Abstract
Surgical wound infections (SWIs) present a major challenge in postoperative care. Covering prepared sterile instrument tables (PSITs) during both idle (inactive) and active surgical phases can significantly reduce contamination by airborne bacteria-carrying particles (ABCPs) that may reach surgical wounds. This narrative review aimed to investigate four key objectives: (1) exploring the role of ABCPs in contaminating PSITs and contributing to SWIs; (2) evaluating the effectiveness of table coverage by operating room nurses (ORNs) in mitigating ABCP during both idle and active surgical periods; (3) assessing the duration of sterility maintained by covered tables and the efficacy of different covering techniques; and (4) recommending optimal covering methods while emphasizing the critical role of ORNs in standardizing and implementing these practices to enhance infection prevention protocols.
A comprehensive search was conducted in MEDLINE, CINAHL, Cochrane, Embase, PubMed, Scopus, Web of Science, and Google Scholar, with a focus on articles examining the role of ORNs in covering sterile instrument tables, preventing airborne contamination, and reducing the incidence of SWIs. Grey literature from the Association of perioperative Registered Nurses (AORN) and the Association of Surgical Technologists (AST) was also reviewed. The literature consistently shows that ORNs play a key role in reducing airborne contamination by covering PSITs during both idle and active phases. The single-drape cover method was effective for up to 60 min, while the double-layer covering provided longer protection, particularly useful during patient transfers in the operating room (OR). Covered PSITs demonstrated minimal contamination even after 24 h in controlled environments, supporting evidence that PSIT covering effectively reduces ABCP contamination and maintains sterility for up to 60 min. This is especially important in complex surgeries, where sterility is crucial for patient safety. Moreover, covering PSITs during both idle and active periods significantly lowers contamination levels compared to uncovered PSITs.
1
Introduction
Surgical wound infections (SWIs) represent serious postoperative complications that significantly increase patient morbidity and mortality, extend treatment duration, and increase healthcare expenditures. In low- and middle-income countries, SWIs affect up to one-third of surgical patients, posing a widespread surgical safety challenge. The World Health Organization (WHO) ranks SWIs as the second most common healthcare-associated infection in low- and middle-income countries (LMICs), with significant financial burdens in both LMICs and high-income countries (HICs). ,
A review of studies from 15 LMICs and 16 European countries found that the additional costs of SWIs range from $174 to $29,610 in LMICs and from $21 to $34,000 in European countries.
SWIs may result from multiple sources, such as the patient’s own microbiota and airborne particles (APs). While endogenous microorganisms contribute to infections, airborne contamination plays a predominant role in clean surgeries, particularly those involving implants (e.g., orthopedic and neurosurgical surgeries). , For instance, in clean procedures like joint replacements, the patient’s skin microbiota accounts for only 2 % of infections, while airborne contamination contributes to 98 %. Approximately 30 % of cases result from direct ABCP deposition on wounds, while 70 % involve indirect contamination via surgical instruments or personnel.
ABCP contamination is especially critical in clean surgeries, where maintaining bacterial loads below 180 Colony Forming Units per cubic meter (CFU/m³) in standard operating rooms (ORs) , and under 10 CFU/m³ in ultra-clean ORs is necessary to mitigate infection risks. However, many LMICs lack advanced ventilation systems and instead rely on suboptimal natural airflow mechanisms. Studies from Iran (means 284–693 CFU/m³) and Ghana (mean 328 CFU/m) reveal ABCP loads far exceeding recommended thresholds, positioning hospital air as a major SWI source. Genetic matches between ABCP and SWI pathogens further confirm airborne transmission risks. Despite stringent skin antisepsis protocols for managing endogenous flora, effective ABCP contamination control remains an overlooked yet critical factor in exogenous infection prevention. ,
Optimizing OR ventilation is crucial in controlling ABCP contamination, yet multiple factors compromise airflow efficiency. , Frequent door openings (DOs), staff movement, OR size, and non-standardized ventilation protocols contribute to increased airborne bacterial counts. , High-efficiency particulate air (HEPA) filters and laminar airflow systems are widely used in HICs to maintain ultra-clean environments, but these technologies are underutilized in LMICs due to cost and infrastructure limitations. , , Surgical team behavior, including unnecessary talking, abrupt movements, and improper use of surgical attire, further exacerbates contamination risks. Addressing these challenges through targeted interventions, such as stricter movement protocols and improved ventilation system maintenance, can significantly reduce ABCP contamination and SWI rates.
