a surgical skin prep is to reduce the risk of postoperative SSIs by removing soil and transient microorganisms from the skin, decreasing the resident microbial count to subpathogenic levels, and inhibiting rapid rebound growth of microorganisms.14 In the past, vigorous washing was recommended, and clinicians believed that the longer the skin was prepped (eg, 10 minutes), the better. It was later theorized, however, that long, vigorous AORN Journal 357 March 2010 Vol 91 No 3 HOPPER—MOSS proper care and attention to detail, it is easy to contaminate the front of the gown when draping the sterile field. For example, when placing a rolled towel around an extremity, the clinician leans forward and it is easy to contaminate the front of the gown on the arm board or OR bed. This may go unrecognized because the clinician begin at the center (ie, at the point of the inciis concentrating on applying the rolled towel. sion) and continue to the periphery of the area Another common error is to touch the prepped and skin or tourniquet when rolling the towel. The never bring a soiled applicator back over a 10 rolled towel concept was classically used to estabpreviously prepped surface. lish a proximal borA common error is der. A stockinette to not follow this was then rolled up to principle rigorously. Clinicians moving in or around the sterile it and the cuff of the field should do so in a manner that does not Another error is for contaminate it. Nonscrubbed personnel should stockinette was used the circulating nurse to secure half-sheets maintain a distance of at least 12 inches from to don the prep with nonperforating all parts of and people in the sterile field. gloves and pick up clamps. This techthe unscrubbed exnique is being used tremity; when prepless because of the ping the extremity, the circulating nurse moves availability of disposable, waterproof, adhesive his or her hand from the unscrubbed section (eg, plastic sheets, applied circumferentially around ankle) to a scrubbed section (eg, lower calf). This the extremity. In situations where disposable action breaks technique by contaminating the aldrapes may not be available, the stockinette ready scrubbed area. Using positioning devices method is still useful. and draping them appropriately during the scrub washing could actually increase dangerous flora by bringing to the surface deeper bacteria lurking in the dermis or could cause damage to the patient’s skin; therefore, rapid, gentle washing might be best. The basic tenets of prepping are to process can prevent this problem. Draping Draping is very important for minimizing the chance of breaks in sterile technique. The principle is simple: sterile drapes are used to establish a sterile field in which to operate.9 During surgical site draping, the potential for complications abounds. When clinicians are moving in the sterile field, their gowns can billow, even when the gowns are turned and tied. All personnel moving in or around a sterile field should do so in a manner that maintains the sterile field without contaminating it. Nonscrubbed personnel should maintain a distance of at least 12 inches from all parts of and people in the sterile field.9 The sterile area of the gown front extends from the chest to the level of the sterile field.9 Without 358 AORN Journal Removing sticky strips. The disposable adhesive sheets have sticky strips that must be pulled off. The ends of these strips can be difficult to control, so they may become contaminated and thus may contaminate drapes or gowns. Contaminating the ends of sheets. When circumferentially wrapping plastic sheets around an extremity, great care must be taken to prevent the ends of the sheets from becoming contaminated and falling back onto the field. This can be remedied by first covering most of the table and arm boards with sterile half-sheets. Then, after a scrubbed team member places the extremity drape, another scrubbed person inserts the extremity through the incise hole and the rest of the extremity drape is placed over previous drapes. COMMON BREAKS IN STERILE TECHNIQUE www.aornjournal.org One scrubbed person placing the drapes. Even with the help of the circulating nurse, it is difficult for one scrubbed person to place the drapes without breaking sterile technique. If at all possible, draping should be a team task. of a break in technique, nonsterile equipment should be covered with sterile barrier materials before being introduced to or brought over a sterile field; sterile barrier material should be applied to the portion of any nonsterile equipment that will be positioned immediately adjacent to the sterile field.9 Furthermore, staff members from the radiology department should receive instruction regarding the principles of aseptic technique to help reduce the chance of a break in technique (eg, proper cleaning of equipment before