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Introduction

The Guideline for Sterile Technique has been approved by the AORN Guidelines Advisory Board. It was presented as a proposed guideline for comments by members and others. The guideline is effective November 1, 2018. The recommendations in the guideline are intended to be achievable and represent what is believed to be an optimal level of practice. Policies and procedures will reflect variations in practice settings and/or clinical situations that determine the degree to which the guideline can be implemented. AORN recognizes the many diverse settings in which perioperative nurses practice; therefore, this guideline is adaptable to all areas where operative or other invasive procedures may be performed.

Purpose

This document provides guidance on the principles and processes of sterile technique. Sterile technique involves the use of specific actions and activities to maintain sterility and prevent contamination of the sterile field and sterile items during operative and other invasive procedures. Thoughtful and diligent implementation of sterile technique is a cornerstone of perioperative nursing practice and a key strategy in the prevention of surgical site infections (SSIs).

All individuals who are involved in operative or other invasive procedures have a responsibility to provide a safe environment for patient care.1  Perioperative team members must be vigilant in preventing contamination of the sterile field and ensuring that the principles and processes of sterile technique are implemented. Perioperative leaders have a duty to promote a culture of safety by creating an environment in which perioperative personnel are encouraged to identify, question, or stop practices believed to be unsafe without fear of repercussions.2 

Adhering to the principles and processes of sterile technique is a matter of ethical obligation, individual conscience, and patient advocacy that applies to all members of the perioperative team.1,3  Surgical patients are vulnerable; thus, perioperative team members are required to mindfully practice the principles of sterile technique to ensure the sterile field is maintained. Perioperative nurses have a long-standing reputation of advocating for patients and working with members of the interdisciplinary health care team to provide a safe perioperative environment.2 

Although these recommendations include references to other AORN Guidelines, the focus of this document is sterile technique. Surgical attire, hand hygiene, product evaluation, and the effects of forced-air warming equipment are outside the scope of these recommendations. The reader should refer to the AORN Guideline for Surgical Attire,4  Guideline for Hand Hygiene,5  Guideline for Medical Device and Product Evaluation,6  and Guideline for Prevention of Unplanned Patient Hypothermia7  for additional guidance.

Evidence Review

A medical librarian with a perioperative background conducted a systematic search of the databases Ovid MEDLINE®, EBSCO CINAHL®, Scopus®, and the Cochrane Database of Systematic Reviews. The search was limited to literature published in English from 2012 through 2017. At the time of the initial search, weekly alerts were created on the topics included in that search. Results from these alerts were provided to the lead author until April 2018. The lead author requested additional articles that either did not fit the original search criteria or were discovered during the evidence appraisal process. The lead author and the medical librarian also identified relevant guidelines from government agencies, professional organizations, and standards-setting bodies.