Operating room nurses (ORNs) are central to infection prevention by maintaining sterile fields, managing instruments, and enforcing aseptic protocols. , Despite these efforts, ABCPs contribute to 80–90 % of pathogens found in clean surgical wounds. OR ventilation is key in reducing contamination, but DOs, personnel movement, OR size, and clothing compromise effectiveness. , Addressing SWIs is a top priority for ORNs and healthcare professionals, given the significant impact on patient safety and healthcare costs. ,
Evidence-based strategies can prevent up to 50 % of SWIs. One such measure, recommended by the Association of PeriOperative Registered Nurses (AORN), is covering prepared sterile instrument tables (PSITs) during idle periods to protect against ABCP contamination. This cost-effective technique is particularly relevant during preoperative delays, such as patient positioning or antisepsis. , However, ORNs often neglect this practice due to time constraints, lack of awareness, and doubts about effectiveness.
AORN guidelines emphasize minimizing exposure time between sterile field preparation and surgery commencement. However, limited research on contamination timelines leads to premature disposal or re-sterilization of PSITs, increasing costs and environmental waste. Unclear best practices on covering methods leave ORNs uncertain about the most effective approach to prevent contamination, particularly once surgery begins.
In Iran, an upper-middle-income country, SWIs remain prevalent, with a 2.4 % infection rate reported in university hospitals. Studies highlight a lack of awareness among Iranian ORNs regarding PSIT covering. , In orthopedic and neurosurgical ORs, where multiple instrument trays are prepared for implant procedures, covering them with sterile drapes is crucial but often overlooked.
Unforeseen OR delays, such as equipment failures or coordination issues, further expose PSITs to ABCP contamination. Effective covering techniques during such periods are essential to minimize risks. , , , , Behavioral change remains challenging, but educating healthcare professionals on SWI risks and prevention strategies can improve attitudes and adherence to best practices. Targeted training programs can bridge the gap between awareness and implementation, enhancing infection prevention efforts. ,
Accordingly, this narrative review aimed to investigates four key objectives: (1) exploring the role of ABCPs in contaminating PSITs and contributing to SWIs; (2) evaluating the effectiveness of table coverage by ORNs in mitigating ABCP during both idle and active surgical periods; (3) assessing the duration of sterility maintained by covered tables and the efficacy of different covering techniques; and (4) recommending optimal covering methods while emphasizing the critical role of ORNs in standardizing and implementing these practices to enhance infection prevention protocols. These objectives are revisited and synthesized in the conclusion section to reinforce evidence-based recommendations and underscore the essential contribution of PSIT covering practices in reducing SWIs.
2
Findings
2.1
Airborne bacteria-carrying particles (ABCPs)
Whyte et al. , established a significant correlation between air contamination and bacterial counts in wound washouts. This was further reinforced by Lidwell et al.’s pivotal randomized multi-center surgery in the early 1980s. Their research demonstrated a direct association between airborne aerobic bacterial counts and the incidence of deep SWIs. , , Elevated levels of airborne microbial contamination are widely recognized as being closely correlated with higher rates of SWIs, underscoring the critical role that APs carrying bacteria play in surgical site contamination. , ,
The likelihood of SWI depends on both the dose of bacterial inoculum and the virulence of the bacteria involved. Specifically, when a wound is contaminated with >10 5 bacterial organisms per gram of tissue, the incidence of SWI rises to between 50 % and 100 %.
