AORN Recommended Practices Committee. Recommended practices for maintaining a sterile field

Contamination of the Mini C-Arm During Foot and Ankle Surgery

BACKGROUND

Many orthopedic surgeries utilize intraoperative fluoroscopy. The mini C-arm is an advantageous device as it can be easily used without the need for a dedicated radiology technician. However, there are concerns that the mini C-arm may represent a potential source of contamination and subsequent postoperative infection. Previous investigations of standard C-arm drapes have shown high rates of contamination. Similar contamination rates would be even more concerning for the mini C-arm as it requires physically maneuvering the machine. This study aimed to determine the rate of mini C-arm drape contamination and identify high-risk areas.

METHODS

Fifty foot and ankle surgeries requiring the use of mini C-arm fluoroscopy were included. Eight locations on the mini C-arm drape were sampled at the conclusion of each procedure. Culture Q-swabs were used for sampling defined locations. Swab samples were then assessed for bacterial growth on a 5% blood agar plate using a semiquantitative technique.

RESULTS

In 70% of surgical cases, contamination was observed in at least 1 location. Six of the 8 evaluated locations were found to have significantly higher contamination in comparison with their corresponding negative controls (Mann-Whitney U test, P < .05). The "outer portion of the upper arm" (location 1) exhibited bacteria growth in 26% (P < .0001) of cases. The "superior portion of the x-ray source" (location 2) exhibited growth in 30% (P < .0001) of cases. These were the highest-risk areas for contamination and were both significantly more likely to be involved than the "inferior portion of the x-ray source" and "superior portion of the beam receiver," locations 4 and 5, respectively. Fourteen percent (7/50) C-arm cases and 1.72% (1/58) Achilles tendon surgery control cases developed surgical site infection (P = .0234; OR, 9.27).

CONCLUSION

Bacterial contamination of the mini C-arm drape was found to be common after foot and ankle procedures. Contamination was more prevalent on the outer ring areas of the C-arm, both at the emitter and receiver.

LEVEL OF EVIDENCE

Level III, prospective cohort study.

Safe Spine Surgery During the COVID-19 Pandemic

Safe spine surgery is possible during the COVID-19 pandemic. Certain urgent procedures must still be performed during this challenging time to prevent permanent long-term disability or death for patients. Precautions must be taken in the operating room to optimize safety, including the use of personal protective equipment and appropriate room setup and anesthesia and equipment optimization. Evidence-based guidelines to create a safe operative paradigm for use in future viral outbreaks are paramount.

The Drape Tower: A "Hands-Free" Draping Technique for Intraoperative Lateral Fluoroscopy Views

Maintaining surgical field sterility during fracture surgery is critical for reducing the likelihood of postoperative infection. Lateral fluoroscopic views are frequently obtained by rotating the emitter under the bed and up immediately adjacent to the sterile field on the side of the injured limb. Contamination can be prevented by sterilely covering the emitter with each rotation from the upright to the lateral positions. Here, we describe a novel draping setup, which maintains fluoroscopic coverage in a "hands-free" manner. The technique uses widely available materials and allows the surgeon to proceed with surgery without the need for additional hands to manage the drape.

Increasing Completion Rate and Benefits of Checklists: Prospective Evaluation of Surgical Safety Checklists With Smart Glasses

BACKGROUND

Studies have demonstrated that surgical safety checklists (SSCs) can significantly reduce surgical complications and mortality rates. Such lists rely on traditional posters or paper, and their contents are generic regarding the type of surgery being performed. SSC completion rates and uniformity of content have been reported as modest and widely variable.

OBJECTIVE

This study aimed to investigate the feasibility and potential of using smart glasses in the operating room to increase the benefits of SSCs by improving usability through contextualized content and, ideally, resulting in improved completion rates.

METHODS

We prospectively evaluated and compared 80 preoperative time-out events with SSCs at a major academic medical center between June 2016 and February 2017. Participants were assigned to either a conventional checklist approach (poster, memory, or both) or a smart glasses app running on Google Glass.

RESULTS

Four different surgeons conducted 41 checklists using conventional methods (ie, memory or poster) and 39 using the smart glasses app. The average checklist completion rate using conventional methods was 76%. Smart glasses allowed a completion rate of up to 100% with a decrease in average checklist duration of 18%.

CONCLUSIONS

Compared with alternatives such as posters, paper, and memory, smart glasses checklists are easier to use and follow. The glasses allowed surgeons to use contextualized time-out checklists, which increased the completion rate to 100% and reduced the checklist execution time and time required to prepare the equipment during surgical cases.

Surgical Gowning Technique: Are We Contaminated Before We Cut?

OBJECTIVES

To assess possible breaches of sterility during the initial gowning step.