bringing it into the OR from outside the restricted area of the surgical suite).15 Moving a drape. During a procedure, it may seem convenient to “adjust” the drapes for additional exposure. This should not be done. The portion of the surgical drape that creates the sterile field should not be shifted or moved after it is positioned; doing so can compromise the sterility of the field.9 Passing off the suction tubing or ESU cords improperly. A common error is for the suction tubing or ESU cord to be passed off in such a way that not enough length is left for use on the sterile field. It may be human nature to tug on the cords to get more play, but this should not be done. When a sterile item extends beyond the sterile boundary, it is considered contaminated and should not be pulled onto the sterile field.10 If there is any doubt about the sterility of an item, the item should be replaced. Suture, suction, or ESU active electrode falling. Based on this same principle, if any item falls beyond the sterile field, it must be considered contaminated and, therefore, cannot be brought back up onto the sterile field.10 Although how far off the sterile field is considered “below the field” may bring up the politics of containment, the prudent course of action is to remove the item carefully from the sterile field without causing further contamination. A nonscrubbed surgical team member then places it in a designated receptacle. X-ray cassette draping. Draping an x-ray cassette with a sterile plastic cover can be the cause of a break in technique. Since the advent of portable fluoroscopy (ie, C-arm), two common errors are possible: neglecting to drape the C-arm and contaminating the drapes when swinging the C-arm for a lateral image. To reduce the chance Environmental Concerns Numerous environmental concerns should be considered to ensure compliance with aseptic technique. Some environmental concerns include dirt falling from overhead lights, turbulent airflow during surgery, and bacterial shedding from personnel. Dirt on lights. Dirt from overhead lights falling into the incision may be inevitable, unless sterile lighting is invented. Therefore, lights always should be meticulously damp dusted before the first scheduled surgical procedure of the day and after each procedure with a facility-approved hospital detergent/disinfectant and water.15 Turbulent airflow during surgery. Turbulent airflow in the OR can increase the patient’s risk of acquiring an SSI. In theory, talking can accelerate the eventual contamination of the mask. Talking, as well as the number of people present in the OR, should be kept to a minimum during procedures. An increase in the amount of talking and the number of people present can increase the number of airborne microorganisms.16 Open OR doors are conduits for potentially contaminated air. Each surgical suite should have strict rules about which doors should remain shut unless entrance or exit is required. Directional airflow, positive air pressure, and use of highefficiency particulate air (HEPA) filters help mitigate this problem, but some older surgical AORN Journal 359 March 2010 Vol 91 No 3 HOPPER—MOSS suites may not have all three components. Traffic skin as much as is practical. In the restricted arin and out of the OR should be kept to a minieas of the surgical suite, surgical attire and hair mum. The doors to the OR should remain closed coverings are required.16 Nonscrubbed personnel except when personnel are entering or leaving or should wear long-sleeved jackets that are buttoned patients, supplies, or equipment are being moved or snapped closed to prevent bacterial shedding 16 in or out of the OR. The air pressure in the OR from bare arms.18 should be maintained under positive pressure with a specified number of total room air exSurgical Technique changes per hour depending on the area in the Dead cells are a natural food source for bacteria, 17 surgical suite. which cause SSIs. Furthermore, antibiotics carried in the bloodstream cannot reach necrotic tissue, Frequently opening and closing doors in the because it has no blood supply. Major sources of OR also increases the risk of insects entering tissue necrosis are the OR. Every OR electrosurgery, reshould have a prototraction, and disseccol to handle this Skin can release microorganisms into the air. tion. Other concerns sort of occurrence Keeping this in mind, everybody in the OR, because this can ocincluding observers and anesthesia care providers, involving surgical technique include cur even when the should cover their skin as much as is practical. dealing with spray, OR suite has sealed bone dust, and dewindows or no winbris; handing off dows at all. Flies and specimens; irrigating the surgical wound; and other insects manage to get into the surgical avoiding sharps injuries. suite—through bay doors in the receiving