APs are responsible for 98 % of bacterial wound contaminations, with 30 % of these caused by direct particles settling on the wound, while the remaining 70 % result from contamination of instruments or surgeons’ hands, which then transfer the bacteria to the wound. , These particles may exist independently as bacterial or fungal spores, or they may be suspended in water droplets or adhere to dust or skin particles.
Under moderate physical exertion, each surgical team member sheds approximately 10 million particles daily. This rate increases to 10,000 particles per minute during walking, with about 10 % of these particles classified as ABCPs. Rui et al. observed that the upper body of OR staff sheds approximately 200 colony-forming units (CFU) per minute, while the lower body sheds about 400 CFU per minute.
Previous literature has shown that ABCPs can readily diffuse into the airflow paths within an OR, with typical particle diameters ranging between 5 and 60 µm. , ,
Hansen et al. found that bacterial counts decreased in environments with fewer APs, especially those larger than 5 µm. Memarzadeh and Manning reported that ABCPs are typically about 10 µm in diameter, with infectious particles in the OR being around 10 µm. Microorganisms associated with human diseases are commonly attached to particles sized between 4 and 20 µm. Therefore, bacteria often combine with other APs, forming ABCPs that can travel through the air and increase the risk of contamination.
A recent study identified OR staff as the primary source of bacteria in ORs, as patients are usually well-covered and exhibit low levels of activity. However, ABCPs produced by patients themselves can also infect surgical wounds. Research shows that 86 % of aerobic bacteria isolated from surgical wounds exhibit multidrug-resistant (MDR) patterns, including Staphylococcus aureus, methicillin-resistant S. aureus (MRSA), and methicillin-sensitive S. aureus (MSSA). , Furthermore, Klebsiella species, which are common contaminants in OR air and hospital equipment, show a 25.93 % resistance rate to all tested antibiotics.
Other bacterial isolates associated with surgical wound contamination include Enterobacteriaceae, Escherichia coli , and Pseudomonas. Among these, Staphylococcus aureus, a frequent cause of hospital-acquired infections, can survive for 7 days to an astonishing 7 months on surfaces. Similarly, Enterococcus spp., another group of opportunistic pathogens, can persist on OR surfaces for up to 4 months, while Clostridioides difficile can survive for up to 5 months.
ABCPs originate from various sources, including textile fibers, dust particles, respiratory aerosols (which contain remnants of droplets expelled during coughing and talking), and condensation droplets smaller than 5 µm ( Fig. 1 ). , , , Dust particles have been found to contain human skin and hair, gram-negative bacteria such as Staphylococcus, mold, fungi, insect parts, and glove powder. Additionally, activities like unfolding surgical gowns, inserting arms into sleeves, and removing gloves are linked with significant AP shedding.
During surgical procedures, APs that settle on non-sterile surfaces in the OR (such as walls, floors, or personnel skin) can be easily dispersed into the room’s air by turbulent airflows generated by DOs and staff movement. These ABCPs can then land on surgical instruments or directly enter surgical wounds, leading to SWIs. The concentration of these ABCPs is positively correlated with the number of occupants in an OR.
In modern hospitals, the primary source of airborne contamination originates from the dispersion of particles by individuals present in the OR and their movements. Increased staff activity and movement significantly elevate CFU levels, potentially heightening the risk of SWIs. , It has been confirmed that microorganisms produced by humans are closely linked to the indoor environment’s microbiota.
2.2
Enhancing ORN awareness and adherence to SWI prevention strategies
International guidelines emphasize the need for healthcare professionals to be aware of the risk factors for SWIs and to implement evidence-based preventive strategies. Numerous studies have shown that insufficient knowledge of SWI prevention guidelines among ORNs contributes to the high incidence of these infections. , Many ORNs fail to consistently follow best practices and established guidelines.
