Abstract
Objective
To assess the frequency of aseptic protocol breaches (APBs) among veterinary students scrubbing, gowning, and gloving into surgery and identify factors that may be associated with APBs.
Methods
This was an observational cross-sectional study. Students on clinical rotations at an academic small animal teaching hospital from May to July 2023 in the services of Orthopedic, Soft Tissue, Oncologic, and Neurologic Surgery were observed while scrubbing, gowning, and gloving into surgery, and APBs and donning times were recorded. Stage of rotation (early vs late), service type, duration of donning surgical attire, and previous surgical experience were also recorded. The χ2 and points biserial tests were used to assess for associations between APBs and the aforementioned factors.
Results
At least 1 APB was noted in 45 (46.3%) of the 96 procedures observed. The most common mistakes noted were contact of the sterile towel onto nonsterile surfaces (17.7%), contact of the gown with nonsterile surfaces (17.7%), touching sterile objects with bare hands (12.5%), and improper scrubbing technique (17.4%). There was no association between APBs and service type, previous scrub experience, or stage of rotation. Those who made an APB had longer gowning and gloving times, 4.60 (1.40) minutes, than those who did not make an APB, 3.71 (0.91) minutes.
Conclusions
These findings demonstrate that APBs are common among veterinary students and highlight reasons for contamination during scrubbing, gloving, and gowning.
Clinical Relevance
The data may be used to help improve asepsis protocols.
Maintenance of proper aseptic technique is essential for limiting surgical site infections (SSIs), particularly with major surgical procedures. Surgical site infections in veterinary medicine are not uncommon, with reported rates ranging from 3% to 18%.1–3 Although the causes of SSI have not been well characterized, intraoperative contamination is regarded as one of the most important mechanisms of inoculation.1,4
Breaks in sterile technique can occur at any stage of the surgical procedure but may be especially prevalent when scrubbing, gowning, and gloving (SGG), since hands, forearms, and the outer sterile surfaces of the gown and gloves are in close proximity to nonsterile surfaces such as scrub attire and tables. Most veterinary studies evaluating contamination have focused on contamination of gloves and the gown-to-glove interface during surgery. In 1 investigation,4 the frequency of positive cultures of surgical gown cuffs was 41.6% (50/120). Similarly, a prospective study1 investigating the bacterial contamination rate of small animal surgeons’ gloves intraoperatively was 21% (17/78). The incidence of contamination events during SGG, however, is unknown. Anecdotally, we have frequently observed errors in aseptic technique during SGG among veterinary students in our teaching hospital.
The purpose of this study was to (1) assess the frequency of aseptic protocol breaches (APBs) during SGG among veterinary students in a clinical setting, and (2) identify factors such as service type (orthopedics, soft tissue, oncology, and neurology), stage of rotation (early vs late), previous experience, or time that may be associated with APBs. Quantifying and characterizing these errors would potentially highlight suboptimal practices in the operating theater, identify the most common reasons for APBs, and promote the development of improved aseptic technique protocols or teaching methods. We hypothesized that most veterinary students would not maintain proper sterile technique and that greater prior surgical experience, shorter donning times, and rotation through orthopedics would be associated with lower APBs.
Methods
Study population
This observational cross-sectional study was approved by the University of Florida’s Institutional Review Board (IRB no. 202300757). Students on clinical rotations at the University of Florida College of Veterinary Medicine small animal hospital in the surgical specialties of Orthopedics, Soft Tissue, Oncology, and Neurology were observed over a consecutive 10-week period (May to July 2023). Verbal consent was obtained before observing students; written consent was not required. Students were informed that they would be observed by a single observer (KMS) who was investigating veterinary student performance during SGG for surgery but were not specifically told that APBs were being recorded. To maintain anonymity, we did not track any student information. The sample size was based on the feasibility of data collection within the 10-week observation period, rather than a formal power calculation. Given the limited number of students rotating through the surgical services, the sample size reflects the practical constraints of the clinical setting. While power calculations were not performed, the study aimed to collect sufficient data to assess trends for APBs within the available timeframe.