area, vents to the outside, or doors opened as people Electrosurgery. In 1926, William T. Bovie, MD, enter the hospital. The principle of containment an American biophysicist, and Harvey Cushing, starts with covering the incision with a hand MD, a neurosurgeon, developed electrosurgical towel while efforts ensue to kill the insect or technology, thermal coagulation by electrical enmove it out of the room. One trick to minimize ergy, to minimize intraoperative bleeding.19 One increased air turbulence when trying to catch a fly drawback of electrosurgery is the production of is to turn out all the lights except one that is char, a by-product of thermal coagulation. If bacaway from the sterile field to lure the insect to the teria are present in the wound, the addition of light. Typically, these simple measures suffice. If charred tissue, a nutrient source for bacteria, is an the problem becomes frequent, the infection coninvitation for the bacteria to flourish. Therefore, trol and plant operations personnel should be notithe scrub person should clean the active electrode fied so that they can initiate an investigation. All tip away from the incision frequently to remove possible entrances to the facility should be evaluchar and debris.20 ated to identify potential problems (eg, the bay Electrosurgery has become indispensable in doors in receiving being left open). A closed-door modern surgery. Some surgeons use the cutting policy in the surgical suite should be enforced. modality of electrosurgery as a dissecting tool. Bacterial shedding. Dirty skin can release microorganisms into the air. Keeping this in mind, everybody in the OR, including observers and anesthesia care providers, should cover their 360 AORN Journal The higher current slices through the tissue and coagulates at the same time, which may be preferable to using a knife. This is especially true for dissecting periosteum off bone or cutting through COMMON BREAKS IN STERILE TECHNIQUE muscle. The char left behind in crevices created by implants, metal, cement, or allografts, however, may create a possible focus of infection because no blood supply can get to it. Bacteria can go into a state of suspended animation, protected by a coat of bioslime (ie, a coating produced by some bacteria that enables them to resist host defenses like phagocytes).21 Over time, the bacteria can establish colonies in dead tissue.21 Many such colonies can be eradicated over time, especially in a healthy person. Occasionally, however, one of the colonies may create an abscess, resulting in a deep wound infection. This theory can offer one explanation for why infections around implants can be so chronic. Charnley believed that some painful joint replacements could be caused by a low-grade infection.22 The model for this is chronic osteomyelitis, where bacteria lie dormant in bone and produce intermittent flare-ups. Electrosurgery should be used prudently to avoid providing microorganisms in a surgical incision with char, a ready nutrient supply. When electrosurgery is used, diligent irrigation should be used to remove as much of the char as possible. Tissue retraction. Retractors facilitate exposure of the surgical site but can cause tissue injury and necrosis, which can produce detritus, increasing the patient’s risk of infection. Even a skin hook can kill cells when used for tissue exposure. Although self-retaining retractors are very helpful for surgeons, they have drawbacks. In return for exposure, self-retaining retractors can cause tissue necrosis and, with time, cell death, especially if too much pressure is applied. In theory, releasing the blades or teeth of the retractor at periodic intervals eases the lack of blood supply to the tissues and gives the tissue a chance to recover from the pressure. Releasing the selfretaining retractor causes loss of surgical exposure, however, so frequently this practice is not possible or practical. www.aornjournal.org Dissection. Using a variety of instruments, the surgeon begins dissection and develops tissue planes for deep exposure. The surgeon uses forceps and scissors to incise the fascia as well as identify and spread or cut the muscle. He or she may use electrosurgery to minimize muscle bleeding. The surgeon may tie, clip, or coagulate vessels. Whether the dissection is sharp (eg, scissors, knife, electrosurgery) or dull (ie, fingers, peanuts, elevators), cell death occurs. Spray, bone dust, and debris. Any aerosol produced during surgery should be dealt with cautiously. Particles may rise in the air, touch unsterile surfaces, and fall back in. This is especially true of bone debris when power tools are used. The classic example is the high-speed burr, which throws a spray of bone debris into the air. Power lavage also can be a culprit. Overzealous spraying can bring microorganisms back into the incision. The