Aseptic technique is defined as any health care procedure in which added precautions, such as use of sterile gloves, are employed to prevent contamination of a person, object, or area by microorganisms.¹ In helping to prevent contamination, these precautions can help reduce the incidence of surgical site infections (SSI). SSI are among the most common health care–associated infections and can lead to delayed wound healing, increased use of antibiotics, lengthy hospital stays, and vision loss.

More commonly known as sterile technique, these precautions are used in the operating room (OR) and are often adjusted for minor surgical procedures performed in the clinic or office. In ophthalmology, office-based procedures may include:

• chalazion incision and curettage
• simple blepharoplasty
• superficial keratectomy
• lesion excision and biopsy
• in-office bleb revisions
• corneal paracentesis
• conjunctival grafts
• simple ectropion or entropion repairs
• simple Mohs repairs
• punctoplasty
• intraocular injection
• Botox injection

Understanding the principles of this technique is crucial for anyone entering the perioperative environment. Some practices are standard across an entire industry; surgeons, for example, almost always don sterile gowns and gloves, while personnel outside of the sterile field use lesser forms of personal protective equipment (PPE) to assist with retrieving additional supplies needed during the procedure. Other practices may be specific to a facility and may require additional training. The following sections discuss the essential elements of sterile or aseptic technique.

Training and education

• Clearly define all facility policies and procedures for aseptic technique in writing. Update policies annually to account for changes in industry standards.
• Make available copies of policies and procedures at a moment’s notice. This may best be achieved by either a binder-type presentation or a cloud-based resource.
• All personnel involved in performing or assisting with office-based procedures should be adequately trained prior to the start of all procedures and whenever policies are updated regarding their role before, during, and after a procedure.
• Familiarize personnel with instruments, including maintenance procedures, methods of disinfection and sterility, as well as the limitations of each instrument.
• Educate personnel on forms of PPE, including situations that would require making the decision to switch from one form to another.
• Prior to the start of any procedure, familiarize personnel who prep instruments and supplies with the procedure for inspecting pouches, packs, and supplies to verify that they have passed disinfection and sterility measures.
• During a procedure, maintain sterility by ensuring personnel do not touch people or objects that are not sterile. A tool dropped on the floor is no longer sterile. If the surgeon bends down to look at it, he is no longer sterile, having passed outside the sterilized area.

Good personal hygiene

• Wash your hands before and after each procedure, and after any interruptions in sterility. The term most commonly used for proper hand hygiene prior to a procedure is “scrub” or “scrubbing”—the rigorous process of cleaning one’s hands prior to donning sterile gloves.
• Remove all jewelry prior to scrubbing and store in a secure place.
• Neatly tie back hair and tuck under a bonnet or surgical cap.
• Clip and file nails to a reasonable length to avoid breakage in gloves. Avoid acrylic nails.
• Wear skid-resistant, closed-toed shoes whenever working in a slick-floored environment that can cause a slip risk.

Personal protective equipment

• In addition to protecting you from hazardous materials and potential blood borne pathogens, wearing PPE reduces the probability of contamination of the surgical site from shed skin as well as dirt and dust from your clothes.
• Wear appropriate PPE for each specific procedure. This can include a mask, gloves, gown, eye shield, etc. Specific PPE is dependent on your facility’s protocol and procedure.
• Take care not to contaminate gown or gloves. Don them away from the main instrument table.
• Before touching a sterile field, scrubbed team members must inspect the integrity of their gloves, checking for holes and defects.
• Replace gloves under these circumstances: after each procedure; when actual or suspected contamination occurs; after adjusting a microscope or optic eyepieces that do not have sterile knob covers; when there is a visible defect, perforation, or suspected perforation.³

Clean work area

• Clinical areas may not be able to adhere to the strict aseptic surroundings of the OR, but take as much precaution as possible.
• The work area is ideally a separate room away from high-volume traffic areas. While not ideal, an exam room with a closed door will work.
• Prepare a work area by washing the counter or table with a disinfectant spray or soap and water. Make sure the surface is dry before you put the sterile supplies down.
• Before and after use, disinfect the work surface thoroughly. Clean surrounding areas and equipment routinely.
• Keep the work surface uncluttered, containing only items required for a specific procedure.
• Touch only the outside wrapper of supplies and instruments. Never touch the inside of the wrapper with ungloved hands.
• Organize supplies in the work area in a way that is easy to maneuver around. Replenish supplies at the end of every day.
• Minimize the number of personnel entering and leaving the work area. Studies have documented the relationship between increased numbers of personnel and higher levels of particulates in the environment which could lead to post-operative complications.²

Sterile field

First, let’s define: A sterile field is an area kept free of microorganisms to protect the health and safety of a patient during surgery.³ The surgical team is made up of sterile and nonsterile members. Sterile members or “scrubbed” personnel (physician, scrub assistant) work directly in the surgical field, while the nonsterile member (known as a circulator) will work in the periphery of the sterile field. In the office setting, the team will likely consist of just the surgeon and assistant.

