Opening Sterile Surgical Packs
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Surgical site infection (SSI) poses a significant risk to patients undergoing surgery. The prevalence of SSI is influenced by various factors.1, 2 Within an ideal perioperative environment, exclusively sterile surgical instruments are employed. Care should be taken to thoroughly explore all methods of maintaining a contamination-free operating room (OR) environment. The proper opening of sterile surgical instrument packs has critical importance in maintaining aseptic conditions in the OR. This video demonstrates all the nuances of this process, emphasizing the importance of package integrity checks and adherence to strict protocols for sterile surgical attire.
The method of packaging, whether in rigid containers or paper, significantly influences the approach to opening and ensuring the sterility of the instruments. One key element in determining the sterilization status of a surgical package is the external chemical indicator tape.3 Various sterilization methods, such as steam sterilization, ethylene oxide (EtO) sterilization cycle, or Sterrad system, employ distinct chemical indicators, represented by color-changing inks. However, the presence of indicators alone does not guarantee sterility. The black lines on the tape only indicate the exposure to steam, but do not specify the duration or temperature used during the procedure.
The external package undergoes a thorough examination before opening. This inspection involves a check for perforations, tears, and labels. As part of the sterilization process, the packages should be labeled before being sterilized. Most facilities use a felt-tip, quick-dry marker for labeling, ensuring the information is clear and durable.4
All the necessary information, including autoclave details, load number, and the sterilization date, can be recorded on the chemical indicator tape or on the plastic portion of the peel packs. This information is essential for tracking sterilization parameters. Many institutions use a label gun to discharge printed labels, providing an efficient and consistent method of labeling. These labels are attached to the package, offering additional information that is often provided and easily accessible upon inspection. This comprehensive approach to labeling and tracking ensures the highest standards of safety and quality control in the sterilization process.4
In cases where paper wrappers may be prone to damage, a secondary wrapping in linen is employed. The contents of a pack can be accessed by either opening a single layer or by opening both layers. If only the first layer is opened, the second layer will be opened by sterile gowned and gloved personnel. One should never reach over a pack. Instead, move around to prevent contamination. Before initiating the process of opening, personnel should wear sterile masks and sterile clothing. The orientation of the package, typically folded in an envelope fold, is crucial. The pack is positioned as close to the surgical technologist as possible before opening. This reduces the risk of contamination when the technologist leans over the Mayo stand to reach the pack. It also helps to cover the front corners of the stand. Then the pack is opened by unfolding the outermost paper wrapper tip away from oneself, followed by unfolding of the two inside tips to the sides (in a side-to-side motion), and is concluded by moving the innermost tip back toward oneself. It is crucial to acknowledge the presence of an imaginary 1-inch border that runs along the perimeter of the table. This border is considered non-sterile and should be avoided when placing items onto the field. Anything below table height is likewise considered to be non-sterile and should be avoided.5
The inclusion of safety measures, such as the "time out" cards, ensures patient safety and enhances the performance of the surgical team.6, 7 This practice serves as a reminder to the surgical team to conduct essential safety checks before initiation of incision, emphasizing the verification of patient identity, procedure details, and the presence of required materials.
To summarize, the process of opening sterile surgical instrument packs involves a comprehensive understanding of chemical indicators, package integrity checks, and adherence to strict protocols. By focusing on these key elements, surgical teams can maintain aseptic conditions and patient safety during surgical procedures.
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Citations
- Alfonso-Sanchez JL, Martinez IM, Martín-Moreno JM, González RS, Botía F. Analyzing the risk factors influencing surgical site infections: the site of environmental factors. Can J Surg. 2017;60(3). doi:10.1503/cjs.017916.
- Papadopoulos A, MacHairas N, Tsourouflis G, et al. Risk factors for surgical site infections in patients undergoing emergency surgery: a single-center experience. In Vivo (Brooklyn). 2021;35(6). doi:10.21873/invivo.12660.
- Centers for Disease Control and Prevention. Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008; Miscellaneous Inactivating Agents. CDC website. 2013;(May).