ORNs may be unaware of several factors that contribute to the rise in ABCPs, including the type of clothing worn by OR personnel, , the number of people present, , activity levels, OR traffic, DOs, , staff turnover, anesthetic gases, non-woven fabric, , and talking or coughing. Consequently, SWIs are prevalent in LMICs, where adherence to SWI prevention guidelines is often inconsistent. ,
To effectively reduce SWI risk, perioperative leaders and ORNs must identify and address the sources of contamination, particularly ABCPs. By understanding these factors, ORNs can implement targeted preventive measures that disrupt the infection chain, improving patient outcomes.
This is particularly critical in neurosurgical and orthopedic surgeries, where ABCPs pose a high risk of directly contaminating surgical wounds or implants, as the risk of SWI is high due to ABCPs directly entering the surgical wound or indirectly through implants.
Implementing evidence-based practices and enhancing infection prevention and control (IPC) skills are essential steps for ORNs to minimize SWIs and protect patient health. ,
2.3
Controlling contamination by ABCPs
A safe and healthy OR, characterized by stringent control over contamination sources and microenvironmental changes, is achieved through meticulous planning, regular maintenance, periodic inspections, and continuous OR staff training. Methods for enhancing air quality in an OR typically involve engineering controls and best practices ( Fig. 2 ). These include maintaining the performance of the ventilation system and timely replacement of its filters, utilizing air barrier systems (ABSs), evacuating surgical smoke and anesthetic gases, minimizing DOs and foot traffic (FT), wearing a modern space suit, wearing long-sleeved jackets, wearing masks employing supplemental high-efficiency particulate air (HEPA)/ultraviolet air recirculation systems (HUAIRS), cleaning the OR, covering sterile areas such as PSITs, , , and completely covering the hair (facial hair, head, and ears).
2.3.1
Laminar airflow (LAF) ventilation system
Ventilation systems in ORs are essential for minimizing SWIs by regulating temperature, humidity, and controlling ABCPs. , Common systems include conventional turbulent ventilation (CTV), unidirectional laminar airflow (LAF), and mixed-flow systems. While LAF systems provide ultraclean air to surgical fields, reducing SWI risks, , , their high costs and maintenance requirements limit widespread adoption, especially in low-resource settings. Furthermore, studies yield mixed findings on LAF efficacy, with some suggesting no significant advantage over CTV in reducing SWIs. Factors such as equipment, staff movement, DO, , and heater-cooler devices also impact airflow performance, complicating sterility maintenance. , Although the WHO highlights ventilation’s importance, no specific system is endorsed. Therefore, the cost-effectiveness and maintenance demands of LAF systems must be carefully considered.
2.3.2
Mobile laminar airflow (MLAF)
Mobile laminar airflow (MLAF) units, portable systems designed to enhance OR air hygiene, act as supplementary devices to reduce ABCPs near sterile fields. While proposed as cost-effective alternatives to ceiling-mounted laminar airflow (LAF) systems, MLAF units have limited performance areas, typically within a 1-meter radius, and their efficacy depends on proximity to sterile surfaces and primary ventilation system efficiency. Research on MLAF is scarce, and these units are underrepresented in infection control guidelines. , Though beneficial in mitigating ABCPs during surgeries, particularly in orthopedic and neurosurgical procedures, their utility is constrained by costs and limited applicability in LMICs. , Consequently, the integration of MLAF systems in healthcare facilities should consider resource availability and local priorities.
2.3.3
Air barrier system
The Air Barrier System (ABS) minimizes airborne CFUs at surgical sites by creating a positive-pressure, non-turbulent air envelope, achieving 99.99 % efficiency for particles ≥0.3 µm. Food and Drug Administration (FDA)-approved, ABS significantly reduces AP deposition on wounds, indicating potential benefits in lowering SWI risks.
However, ABS is costly, with an estimated $8750 per surgery, making its adoption impractical in LMICs, including Iran, where local costs exceed 5.4 billion rials per procedure. , Furthermore, limited research exists on its broader efficacy, particularly concerning contamination of personnel, instruments, and equipment. Future studies are necessary to address these gaps and evaluate cost-effective implementation strategies.
