Treating and maintaining a sterile field with drapes and gowns is one of the cornerstones of infection prevention. Because of its fragility, the sterile field is often on the minds of OR nurses and techs. According to AORN guidelines, scrubbed surgical team members should work within a sterile field to prevent surgical site infections. Gowns and drapes are considered part of the sterile field. For that reason, it's important to understand the basics of draping and gowning.

Establishing the barrier
Draping is used to establish the sterile surgical field around the site of the incision. The goal is to isolate the surgical site from exogenous microorganisms as well as the patient's own endogenous flora, which could infect the site. This is especially important in procedures involving aseptic areas of the body, such as the eyes and most subcutaneous tissue.

Drapes also serve to create a sterile barrier between the patient's skin, which is not sterile, and the sterile area. Drapes not only expose the surgical incision area, but also create a sterile work space for the surgical team.

Over the years, drapes have evolved from standard muslin sheets to specialized products adapted for specific procedures. Today they are made from cotton, cotton-polyester blends, microfilaments and impermeable disposable materials. For increased barrier protection, textile fabric is coated with fluid repellent or can be sandwiched between impervious membranes.

As outpatient surgery becomes less invasive, more water is often required to irrigate the incision. To deal with more fluid in the OR, drape manufacturers have produced coated, fluid-resistant drapes designed to create a barrier and help manage fluid waste. Some drapes have a pouch for capturing and directing fluid and can be attached to a suction device. Other drapes are designed to absorb fluid.

When creating the sterile field in the OR, begin from the periphery of the room and work inward. A scrubbed clinical team member should place drapes wherever needed. Maintain sterility from the time the drape packs are opened until the patient leaves the OR. Drapes shouldn't be shaken when removed from the sterile pack; shaking drapes sends lint into the air and increases the risk of the drape touching the ground, which would contaminate the fabric. An unscrubbed member of the OR team should remove improperly placed or contaminated drapes.

Carefully unfolding and positioning the drape allows the sterile field to be established, thus promoting patient and staff safety. Place drapes on the surfaces, equipment and instrument trays within the designated sterile field. When placing drapes on the patient, begin from the surgical site and drape outward. Before placing drapes over a patient, make sure that the skin prep solution has dried, because a wet drape can wick harmful microorganisms across the barrier.

Allowing the skin prep time to dry before applying drapes on a patient is important in order to create the sterile field and protect the patient. Many of the current skin preps also offer a "tacky" feel once dried, which help hold the drapes in place.

Surgical scrubs should never be considered sterile. For that reason, every member of the surgical team should wear a protective gown inside the surgical field to protect the patient and themselves from potential infection.

In the last two decades, more attention has been given to gowns as a means of protecting healthcare workers from infection related to blood or body fluid exposures. OSHA's 1991 Bloodborne Pathogens Standard requires a gown or apron to be worn whenever exposure is possible. The standard also requires employers to supply necessary barrier protection products for procedures that may expose a worker to blood or body fluids.

Short procedures with little chance of exposure require only minimum barrier protection with respect to gowns. OSHA's standard requires that employees choose the right level of protection for the job, based on anticipated exposure to blood or body fluids.

Gown design is similar to drapes in that they are made from cotton, cotton-polyester blends, microfilaments and impermeable disposable materials. For increased barrier protection, textile fabric is coated with fluid repellent or can be sandwiched between an impervious membrane.

Donning gowns correctly is as critical to the sterile field as correctly placing the drapes. Non-sterile team members should carefully observe those donning gowns for potential breaks in sterility.

Procedure-specific
AORN, in its Recommended Practices for Selection and Use of Surgical Gowns and Drapes, calls for them to be:

• Resistant to blood and other body fluids. Drapes must protect patients, surgeons and staff from contamination resulting from fluid strikethrough. If a drape doesn't have an impermeable surface, microorganisms can wick through the drape — especially cotton drapes — creating an avenue for exposure to blood or other body fluids.
• Durable. Products should be puncture- and tear-resistant to reduce the risk of microorganisms passing through the barrier. Fabrics should be non-linting or low-lint, because bacteria can attach to lint in the air and settle on the surgical site, causing infection.
• Suitable for sterilization. Reusable textiles must withstand steam and ethylene oxide sterilization. Since repeated washing and sterilizing diminishes a fabric's protective barrier quality, it's important to follow the manufacturer's instructions for reprocessing and track how many times the item has been reprocessed.
• Fire resistant. Cautery devices, hot lights and lasers increase the risk of fire in the OR. Drapes and gowns must be flame resistant.
• Comfortable. Although comfort is subjective, gowns and drapes should let surgical team members and patients maintain desired body temperature. Likewise, a gown should not restrict the movements of the clinical team.
• Priced appropriately. Don't make your purchasing decision based solely on price. Use cost-benefit analysis to choose these supplies.

There is little data linking the type of gown or drape to more or less surgical site infections, according to the CDC's Guidelines for Environmental Infection Control in Health-Care Facilities, published in 2003. In the guidelines, the CDC doesn't state a preference for one type of product over the other. More important, according to the guidelines, is the product's barrier protection.

Level of protection
The compatibility and effectiveness of gowns and drapes must be registered with the FDA, which recognizes the barrier resistance levels used by the Association for the Advancement of Medical Instrumentation. Drape and gown products should be classified at one of the following four levels:

• Level 1. For procedures with minimal fluid, spray and splash, and little pressure on the gown or drape, such as ENT and ophthalmic. These products resist liquid penetration but aren't impermeable.
• Level 2. For procedures with a low fluid volume, spray and splash, and little pressure on the gown or drape, such as tonsillectomies, some orthopedic procedures and open hernia repair. These products resist liquid strikethrough and liquid pressure.
• Level 3. For procedures with moderate fluid volume, spray, splash and pressure on the gown or drape, such as mastectomies and arthroscopy. These products resist strikethrough and higher pressure.
• Level 4. For procedures with high fluid volume, spray, splash and pressure on the gown or drape. This level of protection is also used when the surgeon's hands will be placed in a body cavity, such as during cardiovascular and major orthopedic surgeries. These products are impermeable to fluids.

Choosing the right gown or drape for the job is important. If the anticipated exposure to blood and body fluids is "gray," err on the side of caution by using gowns and drapes with a higher protection level than you might need.