Proactive Risk Assessment of Surgical Site Infection in Ambulatory Surgery Centers

Appendix D, Table D2

D2. Operative Steps

Process Step / Facility Feature Academic Hospital, Off-Site ASC Community Hospital, Co-Located ASC Free-Standing ASC Pediatric Hospital, Off-Site ASC

Special/additional equipment for procedure is ordered, if needed

A week before procedure will call reps and order specialty equipment.


Can order extra equipment in advance from reps but can also schedule cases that require the same equipment for different times of day and with other cases between to increase time to sterilize equipment.


At start of day OR is prepared


First case of day before open up any equipment will do damp dust to settle dust since the full clean happened during the night.

Wipe down all flat surfaces in room before starting to get the overnight dust.


Verify patient is in pre-op

Equipment only opened if patient is in pre-op already.


Equipment and supplies in OR inventoried and opened

Before patient comes into the OR, the team will open supplies and instruments in field.

The scrub tech and circulator set up the OR. Set up needed equipment for case. If it is for sure needed, packs will be opened, but if unsure it will be 'on hold' and un-opened. Prep warming blanket, gel pads, pumps etc.

Keep track of inventory of supplies being used.


Equipment sterilization checked

Check indicator tape that is wrapped around instrument package. Stripes on tape change color if package received appropriate sterilization. Lets you know if sterilization met standards. Check if anything wet.

With instrument packs, look at sterilization tags to see if steam or gas has hit outside of tray, then there is a tag on the inside to indicate penetration. Check paper wrapping for holes. There is no 'best by' date, peel packs and things that have been sterilized are event based, so sterile until used or package broken.

Check indicator in instrument tray. If something is not okay they need to be re-sterilized and packaged. This causes risk to patient because they are under anesthesia longer than they're supposed to be if equipment not usable. Check that there is no moisture, open pack and make sure there is sterilizing tape that has turned color on edge of pack, then check that towel indicator on top has passed. The scrub tech picks up wrapped set and checks for holes. Checks that the lock on the autoclave pans is intact and indicator on each level on outside have all turned. If a pack is wet it is not sterile anymore. If sterilization rushed and tools too warm and not dried thoroughly in autoclave, they should be opened and immediately set on towels to cool down. If put in metal pan they get condensation and are no longer sterile.


Sterilization check documented?

SPD documents indicators in cooking process but in OR no, just eyeballed and not documented.


As packs opened will check indicators, no documentation, but required to do check. Hopefully check done before patient gets into room.


Policy on flashing equipment?

Some specialized equipment needs to be flash sterilized and will let the doctor know. Implants never flashed, even if dropped. Lack of enough instruments means more flashing than would like. Can't borrow much of what is needed from hospital, need more instruments. Instrument tech says that they do not flash much but would have to much less if they had more equipment but they try to decrease flashing through scheduling. If many Cystoscopy or endoscopy procedures in one day, they must flash because there are limited scopes. Not much flashing from dropped instruments, mostly limited equipment.

Flashing very, very rare, but if it MUST be done the flash sterilizer is in between the OR rooms and not out in a hallway so the item can be used right away in the OR and not travel outside of it. Would only ever flash if there was a piece of very specialized equipment that was dropped. 

Do not flash at all. Stopped flashing a year ago. The doctors wait to have something processed before they start, so no flashing in between procedures. But, if a one of a kind item is dropped during a surgery and the patient is already under, then will flash. Only happened once or twice last year.


Pre-op informs OR that patient is ready

OR nurse goes to pre-op after it is announced that the patient is ready.


While in pre-op, OR nurse rechecks and interviews patient

OR nurse checks that patient in pre-op and are ready and alerts doctor and anesthesiologist. Interview patient and make sure all documents are ready and consent forms, doctor's orders and instructions and medication forms.



OR nurse re-asks basic check list like allergies and medication then checks consent form and patient bracelet and signs off on the consent form for date, time, and patient name.

Scrubbing requirements before entering OR

Staff scrub before entering OR.  Not allowed to have dangling earrings, no artificial nails, hat should contain all hair, no sleeve or collars of undershirts coming out, if not specific dedicated OR shoes they must wear shoe covers. Also wear eye protection, masks, and hospital laundered scrubs. If scrubs go outside, they need to change. Endoscopy is not a sterile procedure so might not need to change. Doctors will just put gown on over their clothes. If not enough scrubs have bunny suits to wear. Scrub for at least ten minutes in morning.  Going into OR there is a line you can't cross until sterile, since its small only have one hallway, so even though can't go in until proper attire will have to take dirty instruments through hallway at end of procedure.  If equipment is found before procedure to not be sterile, they must rescrub. 