lights over the field are not far away and are unsterile. Spray and debris can rise to touch the surfaces and fall back. When possible, shields (eg, lavage units) should be used to prevent the aerosol from being dispersed away from the point of use. Handing off specimens. Specimens should be handled carefully in a manner that protects and secures the specimen and also prevents contamination of the personnel handling the specimen.23 Typically, the scrub person hands off the specimen to the circulating nurse. It is best for the scrub person to pick up the specimen with an instrument (eg, forceps) and pass the instrument off the field with the tissue. Transferring the specimen into the specimen container with the intention of keeping the instrument presupposes that the tissue will drop neatly off of the instrument. More often, the tissue sticks to the instrument and needs to be manipulated against the side of the container, contaminating the instrument in the process. It is best practice to pass off the tissue and the instrument by placing both into the specimen container. AORN Journal 361 March 2010 Vol 91 No 3 Irrigating the surgical wound. Although studies have not definitively determined whether it is necessary to add antibiotics to irrigation solution, this practice may be beneficial. Irrigation rinses away dead cells, blood, and bacteria and prevents drying of the tissues. Bacteria, invisible to the naked eye, may be settling in the wound throughout the procedure. Irrigation is important during the procedure, as well as during closure. Pausing to irrigate at frequent intervals may help reduce the patient’s risk of acquiring an SSI. This is particularly easy to accomplish when an interruption in surgery occurs (eg, taking an x-ray, preparing an implant). Avoiding sharps injuries. The Occupational Safety and Health Administration requires health care facilities to protect their workers from exposures to bloodborne pathogens and to have a written exposure control plan.24 The Occupational Safety and Health Administration bloodborne pathogen standard requires protection through the use of universal precautions, engineering controls, work practice controls, organizational controls, and communication. It also mandates that employers maintain a log of injuries from contaminated sharps.25 Personnel should report all exposure incidents (eg, needle sticks and other blood exposures) to the health care organization according to the facility policy; prompt reporting allows employers to provide timely and confidential postexposure evaluation, intervention, and testing and appropriate prophylaxis.26 One drawback of the bloodborne pathogen standard is that because the protocol is time consuming, some employees may be reluctant to admit that a needle stick occurred. There are the problematic issues of paperwork, time, and unwanted injections. “Mini” sticks, where there is a question as to whether or not the needle really penetrated, are often the result of using a curved needle. When the problem is announced, the team should freeze, dispose of the needle and suture in 362 AORN Journal HOPPER—MOSS a manner that maintains the surgical count, and inspect the glove and affected hand. The incident must be reported and protocols followed. Bone sticks may accompany attempts to reduce fracture fragments with one’s gloved fingers. If at all possible, instruments should be used to manipulate the fragments, although there will always be a situation during which the surgeon wants or needs to hold a fragment of bone in place manually. Bone tamps should always be used when tamping bone grafts down rather than doing it manually with the fingers. CONTAINING THE CONTAMINATION OF A BREAK IN STERILE TECHNIQUE What should be done if a break in technique has occurred but time has elapsed before the break is recognized (ie, a type 2 or type 3 break)? How can the extent of contamination be determined? How can the contamination be isolated and contained? One recommendation is to institute the use of a watchword, whereupon all surgical team members freeze. Team members would then communicate the dilemma, discuss options, and identify and implement a solution so the procedure can proceed. One facility implemented the FCC plan: freeze, communicate, and contain, using the watchword “Boppo.” The importance of freezing is that when a break is discovered, no one moves, which keeps the contamination from spreading. Communication is crucial at this point. Different options for resolution may be voiced, and all opinions should be considered valid. The circulating nurse, scrub person, surgeon, assistants, and anesthesia care provider all may have valuable input. The team must reach a consensus on how to proceed. Consider the situation of a knife blade penetrating a sterile drape. The first person to notice the problem clearly says, “Boppo,” and