2.3.4
Wearing a modern space suit instead of a conventional surgical gown
The development of body exhaust suits (BES) significantly reduced SWI rates in joint replacement surgeries, leading to their adoption in orthopedic practices. Modern advancements, including surgical helmets and togas, further reduce APs, though concerns persist regarding contamination risks from helmet airflow systems and intraoperative movements.
Despite their benefits, BES and similar systems are costly, require specialized training, and may inadvertently increase contamination risks. , Studies suggest no consistent advantage over conventional surgical gowns in reducing microbial contamination. Their adoption is further limited in low-resource settings like Iran due to high costs, impracticality, and lack of expertise. More rigorous research is required to validate their efficacy and assess their feasibility in diverse healthcare contexts. ,
2.3.5
Integrated HEPA/ ultraviolet -C (UVC) air treatment system: enhancing indoor air quality
Integrated HEPA and ultraviolet-C (UVC) air treatment systems effectively enhance indoor air quality by combining particulate filtration with germicidal UVC irradiation to inactivate airborne pathogens. These systems significantly reduce total and viable APs, potentially lowering infection risks, particularly in total joint arthroplasty (TJA).
Innovative prototypes, such as the FastAir system, integrate UVC germicidal lamps with HEPA filters, removing 97 % of suspended particulates and improving OR air quality. However, a pilot study found no significant reduction in CFU levels, emphasizing the need for further research to assess these systems’ impact on SWI rates.
While promising, HEPA/UVC systems require additional investigation and validation to determine their cost-effectiveness and feasibility in various healthcare settings.
2.3.6
Cost-effective strategies for SWI control in LMIC ORs
HAIs affect millions globally, with SWIs being particularly prevalent in LMICs, where up to 29 % of surgical patients are impacted. , Financial constraints, resource shortages, and limited equipment exacerbate these challenges in LMICs compared to HICs, which implement robust IPC programs. , ,
Although advanced technologies such as LAF, MLAF, ABS, and HEPA/UVC systems show potential in reducing SWIs, their high costs and complex maintenance limit applicability in resource-limited settings. , LMICs must instead prioritize cost-effective strategies tailored to local conditions, such as proper covering of PSITs and targeted IPC programs. Affordable interventions combined with staff training equip ORNs with practical skills to maintain sterility and improve patient safety without imposing significant financial burdens.
2.3.7
Minimizing OR door openings (DOs)
Frequent DOs in ORs disrupt airflow, compromise ventilation, and heighten the risk of SWIs by allowing ABCPs to enter. , DO rates can reach up to 176 per case in orthopedic surgeries, with each opening disrupting airflow for 15–20 min, correlating with a 13 % increase in APs. , ,
Personnel, including anesthesia staff (23 %), operating room nurses (52.2 %), and orthopedic staff (12.7 %), contribute significantly to DOs, often due to factors like information sharing, equipment retrieval, and social interactions. , Even advanced ventilation systems such as LAF are sensitive to these disruptions, potentially increasing SWI risks if not properly managed. , , ,
Reducing DOs is essential for maintaining positive pressure and sterile conditions, as highlighted by the AORN guidelines. Practical measures include improving communication methods and optimizing equipment placement to minimize unnecessary door use, thereby enhancing infection control practices. ,
2.3.8
Minimizing foot traffic
FT in ORs disrupts airflow, introduces airborne contaminants, and increases particle concentrations, elevating the risk of SWIs. Both entering and exiting the OR disturb airflow patterns and compromise surgical sterility. Increased FT can also lead to distractions that may result in surgical errors.
Studies indicate that heightened FT, particularly before and after surgical incisions, significantly contributes to contamination risks. Common causes include supply retrieval, communication, and personnel breaks. , Personnel movement correlates with elevated microbial counts in the OR, as measured in air and wound samples, with exposed skin being a primary pathway for pathogen dissemination. , ,
Excessive FT exacerbates disruptions caused by frequent DOs and compromises positive pressure, further increasing the risk of infection. , Guidelines for preventing SWIs recommend minimizing both DOs and unnecessary movements within the OR.
