Asepsis and anxiety!

[Lillian89]

Hi all.

Thank you for taking the time to read this, I could really do with some help/advice.

I work in interventional radiology where most of our procedure are done under sterile conditions. I am quite new to this environment working in it for about 6-8 months intermittently. I am absolutely ashamed to admit that while I was training I opened a sterile item and as the scrub nurse took it it touched my thumb, I froze like a rabbit in the headlights and by the time I had formed the words to speak up they had already used this item so it was too late.

I went home feeling like a horrible person, that I had put a patient at risk and how I shouldn't be allowed to do this job. Now I feel anxious all of the time around sterile fields, I over analyse everything and seem to be constantly pointing out possible breaks (I am pretty sure no-one is as paranoid as me about sterility) I seem to be the only one that sees things, or at least the only one who worries about them.

I feel guilty all of the time, run through things in my head over and over again, beating my self up over tiny little situations where I feel I could have done better/should have spoken up and worry I haven't learnt from my mistakes.

I spoke to my boss and our infection control nurse who just said "if you're not sure if something has been de sterilised just say" but this doesn't help me as I daily worry about things being contaminated and feel it's all my responsibility to monitor everything!

For example today the xray equipment bumped into a sterile lead shield (I didn't see it, just heard it) I then saw the doctor moving the lead shield, I panicked incase the part he was touching had been contaminated but I was the other side of the room, didn't see where it touched and assumed he had ensured where he touched was fine but now in hindsight worry was it my responsibility to say something? Have I put this patient in danger also?

Any words of wisdom? Am I a terrible person? Do I have lower standards than everyone else?

Wow that was long! Sorry guys xx

[acerbia]

For interventional radiology, what types of procedures do you do exactly? Did you go through a "periop 101" lecture/clinical type program before you started on this unit? I'm afraid I'm not too familiar with the types of procedures you do, as I am relatively new to the OR myself. However, I can tell you that we have very strict rules for maintaining sterile technique in the OR, but each unit that does invasive procedures does things a little differently. There are a lot of procedures where things need to be super strict, but not always. I'll get into that in a minute, but let me address your specific concerns first.

When opening a sterile item for the scrub to either take or add to the field, definitely say something as soon as you notice a break in technique. It's OK that you didn't say something this time; Sometimes no one is around to catch these breaks and they go unreported, especially when you're the only one watching. ("You don't know what you don't know", or so they say.) Part of the scrub's responsibility is to make sure they don't break technique either, so it was quite literally out of your hands at that point. You cannot blame yourself for what someone else does or doesn't do.

The doctor you mentioned that might have contaminated something when he moved the lead shield. Was he scrubbed in? Are you sure the screen was sterile (e.g., came wrapped in a sterile pack of some kind with a sterile indicator strip)? Without getting into too much detail, remember that only sterile to sterile is allowed to touch (and non-sterile to non-sterile). Sometimes items are designed to have sterile protection on only certain areas, but it depends on the equipment and its use.

In some procedures, strict sterile technique is not always necessary. For example, the other day I did some cysto cases, which were mostly kidney stone removals and stent placements. We prepare the sterile field just like for surgeries, but we don't need to wear masks, eye protection, or shoe covers. In surgery you do, especially if you are scrubbed in. In surgery, the C-Arm has its own sterile drape that must be applied prior to it being introduced to the field. In cysto, there is no sterile drape for the x-ray device. As another example, you have to wear sterile gloves and maintain sterility during a foley insert or trach care, but you don't need to wear a mask or gown for that either. So it really does depend.

A good rule of thumb is "when in doubt, throw it out". If you think you might have possibly contaminated something, do not use it. Just get a new one, whatever it may be. Don't be afraid to speak up! If someone gets mad at you for doing your job, don't take it personally. Surgeons especially are great at yelling at people, but 9 times out of 10 they do it because of stress and pressure, not because you're so absurdly dense! Pointing out a break in technique can be very intimidating as the new guy, and I have had moments when I was afraid too, and beat myself up just like you did. Comfort comes with time and practice. Remember that the patient's safety and care comes first, over your own feelings of pride. I don't like being yelled at either, but YOU are the advocate for your patient when they are under anesthesia. The patient is relying on you to speak up for them, since they cannot. This is an important role that is your number one priority, always.

The absolute best resource you have for this type of thing is your hospital's policy database and the Association of PeriOperative Registered Nurses (AORN). The AORN has absolutely everything in great detail listed for you, which are evidence-based recommendations for best practices in surgery. If this is the first time you're hearing about the AORN, it is likely that you are not being trained as a circulating nurse in the OR just yet. Someone in the surgical services department will be able to give you a better answer than the one you received though, so maybe you just didn't talk to the right person. The OR front desk at my hospital has a copy of the AORN's standards. It's a big ol' book that anyone can reference at any time, no questions asked. Find out where yours is.

I hope I helped somewhat and didn't confuse the heck out of you lol If you have any more questions, feel free to ask. This is good for me too so I can check my own knowledge

[Lillian89]

Thank you so much for your reply, I feel less alone and guilty already! It helps to know you've also felt guilty about not speaking up and ended up beating yourself up too.

In IR we do procedures such as angioplasty, PTC's, billiary drains, IVC filters, embolizations, TIPSS, biopsies & more. So a huge variety!

Thank you for your reference of the AORN standards, I will read through it again. I seem to feel competent to speak up without thinking when I am sure of a break - like yesterday I saw a doctor (not scrubbed) touch a sterile cover and I immediately changed it despite him being adamant he had not touched it. The problems arise when I'm not sure or I'm not sure if it's my place to say where I struggle. Especially if I think the other person must have seen? I think if I spoke up every time I wasn't sure I would be questioning things every half hour.

I'm not sure if it's my rational side assesses the situation and decides I don't need to speak up/it's ok & then is it just my anxiety and the what if's that start after that distress me?

Should I be trusting my initial reactions? I just have lost all self confidence and self trust since the couple of times I didn't speak up when I should have & put those patients at risk and I worry I will again