We're learning more all the time about barrier protection, but the most important thing we know and evidence-based research tells us the same thing is something we've known for a long time: Barriers only work as well as the people following the protocols involved. That foundation, the "surgical conscience" that compels us to always to the right things, even if no one is watching, is at the heart of all we do. But recent research is also providing some new insights into why barrier protection matters.
1. Should we cover surgical setups?
In at least one case, we've come full circle. In the 1970s, it was considered acceptable to cover surgical setups, as long as the covering was done correctly and wasn't left in place for a prolonged period of time. Some years later, AORN recommended against covering setups under any circumstances. The rationale: Air currents are created when covers are removed, which threatens the sterile field. Of course, that meant that when cases were cancelled or bumped, everything had to be set up again and this led to considerable waste.
But new AORN standards reflect recent research showing that it's actually safer to cover under certain circumstances if, for example, there's going to be a lot of activity in the room as the patient arrives. After all, the more people coming in and out of the room, the more likely it is that contaminants from the floor and elsewhere are going to become airborne and fall on the instruments.
Studies have found that covering for up to 4 hours can be safe, as long as the covers are both put on and taken off correctly. Since the edges of the table serve as a demarcation line between sterile and non-sterile, covers must be peeled back in a way that doesn't raise the unsterile part of the cover the part that hangs below the table above the sterile field.
Of course, this is a significant change for perioperative nurses who've been taught over the last 20 years not to cover, but it's a great option. The key: Make sure the procedure is standardized and that ongoing staff education includes a demonstration on how to place and remove covers correctly.
2. Should we double-glove?
Also emerging as a recommended practice is double-gloving. Calling on evidence gained from recent studies, AORN provides 4 good reasons to do it. In short, double-gloving:
- reduces the risks related to glove perforation, including small perforations that may not be obvious to the naked eye;
- reduces the risk of infecting the patient;
- provides a better barrier against bloodborne pathogens; and
- minimizes blood exposure in the event of needlesticks or sharps-related injury.
Studies have also shown that using indicator systems with double-gloving provides the best protection and allows the timeliest identification of perforations. One of the best indicators is wearing gloves of different colors, ideally with a sharp contrast that makes it easier to see small perforations. It may take some getting used to, but double-gloving provides extra protection for the staff and the patient.
Incidentally, one way to help ensure that gloves are sterile when you open them on your sterile field is to be sure they don't slide over the edge of the wrapper. It's a detail that's easy to overlook, but sliding them against the outside of the packaging can transfer bacteria.
3. What's new with surgical attire?
In June 2007, the Healthcare Infection Control Practices Advisory Committee recommended for the first time that spinal procedure operators wear surgical masks to prevent infections associated with such procedures as lumbar punctures. Some hospitals post checklists that remind practitioners to don masks when inserting central venous and peripheral catheters. These practices have significantly decreased infections.
Companies are well aware of the growing body of evidence related to barrier protection and are responding accordingly. Different types of procedures may require different types of gowns and drapes. There are now color-coded gowns with different degrees of thickness and durability, which you can select based on the type of surgery. For example, a minor operation does not require the thickness that a multiple trauma would require.
As time goes on, the goal will be to balance the dual needs of keeping your patients and staff safe, while also being economically responsible. Those considerations will help you make the right choices.
Barrier's bottom line
There are several variables and several things that can go wrong in an OR setting. If a patient gets an infection, chances are you're not going to be able to trace the source. Was it because a staff member's hair was hanging out of her cap, or because a team member didn't scrub properly? Was it a hole in a glove or a hole in an instrument wrapper that went unnoticed?
The point is that every team member must practice excellent aseptic technique every day, every time. Not only should you have your hair tucked in with no earrings hanging out, you should gown and glove appropriately, and set up using proper aseptic technique. The environment must be clean. The instruments need to be properly processed and stored. All of these factors together provide protection and add up to a safer environment for your patients.
Reinforcing the basics of barrier protection on an ongoing basis through staff education and in-services is vital. AORN standards are a great resource and striving to meet them is a worthy goal. Vendors, too, have much to contribute to the process, as they offer research updates and in-services.
Above all, though, surgical conscience caring enough to always do what we know is right serves as the most important barrier of all.