Practical strategies to reduce FT include storing essential supplies in the OR, using pass-through windows, displaying “Do Not Enter” or “Implants in Use” signage, and locking doors when appropriate. , Additionally, OR personnel should minimize activities that generate or disperse APs whenever possible.
2.3.9
Covering prepared sterile instrument tables (PSITs)
2.3.9.1
Covering PSITs: a shield against contamination by ABCPs
Extensive research consistently demonstrates that covering PSITs significantly reduces the risk of contamination by ABCPs. Several key studies, including those by Campbell et al. (1993), Chosky et al. (1996), Dalstrom et al. (2008), Amaral et al. (2013), Bible et al. (2013), Sandstrom et al. (2014), Menenkse et al. (2015), Markel et al. (2018), Uzun et al. (2019), Qvistgaard et al. (2020), Zarei et al. (2022, 2023) , and Wistrand et al. (2021, 2024), , , have reinforced this conclusion.
Notably, six of these studies were randomized controlled trials (RCTs) involving patients, , , , while others included randomized trials without patient involvement, one systematic reviews and meta-analyses, and observational or quasi-experimental studies. , , , , ,
The AORN also recommends covering sterile fields with a sterile drape during delays or increased activity to mitigate contamination risks. Covering PSITs proves particularly beneficial in scenarios where sterile tables are prepared in advance, during periods of high FT, surgeon delays, or when multiple tables are prepared simultaneously but not used immediately. , , , , Multiple studies have documented significant reductions in bacterial contamination ( Table 1 ) on covered PSITs. , , , , These findings strongly suggest a correlation between PSIT coverage and reduced bacterial shedding or settling on sterile surfaces.
| Bacterial Genus | Species Identified |
|---|---|
| Staphylococcus spp. | S. aureus, S. epidermidis, S. warneri, S. hominis, S. capitis, S. saprophyticus, S. simulans, S. haemolyticus |
| Micrococcus spp. | M. luteus, M. flavus |
| Corynebacterium spp. | C. diphtheriae, C. fermentans, C. amycolatum, C. mucifaciens, C. sanguinis |
| Streptococcus spp. | S. agalactiae, Alpha Streptococcus, S. anginosus, Group C Streptococcus, S. salivarius |
| Cutibacterium spp. | C. acnes (anaerobic rod), C. namnetense |
| Enterobacter spp. | Ø |
| Brachybacterium spp. | Ø |
| Bacillus spp. | B. cereus, B. licheniformis, B. pumilus |
| Ewingella spp. | E. americana |
| Gram-positive rods | Ø |
| Moraxella spp. | Ø |
| Actinotignum spp. | Ø |
| Arthrobacter spp. | Ø |
| Deinococcus spp. | D. wulumuqiensis |
| Dermabacter spp. | D. hominis |
| Dermacoccus spp. | D. nishinomiyaensis |
| Dietzia spp. | D. papillomatosis |
| Kocuria spp. | K. rhizophila, Kocuria sp. |
| Lactococcus spp. | L. lactis |
| Leuconostoc spp. | L. mesenteroides |
| Microbacterium spp. | Ø |
| Micrococcus spp. | M. lylae |
| Peptoniphilus spp. | Ø |
| Propionibacterium spp. | Ø |
| Rothia spp. | R. dentocariosa, R. koreensis |
| Sphingobacterium spp. | Ø |
| References: 32, 35, 129, 130, 131, 133, 134 | |
Covering PSITs has proven effective across various ventilation systems, including turbulent ventilation, , turbulent mixed ventilation, upward displacement ventilation, , laminar ventilation, , standard hospital ventilation system, High-efficiency particulate air (HEPA) filtration, non-laminar ventilation, Positive airflow, and Conventional plenum ventilation. Chosky et al. demonstrated that instrument contamination was reduced 28-fold when prepared in an ultraclean air environment and covered, compared to only a 4-fold reduction in contamination in a standard environment without covering.
