If you’ve ever stepped foot in an OR, you’ve probably heard ‘don’t touch anything blue’. Meaning, the back table drape, mayo stand cover, and any other table drape or patient drape is usually always blue colored. Anything ON any of the tables or drapes is considered sterile, so it’s best to keep away from the ‘blue’. But, getting too close to the sterile field is NOT the only way contamination can happen. There are a variety of ways contamination can happen inside the OR, and it is nothing to take lightly. Why? Because contaminations are going to greatly increase the risk of your patient contracting a surgical site infection (SSI). I’m going to go through some of the contaminations I’ve came across, some contaminations waiting to happen, but also some non-sterile items that are a source of infection.

Contamination | Wet Trays

A wet tray or a ‘wet pack’ can happen many ways, but it’s an indicator that something within the sterilization process did not go right or it was handled inappropriately. Essentially, if there is any moisture on the inside of your casket, or the blue wrap, it is considered contaminated. Send it back to SPD to reprocess and hope it isn’t a ‘one-of-a-kind’ item.
Exception: If you are using a OneTray, or a similar closed system tray, you will almost always see the lining of the tray wet. These were a lifesaver at a previous hospital I worked at. Read about them here. Plus, those case carts looks awesome!

Contamination | Improper Tray Assembly

You would think this would be hard to miss, right? Unfortunately, if you don’t inspect your tray’s integrity prior to opening you will likely miss this. When you open the lid on this tray as is, you really don’t notice a difference. Which was also the case in SPD when assembling these specific caskets. They were placed in the sterilizer without a proper inspection and placed on the shelf for use. Here’s another case of send it back to SPD for reprocessing and grab another off the shelf.

Contamination | Integrity of Peel Pack Compromised

During a procedure a curved metz was dropped, so I ran to SPD and retrieved another. This was the first one I grabbed, and I immediately noticed an issue, so I grabbed another while I was back there and opened it to the field. If you don’t notice what’s wrong in this picture, the point of the scissors have punctured the peel pack.
Usually, these will have a special protective tip on them to allow for proper sterilization but also to prevent this from happening.

Contamination | Integrity of Wrapped Item

This hole in the blue wrap is pretty obvious. Do you see two holes? There is also one in the tape that is a little harder to see. After opening, blue wraps should always be held up to look through and inspect for holes. If your wrap is blue on one side and pink on the other, hold the blue side away from you and look through the pink— holes will be more noticeable!
Side note: SPD always gets the blame for holes in wrappers, but they shouldn’t. These holes can happen anytime they are handled. The CST or RN removing it from the case cart, if it’s set on something it shouldn’t be on. These holes are usually a ‘handling’ issue versus a ‘sterilizing issue’.

INTRAOPERATIVE TIP

Always inspect the integrity of everything you open on first touch. Save the time having to run and grab another in the event of contamination. Some things can be caught prior to opening, so just save you, your team, your doctor, and the patient some time and be proactive.

INTRAOPERATIVE TIP

Contamination | Failure of Chemical Integrator

This is not a common source of contamination, but it is certainly something to keep an eye out for. You should always be inspecting every integrator that comes in your tray to ensure they have turned colors indicating the sterilization process was complete. In this case, there was a bad batch (or six..) of the 3M indicators and they were leaking the material that is usually housed in the strip itself. You can see the ‘normal’ turned indicator in the picture on the right in the top right corner. Each tray this happened in was considered contaminated because whatever that material is ended up all over the instruments. Looking back on this string of contaminations, I wonder if the strips were placed in the tray first and then instruments laid on top (left pic) which caused the malfunction? I'm not an SPD expert, but I believe that the strips are supposed to be placed in a place where they are untouched. If you’re an SPD expert, please let me know your thoughts!

Contamination | Unidentified (non-flying) Object

This was a sticky drape opened to the field and when the paper strip covering the sticky was removed, the scrub found some ‘fuzz’ looking stuff. She threw it off the field and asked the circulator for another. Something I was taught in the early days of the surgical technology program.. “when in doubt, throw it out”. If you ever question the integrity of an item— throw it out!

“When in doubt, throw it out”

— unknown

Contaminations Waiting to Happen

These next pictures aren’t necessarily ‘contaminations’, but they are ways a contamination can happen, non-sterile items that can harbor bacteria leading to a contamination, etc. I never use to notice these things until I was a manager for an OR for a while, and now these things stick out like a sore thumb! Most of these are all Joint Commission ‘no-no’s’ — and for a valid reason!

Source of Contamination | No Point of Use Cleaning

Instruments should **never** be sent to SPD looking like this. There is no excuse. Gross bioburden should be removed throughout the procedure and the CST needs to take a few minutes to remove as much as possible before sending to SPD. Get a basin of water (not saline— it causes pitting) and do your best. SPD will appreciate your effort, and it will decrease the chances of bioburden being stuck or dried in places that aren’t easily accessible.

Source of Contamination | Dirty Equipment

It may be hard to see, but there are a few specs of blood on this overhead light. This was found between two total joint procedures, luckily before the patient entered the room. In the next photo, of the EKG cord, you can see it just was completely missed. Unfortunately, these things happen, always be on the lookout for missed spots and take care of them. Always notify the team who turned the room over, not to point your finger at them, but so they are aware. They may not even know it happened, they may need more education, or they may have just being lazy. You might get an eye-roll, but it’s about the patient.

Source of Contamination | Improper Instrumentation Storage

In the first picture, wrapped items are stacked higher than 3 item high. This is a ‘no-no’. I’m not sure what the science is behind it, but I’m sure it has something to do with the weight of the trays (should be less than 25 pounds, right??). Removing the items off this shelf would cause shearing of the wraps which could potentially lead to a hole. The second picture is tricky. We kept finding the da Vinci scopes with holes in the same spot of the wrapper. It wasn’t until one of the SPD techs came and inspected the shelf because he couldn’t wrap his head around what was happening (his name was also on the last 3 that were opened and had holes, so he wanted to find the real culprit). See that bracket on the shelf above the scopes? Yep, when they were pulled off the shelf they were hitting that bracket. He removed that bracket and the issue was gone. Sometimes a contamination comes from a storage issue— not a sterilization issue. AAMI and AORN both have plenty of storage guildlines for instrumentation and sterile supplies.

Source of Contamination | Tape

The only time time should be used in the OR is on a patients eyes, to secure their ET tube, and for their dressing. There are a few other instances, but generally speaking just keep it away! The plus ox cord was wrapped in foam tape, why you ask? Oh, exposed wires? Absolutely not. First, if a wire is exposed it should not be used for patient care remove it immediately. Second, do not fix it with tape! Same with the next photo, someone had (hopefully) unintentionally broken the glove box holder and slapped some tape on it. Take off the tape and put in a service request to replace it - no tape! Tape is obviously sticky and just holds onto all the bacteria.

Source of Contamination | People

This is a lovely set of instruments a surgeon took to the floor to help a patient… then just dropped it off at the reception desk. Not the SPD desk, the main OR! He kindly removed the scalpel (surprisingly). Don’t be this guy. Take it directly to SPD.

The point of my post… contamination can happen anywhere, by anyone, at anytime. Always keep an eye out, always protect your patient, always do what’s best.