Scrub and go into OR and then in OR is when they put on gown and get gloves. Nurse do not scrub in since remain from sterile field even if in room, (they act as gopher), but the instrument tech would scrub.  Anesthesia provider not scrubbed but at head of patient so in gown. Everyone must wear shoe covers unless have dedicated shoes, If messy case wear shoe covers too. Only beyond red lines in OR hallway have to gown, no open toed shoes allowed, leather is best. Total joint cases require full wash and scrub regardless of case.


Transport to OR: who goes with patient and mode of transportation

Endoscopy and pain patients go into OR on stretcher, all others are walked.

Straight from pre-op into the OR on the stretcher (locals walk in). Transfer from stretcher to operating table, then the stretcher is taken down the hall.

Nurse, anesthetist, operating room nurse takes the patient back. Scrub nurse would already be in the room.

Parents go with patient during transport then wait during procedure in post op, if patient asleep already the parents will be escorted to recovery room.

Who enters OR?

Surgeon, anesthesiologist, scrub nurse (handles instruments in sterile field), circulating nurse (gopher outside of sterile field), rep (if trying new equipment out), resident or fellow (maybe), radiology technician (maybe), surgical assistant (in some cases, like hernia, orthopedic, etc). Try to minimize the people in the OR but can be hard if the surgeon is well known or the case is rare, they might bring a lot of residents in to watch. In hospital might bring 10 residents to view, but at ASC just a few but all the people add up.


Anesthesiologist, surgeon, nurse, scrub tech, patient. The traffic in and out of the room is always a concern, people go in and out. The doctors will not always let the ASC know what special things they need, if the surgeon would tell them then they could have it ready but as it is now sometimes they request special things during surgery so those things need to be brought in. Also people go on brakes for lunch. Reps come too sometimes and they have to be in room during procedure.

Anesthesiologist, surgeon, nurse, scrub tech, patient, and patient's parents all go to OR. Parents stay until patient asleep. Some surgeons have residents too. Try and never have more than 8 people in the room.

Put on gowns and gloves when enter OR

Gown and glove. Double glove is not required. If surgeon asks then you do it, they never do though. Only orthopedic surgeons really do it. One nurse had interesting gloving technique from a podiatry doctor who uses orthopedic thick gloves and normal gloves on top of them, for while they do draping, and when they are done draping they remove the top layer of gloves and just use the thick gloves during the procedure. Don't have indicator gloves-ones that have a colored lower layer and can see if there is a hole, would like to use those.

Gown and get gloves. Everyone scrubbed into sterile field gets gloves. Double gloves required but not all surgeons will double glove and can't mandate since they are not employees of the ASC.


Transfer patient to operating table and position them

Anesthesiologist positions patient.

Transfer from stretcher to operating table, then the stretcher is taken down the hall. 

Patient got onto operative stretcher themselves so not have to move patient. Nurse, OR nurse, surgeon etc comes out to pre-op when they got on stretcher and made sure they were on stretcher correct, make sure comfortable. Patient will move onto OR bed themselves or stay on stretcher. If on belly for surgery will position themselves ahead of time, not often done other places. Other places will position them on belly after asleep, but then unknown pressure and discomfort can build up.


Hook patient up to monitor



Administer prophylactic antibiotics

Administered within hour of cut time (unsure when drip actually started).

For prophylactic antibiotics, nurse will hang bag in pre-op but not start it. Anesthesiologist will start it as enter OR because have to administer within one hour so wait until enter OR. This is in case the procedure time changes unexpectedly. Prophylactic antibiotics are driven by type of procedure not patient, colon surgery, hysterectomy and total joint.


Administered after patient is sedated.

Take patient's temperature

Anesthesiologist checks the temperature.

Patient getting too cold is an issue. If their belly is open they can cool down quick, higher risk of infection post op if cold. Room is 68 degrees before patient go under in OR, 68 when patient taken into room, lower temperature once patient is asleep and under warmed blankets and have fluid warmers for iv fluid, and blood etc.


Post-op pain block administered in OR or previously in pre-op

Anesthesiologist checks the temp and positions them, hooks them up to monitor, then do blocks. If podiatry case they sedate a bit before doing blocks.


Done in pre-op.


Patient is sedated (and intubation?)

If podiatry case they sedate a bit before doing blocks and then they prep the site then do the drape and then they do the time out. After the time out is the full sedation. After the time out is the sedation for all other cases too, the patient is awake until the time out.

Patient sedated before skin prep, drapes and time out.

