10 Areas of Focus for Maintaining a Sterile Field in an ASC

The following article was written by Kathleen Bernicky, RN, BSN, director of clinical operations for Regent Surgical Health.


Surgical infections are a leading cause of patient morbidity and mortality in the United States.  Adherence to the principles of asepsis is the foundation of surgical site infection prevention, and it should never be circumvented to save time or money. A sterile field should be prepared and maintained for every surgical patient.

A sterile field is a specific area that is considered free of microorganisms. Maintaining a sterile field is not an easy task because there are many chances for a breach in sterility during set-up and maintenance of the sterile area.

AORN and The Association of Surgical Technologist have developed Recommended Standards of Practice for creating and maintaining a sterile field. It is the responsibility of the healthcare facility to develop, approve and implement policies and procedures, as well as educate staff on these procedures. The entire surgical team has a responsibility to provide and maintain a safe environment for patient care.

Ongoing education is critical and will create a higher level of awareness. Putting the topic on monthly department meeting agendas will keep it front and center. It's also important to encourage staff to speak up when they have a concern or have witnessed a breach in sterility.  ASC administrators should perform periodic audits, identify areas for improvement and share the results with the staff in order to educate the surgical team.

10 Areas of Focus for Maintaining a Sterile Field

1. Involve all team members.
The entire surgical team — the circulator, the scrub, the surgeon and the anesthesiologist — are responsible for monitoring the sterile field and speaking up if a breach of sterility occurs. It needs to be a team effort.

2. Follow the same practices every day. Establishing routines and expectations for opening and setting up the sterile field is helpful. The team should be mindful of what they are doing. It's easy for staff members to be distracted by conversations with their colleagues, which take their attention away from the task of correctly opening and preparing a sterile field.

3. Reduce conversation in the sterile field. AORN suggests that conversations in the presence of a sterile field should be kept to a minimum to reduce the spread of droplets. Air contains microorganisms on airborne particles, such as respiratory droplets. The primary source of airborne bacteria is healthcare personnel

4. Inspect instruments and trays for tears. The sterile wrapped instruments and trays should be purposely inspected for small tears that would compromise sterility before opening and placing the instruments on the field. Staff members often skip this step.  

5. Include a sterilization indicator with each item/tray. Each sterile item or tray of sterile items must include a sterilization indicator. The indicator must be inspected before opening to note whether the indicator color has changed to the appropriate color for the indicator type. This will verify that the sterilization process was completed. It's helpful if the staff member opening the instruments verbalizes the indicator results.

6. Be sure before using an item. It's either sterile or it's not. If in doubt, don't use it.

7. Face the sterile field at all times.
The scrub person and the OR team should never turn their back to the sterile field. The fronts of sterile gowns are considered sterile from the chest to the level of the sterile field. The sterile area of the gown front extends to the level of the sterile field because most scrubbed personnel work adjacent to a sterile bed and/or table. Gown sleeves are considered sterile from two inches above the elbow to the cuff, circumferentially.

8. Reduce the number and movement of OR team members as much as possible. The number and movement of individuals involved in a surgical procedure should be kept to a minimum per AORN's "Recommended practices for traffic patterns in the perioperative practice setting." Bacterial shedding increases with activity, and air currents can pick up contaminated particles shed from patients, personnel and drapes and distribute them to sterile areas.

9. Keep the OR door closed. Leaving the OR door open or frequent opening of the door will interrupt the air exchange system. The OR suite will also lose negative pressure. allowing airborne contaminates in.

10. Monitor the field in case of delay. In the event a case is delayed, the only way to assure sterility is for the field to be constantly monitored. Covering a sterile field and then uncovering it increases the chances for contamination as you remove the cover.

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Education is critical to empowering ASC staff members. It gives them the knowledge they need to provide safe patient care. Ongoing education helps to develop surgical consciousness or awareness.

The responsibility of the facility's leadership team is to create a culture of safety so staff members feel free to speak up when they witness a possible or definite interruption in sterility or any patient safety issue. Many staff members are afraid to say something due to repercussions from an angry surgeon or surgical team. Changing gloves, gowns or the sterile field can delay the procedure or surgery for a few minutes, but staff should always be encouraged to speak up and do the right thing.

Learn more about Regent Surgical Health.

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