Scrubbing, gowning, and gloving procedure
Students utilized the SGG technique in accordance with methods taught in mandatory surgical courses in the doctor of veterinary medicine (DVM) curriculum and as described in veterinary surgical textbooks.5 Briefly, students could use either the anatomical timed or counted brush stroke methods of scrubbing, with a minimum total scrub time of 5 minutes. Hands must have remained above the elbow during rinsing, and any skin distal to the elbow could not touch nonsterile surfaces such as the faucet or scrub sink. The towel was to be picked up without dripping water onto the sterile gown, gloves, or underlying drape and without touching any sterile surfaces (other than the towel) with bare hands. For drying the hands, one end of the towel was used to dry one hand and forearm, moving from distal to proximal, and the same process on the opposite hand with the other end of the sterile towel. The sterile gown should have been picked up at the spine end, the hands and arms placed into each sleeve, and subsequently unfolded with adequate room to fully gown while avoiding contact with nonsterile surfaces. Finally, the gloving was performed as per the closed gloving method, making sure to not push the hands or fingertips through the gown.5
Data collection
After consent was obtained, students were observed by a second-year veterinary student (KMS) who was trained by a board-certified surgeon to properly observe and note APBs during SGG, and any breaks in aseptic technique or proper contact time were recorded. Notable APBs included touching the sink or faucet, dropping fingertips below the elbows during rinsing, touching any part of the body (other than scrubbed hands and forearms) after scrubbing, or deviations from normal contact time (5 minutes). While donning the surgical gown and gloves, students were observed with a particular focus on detecting any contact of the sterile outer surfaces of the gloves and gowns with nonsterile surfaces or liquids. Notable APBs included dripping water from the hands onto the sterile field, touching sterile objects (other than the towel or inner surface of the gown) with bare hands, improper use of the towel, and contact of the gown with nonsterile surfaces such as the table and nonsterile margins of the gown drape, or other parts of the body. Prompts regarding proper technique by the surgical technicians and clinicians were also recorded. This included instructions on proper SGG procedure or reminders to stand back from the table while gowning and gloving. An APB was not recorded if the student independently recognized and addressed the breach. Students were timed from the moment they picked up the sterile towel to dry their hands until the completion of donning the surgical attire.
Statistical analysis
Stage of rotation (week 1 of 2 or week 2 of 2), service type, start and end time of donning the surgical attire, previous surgical experience (yes/no), and prompts from the technicians or clinicians regarding proper technique (yes/no) were recorded for each participant. Week 1 was described as early rotation, and week 2 was described as late rotation. Students who had scrubbed into at least 1 previous surgical procedure outside of veterinary school (surgery class and clinical rotations) were considered as having previous surgical experience. Aseptic protocol breaches such as dripping water (yes/no), touching sterile objects with bare hands (yes/no), contact of the sterile towel with nonsterile surfaces other than the clean hands and forearms (yes/no), or contact of the gown with nonsterile surfaces (yes/no) were recorded and reported using descriptive statistics. The χ2 test was used to assess for associations between APBs and the clinical factors. Points biserial tests were used to assess for associations between APBs and gowning and gloving times. Proportions of APBs and categorical variables were reported with 95% CIs, calculated using the Wald method. The data were analyzed using χ2 and points biserial tests (GraphPad Prism version 9; GraphPad Software Inc). A P value of < .05 was considered statistically significant.
Results
Students were observed SGG for a total of 96 times with 39 occurring on the orthopedic surgery service, 29 on the soft tissue surgery service, 18 on the surgical oncology service, and 10 on the neurology service. An APB occurred at least once in 45 (46.9% [95% CI, 36.9% to 56.9%]) procedures, with a single APB in 27 (28.1% [95% CI, 19.1% to 37.1%]) procedures, 2 APBs in 14 (14.6% [95% CI, 7.5% to 21.6%]) procedures, and 3 or more APBs in 3 (3.1% [95% CI, 0.0% to 6.6%]) procedures. The most common APBs were contact of the towel with the scrub top, contact of the gown with the nonsterile peripheral margin of the gown drape or table, and improper scrubbing technique, with 9 APBs categorized as dropping hands below the elbows allowing water to drip to the fingertips and 8 APBs being categorized as touching sterile hands to nonsterile objects while scrubbing (Table 1).
Frequency of observed aseptic protocol breach.