Patient sedated before skin prep, drapes and time out.

Patient sedated before skin prep, drapes and time out.

Surgical site is prepped



One doctor does his own preps but it is most often done by the circulator. Wear sterile gloves for prep and then go and rescrub before draping.

Circulating nurse or resident does prep then scrub, patient already asleep.

What is used for site prep?

Clean with either betadine or Chlorhexidine. 

Chlorhexidine has a required wait time to dry between site prep and draping. Also, it cannot be used on mucosal areas so betadine is used then. Prep is done specifically from center of site and work circular out.  Must wait 5 minutes. BOVI (laser to cauterize bleeders) could cause fire if used before it is dry. Then patient is draped.

Used to always be betadine, now Chlorhexidine. Up to doctor to choose which to use, but it is often Chlorhexidine. Only one surgeon still likes to use betadine scrubs.

Use Chlorhexidine. But some procedures use betadine (mucosal), like anything with scrotum.  Chlorhexidine left to dry for three minute to avoid igniting during cauterizing. Use betadine for C-section etc if not enough time to dry.

Patient is draped

Surgical site area is isolated then draped. Type of procedure or location determine which type of drape to use. If extremity use the U drape- example is leg placed in stirrup. The surgical assistant and the scrub tech or nurse will do the big drape.

Scrub tech checks drapes for holes. Then patient is draped. Specific ways for draping. Drape comes folded up. Instructions tell you how to lay it down so that it is in correct position. Never drop hands below level of patient's body. Fold drape around sterile glove to pass it off to others.

Scrub tech and surgeon do draping after prep. The circulator holds extremity until done with draping.  Nurse would like to see universal use of U drapes (used in shoulder surgeries?).


All needles, sponges, sharps etc. are counted


Count sponges, sharps, needles.

Time out done: everyone involved re-verifies patient, procedure, site etc. one last time before cutting

The patient is awake until after they do the time out.


It is required of anesthesiologist, surgeon, scrub tech, circulator, and surgeon assistant all do the time out.

Yes, and double check bracelet and consent then go ahead. 

Circulator monitors sterile technique


Circulator watch for breaks in sterile technique before and during procedure. In charge of patient safety, even after (until recovery room).


Break in sterile technique/ sterile field


Gown is considered sterile from mid-chest to just above hips/waist only on front. Hands cannot leave this area. Armpits and back are not sterile. Two sterile people only pass face to face. People not wearing sterile gown and gloves should not pass between sterile table and patient. Doctors may not sit during procedures unless specifically mandated by procedure. No one sits unless everyone sits, this changes the sterile field. If you drop something below the level of the patient it may not be brought back up to the level of the field.

Bringing hands below waist or touching non-sterile item breaks sterile field. The sterile operative field varies depending on procedure and as long as stay in sterile field then can use instrument even if dropped (clearly dropping on floor moves instrument below waist thus out of sterile field). Sterile field can vary. If there is ever doubt about whether something remained sterile or not, then it's not sterile. If there is a hole in the drapes can't re-drape, must patch with impervious cover and maybe increase antibiotics. Major break in sterile field increases the CDC classification. Also specific technique to maintain sterile if changing gloves.  Changing sterile gloves when gowned. Need to do open glove technique. Cuff on gown is no longer sterile. Must not come down over hand. Remember, not everyone in OR is in sterile field, not anesthesiologist or circulating nurse.


Specific concerns for sterile field with arthroscopy?


Cords dropping below sterile limits. Irrigation runs to floor, so floor has to be cleaned constantly. Pump tubing is used all day long. Separate tubing that comes from the field. That end is supposed to be kept sterile.


Length of procedure?


Procedures are simple from 15 minutes to one hour since generally healthy patients. ACL repair is 4 hours, arthroscopy longer, urology 2 hour. Time on table is greatest risk, longer is worse.

After procedure: surgical sit dressed


After procedure put on sterile dressing.

After all sterile dressings applied, member of team in sterile field make sure that dressing is correctly in place.  Team member holds dressing in place while the circulator assists with unsterile dressings like braces and slings.

Dressing and bandage.

Double check that all procedures done


At times do more than one procedure and check that all were done that were needed for patient

Equipment unhooked and intubation tube removed




All needles, sponges, sharps etc. are re-counted


Sharps counted and go into impervious container.

Count sponges, sharps, needles.

Patient dressing gown put back on



Drapes are removed

Drapes removed.

Drapes don't come off until the dressing is on.

Do not remove drapes until after most dressings are on, some dressings not 'sterile', like a brace. So brace would be done after removal of drapes. All drapes discarded, no reusable drapes, disposable supplies disposed.