- Tennant K, Rivers CL. Sterile Technique. 2022 Sep 19. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan–.
- Frey KB Association of Surgical Technologists. Surgical Technology for the Surgical Technologist : A Positive Care Approach. 5th ed. Cengage Learning; 2018.
- Freundlich RE, Bulka CM, Wanderer JP, Rothman BS, Sandberg WS, Ehrenfeld JM. Prospective investigation of the operating room time-out process. Anesth Analg. 2020;130(3). doi:10.1213/ANE.0000000000004126.
- Papadakis M, Meiwandi A, Grzybowski A. The WHO safer surgery checklist time out procedure revisited: strategies to optimize compliance and safety. Int J Surg. 2019;69. doi:10.1016/j.ijsu.2019.07.006.
Cite this article
Buckner B. Opening sterile surgical packs. J Med Insight. 2024;2024(300.4). doi:10.24296/jomi/300.4.
Procedure Outline
Transcription
Opening sterile surgical instrument packsdepends on how the pack is packaged.In most operating rooms, we will package theseeither in rigid containers or in paper.It's very common to use paper.Paper has to be used either two-ply,or you wrap it in two layers.
When we look at a surgical package,the way that we tell whether or not it's been sterilizedis by the external chemical indicator tape.Now, each method of sterilization, whether it be steam,EtO gas, or Sterradhas its own chemical indicators.The only thing a chemical indicator isis a color change ink. It changes colorwhen it gets to the proper parameters.
What we have here is a steamed sterilized package.We see the black lines appear on the tape.Although the black lines are an indicator,they don't guarantee sterility.What they tell usis that this package was exposed to steam,but it doesn't tell us for how long or at what temperature,so it's not the only method that we will use.
We look at the outside package, and like all packages,we want to check its integrity.We look for holes, tears, and watermarks.We look to see that our package has changedfrom the white lines of the tape to black.Then we look at the sticker that's on here.The sticker usually holds three key pieces of information:the autoclave, the load number, and the date.
Before we open up a sterile supply,we need to make sure that we're ready to do so.I would need to be in sterile attire with a mask on.Anytime that we open a sterile equipmentwe need to be wearing a mask.
This package is folded in the envelope fold.We want to orient the package onto the Mayo stand.We want to bring it as close to us as we can,and we want to find that courtesy tab.The courtesy tab tells us in which directionwe're going to open, and in this package,we're going to open away from us, side-to-side,and then back towards us.
The first thing we want to do is confirmthat our chemical indicator tape has changed,and then we want to break the tape right on the seam.I do not want to remove the entire tapebecause that could cause a hole in my wrapper.
So I'm going to tear the tape.Now my courtesy tab -whenever I open this package, I can always touchthe 1-inch outside perimeter. I don't want to reachover the sterile contents, so as I do thisI want to open away from me -pull to tear here, and once again,we have our courtesy tab.I'm going to open side-to-side, and then the last oneis going to open back towards me.I can touch the 1-inch outside perimeter at all times.
Because the paper wrappers often get holes in them,this one is secondarily wrapped in linen.The same technique still applies. Here's my courtesy tab.I'm going to open away from myself, side-to-side,and then the last one, I'm going to pull back some,and I will bring that down.
Now, everything on the top surface of the Mayo standis sterile except for that 1-inch perimeterand anything that falls below table level.
Looking at the package,I can see that there's a time out card,I can see the internal chemical indicator has also turned,and my count sheet to count this set is within the package.
So the set we just open contains a yellow cardwith the words "time out" on it.This is a safety precaution that we've developed down here,and what it does is it prevents the surgical teamfrom forgetting the timeout. We place the cardon the Mayo stand, and before we would ever hand a scalpelto a surgeon, we ensure that the time out has been done.It's just a reminder, something that we do to make surethat we have the right patient, procedure, implants,the right X rays - everything is in the room -the right side, and it's just a reminder to us.Some things in surgery are very regional.This is just something that we do.