• If changing positions with another scrubbed team member, turn back-to-back or face-to-face while maintaining distance from each other, unsterile areas, and the sterile field.
• Maintain a minimum of 12 inches between unscrubbed team members and the sterile field and scrubbed team members.³
• Around a sterile field, keep conversations to a minimum to avoid dispersion of droplets of saliva to the sterile field.
• Keep the door to the surgical space closed as much as possible to decrease the number of particulates entering the room.

Sterile tray

• Drapes should only be opened by those who have properly cleaned, disinfected, and protected any area of their body that will come in contact with the drape.
• The outer two inches of a tray drape are not considered sterile due to having to handle the drape to place it on the stand.
• Lay out instruments on a sterile drape, likely on a Mayo stand. Each instrument should be inside a sterilization pouch or pack with an indicator showing it has passed appropriate sterilization procedures prior to placement on the tray.
• When dropping instruments onto a tray from a pull pouch (commonly referred to as the “drop technique”), pull back the flaps without touching the inside of the package or allowing the contents to slide over the unsterile edges of the package.
• Keep hands and arms above waist level at all times.
• Once established, the sterile tray should not be left unattended until the procedure has been completed. If there is an unanticipated delay or during periods of increased activity, such as when the patient is being brought into the room, the sterile field not in immediate use may be covered with a sterile drape.³
• Providers and assisting personnel should be familiar with the mutually-agreed neutral zone or hands-free technique for passing sharps, blades, and needles.

Good team communication

Be aware that competing responsibilities, noise and distractions, and reluctance of team members to speak up regarding a potential patient safety issue are all barriers to effective communication in the perioperative setting.⁴ Communication breakdowns among personnel can lead to medical errors and harm to both personnel and patients.

• To verify the correct patient, procedure, site, and side of the body, perform a briefing to share the surgical plan, (referred to as a “time out” in the OR), prior to every procedure.
• Before and after each procedure, take an inventory of all sharps used to ensure that they are accounted for and disposed of properly. Ideally, this inventory is displayed on a whiteboard within the room and maintained by the circulator or assistant. Blades, hypodermic needles, and suture needles should all be accounted for.

Prevent contamination

In conclusion, the following points should be paramount whenever a procedure is being performed in the office:

• Only sterile items are used within the sterile field.
• Sterile personnel are gowned and gloved.
• Tables are only sterile at table level.
• Sterile personnel touch only sterile items while unsterile personnel touch only unsterile items.
• Unsterile persons avoid reaching over sterile field and sterile persons avoid touching or leaning over an unsterile area.
• Edges of anything that encloses sterile contents are considered unsterile.
• Sterile field is set-up just before a surgical procedure.
• Sterile areas are continuously kept in view.
• Sterile persons should keep well within sterile area. OP

REFERENCES:

1. Standard Precautions, Transmission Based, Surgical Asepsis: NCLEX-RN https://www.registerednursing.org/nclex/standard-precautions-transmission-based-surgical-asepsis/ . Accessed 2/13/2019
2. New AORN Recommendations Focus on Infection Prevention, Patient Safety [fee required]. https://www.ormanager.com/wp-content/uploads/2013/06/ORM_0613_20_RP.pdf . Accessed 2/13/2019
3. AORN. Sterile Technique: Key Concepts and Practices [PDF]. Woodbury, CT: Cine-Med; 2013. https://cine-med.com/index.php?nav¼aorn&cat¼AsepticþPractices&id¼1964 [fee required]. Accessed January 2/13/2019
4. Implementing AORN Recommended Practices for Sterile Technique. Lynne Kennedy PhD, MSN, RN, CHPN, CNOR, CLNC First published: 25 June 2013 https://doi.org/10.1016/j.aorn.2013.05.009 [Fee Required]. Accessed 2/14/2019

Lynn Girdlestone, COA, OSA, OSC, is a Certified Ophthalmic Assistant at The Everett Clinic in Everett, WA, and a Vision Director for the Seattle/King County Clinic in Seattle. She has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.