all team members freeze while the situation is assessed and options are discussed. One team member might question whether the area is contaminated because the knife blade was sterile before it went through the sterile COMMON BREAKS IN STERILE TECHNIQUE drape. One team member might want to investigate to determine how many layers of sterile drapes were penetrated. How can this be accomplished safely and efficiently? The team might discuss this option but decide that in the effort to determine the level of contamination, drapes would have to be pulled up, which would further spread the contamination. Another team member might suggest using scissors to cut a wide patch out of the drape to see the extent of the contamination. One team member might question whether antibiotic prophylaxis is advisable. In the end, the team decides that the basic principle of sterile technique applies: if in doubt, treat it as contaminated. Cooperatively, the team decides that the knife blade and handle should be discarded immediately, not placed on the Mayo stand or back table, and the hole should be covered with a new, impermeable drape. The team determines that additional antibiotics are not required because an antibiotic was administered 15 minutes before the initial incision. At this point, the surgeon determines whether it is safe to continue surgery. Occasionally, heated disagreements may occur regarding how to handle a break in technique. The attending surgeon has the ultimate responsibility for determining when to resume the procedure, but what if the circulating nurse, scrub person, or an assistant (eg, RN first assistant) disagrees? The dictatorial ways of the old-time surgeons and “captain of the ship” philosophy have largely been modified by new policies and changes in the workplace environment. This has given rise to a healthier atmosphere in which there is more of a team approach. CORRECTIVE ACTION AND REPORTING When a break in sterile technique occurs and cannot be rectified, appropriate corrective actions should be implemented immediately unless doing so would compromise the patient’s safety. If the patient’s safety would be at risk, the break should be corrected as soon as it is safe to do so.9 In these situations, the policies and procedures of the health care facility should specify how to report the break in sterile technique to appropriate risk management www.aornjournal.org personnel and how to revise the wound classification after a break in sterile technique occurs.9 CONCLUSION For the surgical patient, acquiring an SSI leads to needless discomfort and treatments, as well as an increased hospital stay. For the health care facility, an SSI also means additional cost. A break in sterile technique is one potential cause of an SSI. As patient advocates, all members of the perioperative team must have a good surgical conscience; be knowledgeable about the principles of sterile technique; remain vigilant to prevent and identify breaks; and initiate appropriate corrective actions as soon as possible after a break is realized. With this knowledge and skill, each member of the perioperative team can proactively reduce the adverse effects of a break in sterile technique and, consequently, an SSI, ultimately improving the patient’s surgical outcome. References 1. 2. 3. 4. 5. 6. Petersen C. Perioperative Nursing Data Set: The Perioperative Nursing Vocabulary. 3rd ed. Denver, CO: AORN, Inc. In press. Health-care associated infections (HAIs). Centers for Disease Control and Prevention. http://www.cdc.gov/ ncidod/dhqp/healthdis.html. Accessed November 9, 2009. Estimates of healthcare-associated infections. Centers for Disease Control and Prevention. http://www.cdc .gov/ncidod/dhqp/hai.html. Accessed November 9, 2009. de Lissovoy G, Fraeman K, Hutchins V, Murphy D, Song D, Vaught BB. Surgical site infection: incidence and impact on hospital utilization and treatment costs. Am J Infect Control. 2009;37(5):387-397. Medicare and Medicaid move aggressively to encourage greater patient safety in hospitals and reduce never events [news release]. Baltimore, MD: Centers for Medicare & Medicaid Services; July 31, 2008. http:// www.cms.hhs.gov/apps/media/press/release.asp? Counter⫽3219&intNumPerPage⫽10&checkDate⫽ &checkKey⫽&srchType⫽1&numDays⫽3500&srch Opt⫽0&srchData⫽&keywordType⫽All&chkNews Type⫽1%2C⫹2%2C⫹3%2C⫹4%2C⫹5&intPage⫽& showAll⫽&pYear⫽&year⫽&desc⫽false&cboOrder ⫽date. Accessed November 9, 2009. Accreditation Program: Hospital National Patient Safety Goals. The Joint Commission. http://www.joint AORN Journal 363 March 2010 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 364 Vol 91 commission.org/NR/rdonlyres/31666E86-E7F4-423E9BE8-F05BD1CB0AA8/0/09_NPSG_HAP.pdf. Accessed November 9, 2009. Recommended practices for hand hygiene in the perioperative setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2010:75-89. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol. 1999;20(4):250-278. Recommended practices for maintaining a sterile field. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2010:91-99. Nicolette LH. Infection prevention and control in the perioperative setting. In: Rothrock JC, ed. Alexander’s Care of the Patient in Surgery. 13th ed. St Louis, MO: Mosby Elsevier; 2007:75. Charnley J. Surgical infection in orthopaedic surgery, Wrightington’s “glass-house” [in French]. Rev Chir Orthop Reparatrice Appar Mot. 1969;55(3):231-233. [ST-58] Statement on sharps safety. American College of Surgeons. http://www.facs.org/fellows_info/statements/ st-58.html. Accessed December 7, 2009. Information statement: preventing the transmission if bloodborne pathogens. American Academy of Orthopedic Surgeons. http://www.aaos.org/about/papers/ advistmt/1018.asp. Accessed December 7, 2009. Recommended practices for preoperative patient skin antisepsis. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2010:351-369. Recommended practices for environmental cleaning in the perioperative setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2010:241-255. Recommended practices for traffic patterns in the perioperative practice setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2010:101-104. American Institute of Architects Academy of Architecture for Health. Guidelines for Design and Construction of Hospital and Health Care Facilities. Washington, DC: American Institute of Architects Press; 2006:130131. Recommended practices for surgical attire. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2010:67-73. AORN Journal HOPPER—MOSS No 3 19. 20. 21. 22. 23. 24. 25. 26. Ball KA. Surgical modalities. In: Rothrock JC, ed. Alexander’s Care of the Patient in Surgery. 13th ed. St Louis, MO: Mosby Elsevier; 2007:219. Recommended practices for electrosurgery. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2010:105-125. D’Ambrosio R, Masier R. Orthopaedic Infections. Thorofore, NJ: Slack, Inc; 1989:53-55. Charnley J. Acrylic Cement in Orthopaedic Surgery. Edinburgh, Scotland; Churchill Livingstone; 1970: 42. Recommended practices for the care and handling of specimens in the perioperative environment. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2010:269-276. AORN guidance statement: Sharps injury prevention in the perioperative setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2010:697-702. Standards – 29 CFR. Bloodborne pathogens. – 1910.1030. Occupational Safety and Health Administration. http:// www.osha.gov/pls/oshaweb/owadisp.show_document?p_ table⫽STANDARDS&p_id⫽10051. Accessed November 9, 2009. Recommended practices for prevention of transmissible infections in the perioperative practice setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2010:277-287. William R. Hopper, MD, FAAOS, is a retired attending orthopaedic surgeon, AO Fox Memorial Hospital, Oneonta, NY. Dr Hopper has no declared affiliation that could be perceived as a potential conflict of interest in publishing this article. Rose Moss, RN, MN, CNOR, is an independent nurse consultant, Hendersonville, NC. Ms Moss has no declared affiliation that could be perceived as a potential conflict of interest in publishing this article. EXAMINATION CONTINUING EDUCATION PROGRAM 3.4 Common Breaks in Sterile Technique: Clinical Perspectives and Perioperative Implications PURPOSE/GOAL To educate perioperative nurses about identifying and preventing common breaks in sterile technique. OBJECTIVES 1. Identify sources of surgical site infection. 2. Identify common breaks in sterile technique. 3. Describe means to prevent common breaks in sterile technique. The Examination and Learner Evaluation are printed here for your convenience. To receive continuing education credit, you must complete the Examination and Learner Evaluation online at http://www.aorn.org/CE. QUESTIONS 1. Transient flora 1. are considered to be permanent residents of the skin. 2. are easily transmitted to hands from patients and inanimate surfaces. 3. can be removed by hand washing or use of a hand rub agent. 4. are not readily removed by hand washing. 5. colonize the superficial layers of the skin. a. 1 and 4 b. 2, 3, and 5 c. 1, 2, 3, and 5 d. 1, 2, 4, and 5 2. The risk of a surgical site infection increases with the dose of bacterial contamination and the virulence of the bacteria. a. true b. false © AORN, Inc, 2010 3. A a. b. c. d. type 3 break in sterile technique is one that is recognized immediately. recognized shortly after occurrence. recognized at a later time. not recognized at all. 4. To ensure that items used within the sterile field are sterile, perioperative personnel preparing an OR for a procedure must inspect all items immediately before they are presented to the sterile field for 1. an intact seal. 2. correct processing. 3. inclusion of the proper sterilization indicator. 