While ventilation systems help mitigate contamination, their effectiveness can be compromised by factors such as increased foot traffic, personnel presence, and frequent DOs. In such cases, covering PSITs is particularly crucial for preventing bacterial deposition and maintaining the sterility of surgical instruments.
2.3.9.2
Time-dependent contamination of PSITs: the role of coverage in reducing ABCP contamination
Research consistently shows that uncovered PSITs become contaminated over time, with bacterial presence detected as early as 15 min in static environments and 30 min in dynamic surgical settings. , , Bussières et al. found that while contamination rates for surgical trays are low (4 %) within the first 30 min, they increase significantly over time.
In contrast, covering PSITs significantly delays bacterial contamination, providing protection for up to 60 min. , After this period, while some bacteria may penetrate the cover, contamination levels remain significantly lower compared to uncovered tables. , , ,
Qvistgaard et al. emphasize the importance of covering PSITs in uncontrolled environments. Using at least one drape layer reduces microbial load and lowers the risk of SWIs, while employing double-layer draping further enhances protection. This method is beneficial when delays exceed one hour or when PSITs are transported between ORs.
Although contamination risk increases after 60 min, the double-layer cover method effectively reduces bacterial exposure, providing a longer window of protection. Evaluations conducted at various time points (0 min, 15 min, 30 min, 45 min, 60 min, 90 min, 2 h, 3 h, 4 h, 8 h, 12 h, 15 h, 16 h, and 24 h) consistently support the use of PSIT coverings as a critical measure in reducing airborne bacterial contamination. , , , , , ,
Wistrand et al. reported that PSITs can maintain sterility for up to 24 h under controlled conditions, though more research is needed to verify these findings in standard OR environments. Their study showed significantly higher bacterial growth rates on uncovered tables compared to covered ones, underscoring the importance of covering PSITs to reduce airborne contamination. However, the sterility of covered tables for later use remains uncertain, as bacterial colonies were found under the covers within 4 to 24 h.
Additionally, Wistrand and colleagues’ study on 69 open-heart surgeries revealed that sterile drapes significantly reduce bacterial contamination. Agar plates covered the evening before surgery showed only 7 CFU after 15 h, compared to 312 CFU when uncovered. Morning-prepared agar plates showed 17 CFU with covers versus 163 CFU without. 75 % of covered instruments had no contamination, against 9 % of uncovered. Common bacteria were Cutibacterium acnes and Staphylococcus epidermidis , some resistant to antibiotics. The study underscores sterile covers’ role in reducing contamination and preventing SWIs but calls for further research to confirm these results.
2.3.9.3
The role of covering methods in mitigating PSIT contamination by ABCPs
Concerns about the effectiveness of different covering methods for PSITs have been raised following the latest guidelines from the AST. The AST does not recommend the single-drape cover method due to the potential risk of contamination during removal. The concern is that sections of the drape may touch the sterile surface of the instruments, allowing microorganisms, dust, and debris from the floor to contaminate the PSITs through air currents. However, this guideline is based on a hypothesis, as there is no scientific evidence to support these claims.
In contrast, the AORN recommends the two-drape cover method (also referred to as the “cuffed” two-drape method), which involves using two sterile folded drapes. This method is believed to reduce the risk of contamination during removal. While AORN endorses this approach, no conclusive evidence has demonstrated that the two-drape method is significantly superior to the single-drape method in reducing contamination.
Numerous studies have explored various covering methods for PSITs ( Fig. 3 ), including single-drape covers, , , , , , , , two-drape cover, , double-layer cover methods and commercially available plastic covers, such as novel single-drape covers and Z-TIDI products (Neenah, WI). Zarei et al. found no significant difference in contamination prevention between the novel single-drape cover and the standard two-drape cover. In another study, Zarei et al. demonstrated that covering PSITs during both idle periods and active surgeries effectively prevents contamination, without showing a significant advantage of the two-drape cover method over the single-drape method.
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