Brought out of anesthesia





OR nurse calls PACU


Nurse will call to check that recovery has room for them, otherwise wait in OR, give report to recovery room nurse.


Placed on stretcher and transported to PACU

Surgical assistant, nurse and anesthesiologist take patient to PACU.

Surgical assistant, nurse and anesthesiologist take patient to PACU.

Anesthesiologist and nurse take to PACU.

Circulating nurse take to PACU.

Instruments taken to SPD

Instruments taken to decontaminated dirty area of SPD. Cover instruments with drape and roll through main corridor. There is a window between dirty and clean area.

Everything is rolled up to contain everything. Put in contaminated bag. Instruments are contained in closed case cart, transferred to SPD to be processed.


Scrub nurse take instruments to SPD. Everything considered dirty if leave OR, whether used or not.

Staff remove gowns and gloves

Special process to take off gown and gloves. Any blood soaked go into the red bin, any wrappers from other things go in clear trash, have soaking mats for bloody cases or suction disks. 


Wash hands


Pump in, pump out.



OR cleaned between cases

Cleaning staff come in and change the anesthesia circuit and wipe all of the surfaces and lights.  Special material used call SANI wipe, every time they mop floor between cases, even if not messy, all cases except pain and ophthalmology have linens changed. 

Protocols for cleaning ORs in-between patients: after unused equipment is removed, cleaning solution must sit on table for at least 10 minutes. Scrub tech gowns and robes then cleans room. Every patient is considered contaminated and cleaned the same, except CDIF patient rooms are cleaned differently. (GI cases are an influx of bad bacteria as spores, no good bacteria since it was all killed by antibiotics). Regular patient: every flat surface is cleaned, solution has to dry for 10 minutes, floors are cleaned 3 feet beyond the OR table. (eye and ear procedures don't require floor cleaning). For other areas, use common sense (i.e. is there blood or anything there). Clean walls if necessary. Drapes and instruments are taken out before cleaning starts. Can't clean the room until the patient leaves the room. EKG cables get wiped off. For CDIF: call environmental services, and they use a bleach solution, then the room has to be closed for an hour.

In-between cases mop floor, use microfiber dust mops, use for one case then is reprocessed by linen company between cases, mop down everything between. Changed to wipes for surfaces, which dry really fast, changed to those in last 6 months, big change in turnover time since changed.

No set thing each person cleans, small team, so everyone just automatically gets things done and runs through a checklist. They clean the bed and floor and anesthesia equipment, anything specific to patient and instruments. 

OR turnover time

15 minutes, endoscopy, pain and ophthalmology faster.

At least 10 minutes.

Turnover 5-7 minutes. 

5 to 10 minutes turnover.

Turnover documentation?

Document the times of the cleaning start and finish, but no incentives or punishments based on turnover time.


End-of-day cleaning

End of day cleaning of all ORs.

End of day: environmental services come and do thorough cleaning including walls. Split up in teams that service OR suites. Each team responsible for 3-4 rooms. Terminal clean at end of day. Once a week floors get scrubbed. Checklist at the front desk to verify that this has taken place (daily and weekly). Top down cleaning. From ceiling down to floor. Microfiber mops for walls. Wet pad soaked in disinfectant. Bed last. Bed is most tedious. Have to take it apart and get into crevices. Use as cleaner in general: Virex 256, which has a 10 minute air dry. Use wipes rather than spray bottles or a bucket with rags. Oxyveer has a much shorter kill/dry time of 2 minutes, but it is too expensive. Not cost effective. Too much chemical will ruin floors and is bad for the applicator. So the fill (?) is tampering proof and removes the human factor of diluting the cleaning solution. Otherwise use cleaning wipes instead of self-measured bleach solutions. One microfiber mop per room. Supervisor will audit cleaning once a week, when people come on, they have a quiz about cleaning for ORs. Laundry service: standard precautions for soiled linens. Cleaners wear gloves etc. not exposing self to anything that could be hazardous. Have soiled hold room, gets removed 3 times a day, gets weighed and moved to main soiled hold room.

At end of the day when house cleaning comes do walls, lights everything.

If a patient is known to have pre-existing infection, procedure will be done as the last case so as to get a very thorough end of day cleaning afterwards. Cleaning staff come in at night. Clean everything touch patient, clean and mop floor. End of the day is walls and floor and all equipment and go under table and equipment and polish sometimes.

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Page last reviewed April 2013
Page originally created April 2013
Internet Citation: Appendix D, Table D2. Content last reviewed April 2013. Agency for Healthcare Research and Quality, Rockville, MD.