DESIGN

Observational study. Twenty-seven gowning events were monitored for contamination during a simulated two-person gowning process in which a surgical technician assists a surgeon in the gowning process at the beginning of a surgical procedure. The lower portion of the technician's gown was coated with resin powder before the gowning process to simulate contamination.

SETTING

Single-institution Level 1 trauma center.

PARTICIPANTS

Three physicians and 3 tenured surgical technicians.

INTERVENTION

Observed contaminated areas represented by ultraviolet resin powder under ultraviolet light on the gown of the surgeon after the two-person gowning step.

MAIN OUTCOME MEASUREMENT

Number and surface area of contamination events.

RESULTS

There was a 66.67% rate of contamination of the surgeon's gown sleeves while being gowned by a surgical technician. The overall median contamination for the short surgeon was 1.3 cm. For the medium height surgeon, the overall median contamination was 1.4 cm. The tall surgeon had an overall median contamination of 2.9 cm. Of the short, medium, and tall surgeons, the number of contamination events was 6, 5, and 7, respectively. The study suggested that the surgeon's height was a significant source of variation (P = 0.046).

CONCLUSION

We present an observational pilot study that suggests that to reduce contamination in the operating room, the two-person method must be highly monitored. This study also proposes that the single-person gowning technique should be used to reduce contamination rate during the gowning process.

Reducing levels of medical device contamination through package redesign and opening technique

Objectives

The goal of this research was to evaluate how material curl, package structure and handling of pouches containing medical devices affect rates of contact between non-sterile surfaces and sterile devices during aseptic transfer.

Methods

One hundred and thirty-six individuals with practical experience in aseptic technique were recruited. Participants were asked to present the contents of four different pouch designs (a standard, one designed to curl in, another to curl out and one that incorporated a tab) using two transfer techniques. During the first block of trials “standard technique” was used; participants presented using their typical methods to the sterile field. Trials in the second block employed “modified technique”; participants were instructed to grab the package at the top center and present package contents using a single, fluid motion. The outside of the pouch and the backs of the participants’ hands were coated using a simulated contaminant before each trial. The simulant was undetectable in the visible spectrum, but fluoresced under a black light. The dependent variable was recorded in a binary fashion and analyzed using a generalized linear mixed model.

Results

Participants were between 20–57 and the averaged year 5.1 years of experience in aseptic technique. The data analysis was based on generalized linear mixed effects (GLMM) model, which accommodates the repeated measurements within the same participant. The effect of the pouch design was significant (P‹0.001), but the effect of aseptic technique did not suggest significance (P = 0.088). Specifically, pouches designed with the material curled outward resulted in significantly fewer contacts with non-sterile surfaces than the other styles, including the inward, tab, and standard styles; this was true regardless of the used aseptic technique, standard (P = 0.0171, P = 0.0466, P = 0.0061, respectively) or modified (P‹0.0001 for all comparisons)).

Conclusion

Results presented here contribute to a growing body of knowledge that investigates packaging as a potential route of contamination for sterile devices during aseptic presentation. Specifically, we provide insights regarding how both package design and opening technique can be informed in ways that build safety into the healthcare system.

A Comparison of Three C-Arm Draping Techniques to Minimize Contamination of the Surgical Field

The use of intraoperative fluoroscopy has become a routine and useful adjunct within orthopaedic surgery. However, the fluoroscopy machine may become an additional source of contamination in the operating room, particularly when maneuvering from the anterior-posterior position to the lateral position. Consequently, draping techniques were developed to maintain sterility of the operative field and surgeon. Despite a variety of methods, no studies exist to compare the sterility of these techniques specifically when the fluoroscopy machine is in the lateral imaging position. We evaluated the sterility of 3 c-arm draping techniques in a simulated operative environment. The 3 techniques consisted of a traditional 3-quarter sterile sheet attached to the side of the operative table, a modified clip-drape method, and a commercially available sterile pouch. Our study demonstrated that the traditional method poses a high risk for sterile field contamination, whereas the modified clip-drape method and commercially available sterile pouch kept floor contamination furthest from the surgical field. With the current data, we urge surgeons to use modified techniques rather than the traditional draping method.

A Step by Step Protocol for Subretinal Surgery in Rabbits

Age related macular degeneration (AMD), retinitis pigmentosa, and other RPE related diseases are the most common causes for irreversible loss of vision in adults in industrially developed countries. RPE transplantation appears to be a promising therapy, as it may replace dysfunctional RPE, restore its function, and thereby vision.

Here we describe a method for transplanting a cultured RPE monolayer on a scaffold into the subretinal space (SRS) of rabbits. After vitrectomy xenotransplants were delivered into the SRS using a custom made shooter consisting of a 20-gauge metallic nozzle with a polytetrafluoroethylene (PTFE) coated plunger. The current technique evolved in over 150 rabbit surgeries over 6 years. Post-operative follow-up can be obtained using non-invasive and repetitive in vivo imaging such as spectral domain optical coherence tomography (SD-OCT) followed by perfusion-fixed histology.