Search terms included subject headings such as abdominal and perineal surgery, aerosolization, asepsis, aseptic practice, aseptic technique, assembled instruments, assisted gloving, barrier precautions, blocked vents, blood, body exhaust suits, bone and bones, bone cements, bowel isolation technique, bowel surgery, bowel technique, break in sterile technique, C-arm, case classifications, cerebrospinal fluid shunts, cesarean birth, cesarean section, changing levels, chemical indicator, chemical integrator, chewing gum, clamped instruments, clean closure technique, clean to dirty case, closed gloving, closing instruments, closing trays, colorectal surgery, complex procedure, contamination, conversations, corrective actions, cough, cover equipment, cover implants, cover instrument trays, critical zone, cuffing, cystoscopic surgery, cystoscopy, debris, delivery of sterile items, delivery to sterile field, dispensing sterile items, doffing, donning, door openings, double gloving, dual sterile fields, education, endovascular procedures, endovascular surgery, event-related sterility, extended cuffs, facing back to back, facing front to front, fluid and fat absorption, fluid warmers, fluoroscopy, gastrointestinal tract, glove compromise, glove expansion and fluid, glove gown interface, glove inspection, glove integrity, glove perforation, gloves (surgical), gowns, grease, hair, hand hygiene, handling sterile items, health physics, heavy items, human factors, hybrid operating room, hybrid procedure room, hybrid surgical suites, immediate action, increased activity, indicator systems, indicators and reagents, individual interventions, inspection of sterile supplies, instrument inspection, instrument set removal, instrument trays, instrument wrap, interoperative MRI, intraoperative MRI, introduction of sterile supplies, Ioban, iodine impregnated drape, isolation technique, Kimguard, lead apron, lead garment, leaning over, level of the sterile field, maintain integrity, major break, Maxair, medications, metastatic tumors, methyl methacrylate, microscope eyepiece, microscopes, minimally invasive, minimally invasive procedures, minimally invasive surgical procedures, minimize handling, minor break, monitoring sterile field, movement of personnel, multiple sterile fields, multiple surgical specialties, neoplasm metastasis, non-penetrating clamps, opening sterile items, opening sterile items in a rigid container, operative microscope, organic material, orthopedic hoods, otolaryngology, package integrity, packaging, pharmaceutical preparations, plastic adhesive incise drape, plastic bandages to cover holes, polymethyl methacrylate, procedural drapes, product evaluation, product packaging, product selection, protective clothing, radiologic exposure, retrieve sterilizer items, robotic surgery, robotic surgical procedures, seated procedures, securement, sharp items, simulation, slush machines, sneezing, solutions, space suits, Spaulding classification, speech, sterile areas or sections, sterile barrier, sterile drapes, sterile field, sterile field preparation, sterile part of gown, sterile practices, sterile surgical gloves, sterile surgical gown, sterile technique, sterility, strikethrough, sub-sterile, surgery (digestive system), surgical air systems, surgical conscience, surgical doors shut, surgical drapes, surgical draping, surgical equipment and supplies, surgical gown, surgical gown cuffs, surgical gown seams, surgical gown strikethrough, surgical helmet system, surgical hood, surgical instruments, surgical site infection bundle, surgical wound, table covering, talking, tape doors, team interventions, time-related sterility, tissue, traffic patterns, training, unanticipated delay, ventriculoperitoneal shunts, visible defect, waist level, wound classification, and wrapped items.

Included were research and non-research literature in English, complete publications, and publications with dates within the time restriction when available. Excluded were non-peer-reviewed publications and older evidence within the time restriction when more recent evidence was available. Editorials, news items, and other brief items were excluded. Low-quality evidence was excluded when higher-quality evidence was available (Figure 1).

Figure 1
Flow Diagram of Literature Search Results

Flow Diagram of Literature Search Results

Adapted from: Moher D, Liberati A, Tetzlaff J, Atman DG; The PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA Statement. PLoS Med. 2009;6(6):e1000097.

Articles identified by the search were provided to the project team for evaluation. The team consisted of the lead author and two evidence appraisers. The lead author divided the search results into topics and assigned members of the team to review and critically appraise each article using the AORN Research or Non-Research Evidence Appraisal Tools as appropriate. The literature was independently evaluated and appraised according to the strength and quality of the evidence. Each article was then assigned an appraisal score agreed upon by consensus of the team. The appraisal score is noted in brackets after each reference as applicable.

The collective evidence supporting each intervention within a specific recommendation was summarized, and the AORN Evidence Rating Model was used to rate the strength of the evidence. Factors considered in the review of the collective evidence were the quality of the evidence, the quantity of the evidence, and the consistency of the evidence supporting a recommendation. The evidence rating is noted in brackets after each intervention.

Note: The evidence summary table is available at http://www.aorn.org/evidencetables/.

Editor’s note: MEDLINE is a registered trademark of the US National Library of Medicine’s Medical Literature Analysis and Retrieval System, Bethesda, MD. CINAHL, Cumulative Index to Nursing and Allied Health Literature, is a registered trademark of EBSCO Industries, Birmingham, AL. Scopus is a registered trademark of Elsevier B.V., Amsterdam, The Netherlands. Ioban is a registered trademark of 3M Company, St Paul, MN. Kimguard is a registered trademark of Kimberly-Clark Worldwide, Inc, Neenah, WI. Maxair is a registered trademark of Maxair Manufacturing Ltd, Port Coquitlam, British Columbia, Canada.

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