4. package container integrity. 5. proper packaging. a. 1 and 3 b. 2, 3, and 5 c. 1, 2, 4, and 5 d. 1, 2, 3, 4, and 5 March 2010 Vol 91 No 3 ● AORN Journal 365 March 2010 Vol 91 No 3 5. There is no specified amount of time that a setup can remain open and unused and still be considered sterile because the sterility of an open field is event related. a. true b. false 6. For surgical skin prep, a. rapid, gentle washing is recommended. b. the longer the skin is prepped, the better. c. vigorous scrubbing is recommended. 7. Turbulent airflow can be caused by 1. excessive talking. 2. frequent opening and closing of the OR doors. 3. an increased number of personnel in the OR. 4. directional airflow, positive air pressure, and use of high-efficiency particulate air (HEPA) filters. a. 1 and 2 b. 2 and 4 c. 1, 2, and 3 d. 1, 2, 3, and 4 8. Char 1. is a by-product of thermal coagulation. 2. is a nutrient source for bacteria. CE EXAMINATION 3. should frequently be cleaned off the active electrode tip. a. 1 b. 1 and 3 c. 2 and 3 d. 1, 2, and 3 9. The policies and procedures of a health care facility should specify how to 1. report the break in sterile technique to appropriate risk management personnel. 2. discipline the individual responsible for the break in technique. 3. revise the wound classification after a break in sterile technique occurs. a. 1 b. 1 and 3 c. 2 and 3 d. 1, 2, and 3 10. As patient advocates, all members of the perioperative team must 1. be knowledgeable about the principles of sterile technique. 2. have a good surgical conscience. 3. initiate appropriate corrective actions as soon as possible after a break is realized. 4. remain vigilant to prevent and identify breaks. a. 1 and 3 b. 2 and 4 c. 1, 2, and 3 d. 1, 2, 3, and 4 The behavioral objectives and examination for this program were prepared by Rebecca Holm, RN, MSN, CNOR, clinical editor, with consultation from Susan Bakewell, RN, MS, BC, director, Center for Perioperative Education. Ms Holm and Ms Bakewell have no declared affiliations that could be perceived as potential conflicts of interest in publishing this article. 366 AORN Journal LEARNER EVALUATION CONTINUING EDUCATION PROGRAM 3.4 Common Breaks in Sterile Technique: Clinical Perspectives and Perioperative Implications T his evaluation is used to determine the extent to which this continuing education program met your learning needs. Rate the items as described below. OBJECTIVES To what extent were the following objectives of this continuing education program achieved? 1. Identify sources of surgical site infection. Low 1. 2. 3. 4. 5. High 2. Identify common breaks in sterile technique. Low 1. 2. 3. 4. 5. High 3. Describe means to prevent common breaks in sterile technique. Low 1. 2. 3. 4. 5. High CONTENT 4. To what extent did this article increase your knowledge of the subject matter? Low 1. 2. 3. 4. 5. High 5. To what extent were your individual objectives met? Low 1. 2. 3. 4. 5. High 6. Will you be able to use the information from this article in your work setting? 1. Yes 2. No 7. Will you change your practice as a result of reading this article? (If yes, answer question #7A. If no, answer question #7B.) 7A. How will you change your practice? (Select all that apply) 1. I will provide education to my team regarding why change is needed. 2. I will work with management to change/ implement a policy and procedure. 3. I will plan an informational meeting with physicians to seek their input and acceptance of the need for change. 4. I will implement change and evaluate the effect of the change at regular intervals until the change is incorporated as best practice. 5. Other: 7B. If you will not change your practice as a result of reading this article, why? (Select all that apply) 1. The content of this article is not relevant to my practice. 2. I do not have enough time to teach others about the purpose of the needed change. 3. I do not have management support to make the change. 4. Other: 8. Our accrediting body requires that we verify the time you needed to complete this 3.4 continuing education contact hour (204-minute) program: This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements. AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. AORN recognizes these activities as continuing education for registered nurses. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity. AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this activity for relicensure. Event: #10011; Session: #4003 Fee: Members $17, Nonmembers $34 The deadline for this program is March 31, 2013. A score of 70% correct on the examination is required for credit. Participants receive feedback on incorrect answers. Each applicant who successfully completes this program will be able to print a certificate of completion. © AORN, Inc, 2010 March 2010 Vol 91 No 3 ● AORN Journal 367