The method has well-defined steps for easy learning and high success rate. Rabbits are considered a large eye animal model useful in preclinical studies for clinical translation. In this context rabbits are a cost-efficient and perhaps convenient alternative to other large eye animal models.

its about the journey!

The aim of this article is to discuss: the importance of effective communication, the importance of maintaining confidentiality and equality for all individuals, the importance of maintaining a secure, safe and hygienic environment within the operating department, the principles of maintaining sterility and controlling infection, and the resulting hazards if these are not maintained. A paediatric patient was followed through her perioperative journey to find out if routinely, at the author's trust, the values of the NHS constitution--the six Cs--are being upheld.

Using a depth-sensing infrared camera system to access and manipulate medical imaging from within the sterile operating field

BACKGROUND

As surgical procedures become increasingly dependent on equipment and imaging, the need for sterile members of the surgical team to have unimpeded access to the nonsterile technology in their operating room (OR) is of growing importance. To our knowledge, our team is the first to use an inexpensive infrared depthsensing camera (a component of the Microsoft Kinect) and software developed inhouse to give surgeons a touchless, gestural interface with which to navigate their picture archiving and communication systems intraoperatively.

METHODS

The system was designed and developed with feedback from surgeons and OR personnel and with consideration of the principles of aseptic technique and gestural controls in mind. Simulation was used for basic validation before trialing in a pilot series of 6 hepatobiliary-pancreatic surgeries.

RESULTS

The interface was used extensively in 2 laparoscopic and 4 open procedures. Surgeons primarily used the system for anatomic correlation, real-time comparison of intraoperative ultrasound with preoperative computed tomography and magnetic resonance imaging scans and for teaching residents and fellows.

CONCLUSION

The system worked well in a wide range of lighting conditions and procedures. It led to a perceived increase in the use of intraoperative image consultation. Further research should be focused on investigating the usefulness of touchless gestural interfaces in different types of surgical procedures and its effects on operative time.

A standardized and safe method of sterile field maintenance during intra-operative horizontal plane fluoroscopy

Background

Intra-operative fluoroscopy for orthopaedic procedures frequently involves imaging in the horizontal plane, which requires the lower portion of the C-arm (x-ray tube) to be rotated from an unsterile zone (beneath the table) into the sterile field. To protect the integrity of the sterile field the C-arm must be draped repeatedly throughout the surgical case. The current, un-standardized, practice employs draping procedures which violate the Association of peri-Operative Registered Nurses (AORN) Standards and Recommended Practices, waste time and material, and pose an increased risk for surgical site infection.

Presentation of the hypothesis

Use of a novel sterile C-arm drape (C-armor) that maintains the integrity of the sterile field, will improve operating room efficiency and reduce surgical site infection risk factors. This reduction in risk factors may potentially reduce surgical site infections in orthopaedic surgical cases requiring repeated horizontal x-ray imaging.

Testing the Hypothesis

Savings in time and material and the reduction in surgical site infection risk factors afforded by using C-armor are intuitive to those skilled in the practice of orthopaedic surgery. Testing for a reduction in the number of microorganisms introduced to the surgical site by improved C-arm draping would be challenging due to the multiple confounding factors during a surgical operation. Determination of an absolute reduction in surgical site infections may be possible, but will require accounting for many confounding variables and a large study sample in order to achieve statistical significance.

Implications of the Hypothesis

Improved intraoperative workflow, healthcare savings and a reduction in surgical site infection risk factors will be achieved by utilizing a standardized and safe method of sterile field maintenance during intra-operative horizontal plane fluoroscopy.

Which regions of the operating gown should be considered most sterile?

Various guidelines have been proposed regarding which portions of a surgical gown may be considered sterile. Unfortunately, the validity of these recommendations has not been definitively established. We therefore evaluated gown sterility after major spinal surgery to assess the legitimacy of these guidelines. We used sterile culture swabs to obtain samples of gown fronts at 6-inch increments and at the elbow creases of 50 gowns at the end of 29 spinal operations. Another 50 gowns were swabbed immediately after they were applied to serve as negative controls. Bacterial growth was assessed using semiquantitative plating techniques on a nonselective, broad-spectrum media. Contamination was observed at all locations of the gown with rates ranging from 6% to 48%. Compared with the negative controls, the contamination rates were greater at levels 24 inches or less and 48 inches or more relative to the ground and at the elbow creases. The section between the chest and operative field had the lowest contamination rates. Based on these results, we consider the region between the chest and operative field to be the most sterile and any contact with the gown outside this area, including the elbow creases, should be avoided to reduce the risk of infection.