| Aseptic protocol breach | No. (%) of total events |
|---|---|
| Contact of towel with nonsterile surfaces | 17 (17.7) |
| Contact of gown with nonsterile surfaces | 17 (17.7) |
| Touching sterile objects with bare hands | 12 (12.5) |
| Improper scrubbing technique | 17 (17.7) |
| Dripping water | 1 (1) |
Of the observed SGG procedures, 19/39 (48.7% [95% CI, 33.0% to 64.4%]) APBs occurred on the orthopedic surgery service, 13/29 (44.8% [95% CI, 26.7% to 62.9%]) APBs occurred on the soft tissue surgery service, 8/18 (44.4% [95% CI, 21.5% to 67.4%]) APBs occurred on the surgical oncology service, and 5/10 (50.0% [95% CI, 19.0% to 80.9%]) APBs occurred on the neurology service (Figure 1). There was no association between service type and APBs (P = .9608). Of the 96 SGG procedures observed, 35 had a student who had previous experience scrubbing into surgery, with 14 (40.0% [95% CI, 23.8% to 56.2%]) making an APB; among the 61 procedures with students who had no previous experience scrubbing into surgery, 33 (54.1% [95% CI, 41.6% to 66.6%]) had an APB (Figure 2). There was no association between previous scrubbing experience and breaches in aseptic technique (P = .2921). There was a total of 47 SGGs observed during the early rotation stage and 49 SGGs observed during the late rotation stage. There were 24 (51.0% [95% CI, 36.8% to 65.4%]) and 20 (40.8% [95% CI, 27.1% to 54.6%]) APBs in the early and late rotation stages, respectively (Figure 3). There was no association between the stage of rotation and the APB (P = .3637). The mean total SGG time when an APB was made was 4.60 (1.40) minutes, which was longer than when an APB was not made, at 3.71 (0.91) minutes (P = .001). Prompts from technicians or clinicians were noted in 45 procedures with students making an APB in 27 (60%) of them.
Aseptic protocol breaches (APBs) by service.
Citation: American Journal of Veterinary Research 86, 6; 10.2460/ajvr.25.01.0006
Associations between previous experience and APB events. Each blue bar represents the number of times an APB was observed. Each orange bar represents the number of times no APB was observed.
Citation: American Journal of Veterinary Research 86, 6; 10.2460/ajvr.25.01.0006
Associations between stage of rotation and APB events. Each blue bar represents the number of times an APB was observed. Each orange bar represents the number of times no APB was observed.
Citation: American Journal of Veterinary Research 86, 6; 10.2460/ajvr.25.01.0006
Discussion
The results of this observational study support that APBs are common among veterinary students within a teaching hospital setting, despite having previously learned SGG earlier in the DVM curriculum. Service type, prior experience, or stage of rotation was not associated with increased rates of APBs; however, SGG times were longer when an APB was detected when compared to SGG that was successfully performed.
It is important to note that we did not definitively assess contamination rates; that is, all APBs do not result in contamination. For instance, the sterile regions of the gowns and gloves could theoretically remain sterile despite improper scrubbing techniques or poor use of the towel. Nevertheless, studies6 have shown that APBs can lead to higher SSI rates; in a study7 evaluating the impact of intraoperative behavior on SSIs in humans, the risk of SSI was 3.5 times greater when there were lapses in adherence to principles of asepsis, including issues that are not obvious contamination events such as general movement and visitors in the operating theater. The association between SSIs and failures to consistently follow aseptic principles could be attributed to recurring minor infractions rather than a single major contamination event.7 In that light, the 46.8% APB rate in our study is concerning.
There are several potential explanations for the high incidence of APBs in our study. Aseptically preparing for surgery is a multistep process with several opportunities for error. The students in our cohort learn how to SGG in laboratory courses that are typically completed 3 to 5 months before entering clinics; although students are expected to review the SGG procedure in preparation for their surgery rotation, lack of opportunities to practice and poor knowledge retention may have played a role. Also, the common APBs we detected in our study may not have been emphasized enough during training.
Improper use of the towel when drying hands after scrubbing and contact of the gown with nonsterile surfaces were the most common APBs noted. This included the sterile towel contacting the students’ scrub shirt and the gown contacting nonsterile surfaces and regions of the gown drape such as the margins or corners that are used by nonsterile personnel to open the drapes. While performing the SGG procedure, students appeared to be generally unaware of the entire towel or gown locations during these activities. In addition, the distance between nonsterile and sterile surfaces in both cases is small with a natural standing posture so to increase the distance, an awkward posture is needed. Lack of spatial awareness while completing SGG may help to explain the high rate of APBs in our study.
Our results could be used to refine teaching protocols in aseptic technique by highlighting the most prevalent APBs in a clinical setting. For instance, modifying the teaching of scrubbing in the DVM curriculum to emphasize key APBs found within our study may be warranted. Alcohol-based rubs may be just as effective as antibacterial hand scrubbing methods,8–10 and using rub-based antiseptics would eliminate towel-related APBs. Similarly, the use of an alcohol-based scrub removes the need for the traditional scrub technique, which was another opportunity for APBs found in our study. Other common APBs were touching objects with bare hands and contact of the gown with nonsterile surfaces, both observed during the single-person gowning and gloving technique. A modification of protocol that may decrease this risk would be utilizing a 2-person gloving technique. Seen commonly in human medicine, an already sterile individual places the gloves onto the students instead of the students doing it themselves, eliminating the risk of brushing the gown on nearby surfaces or touching the sterile gloves with their hands. Previous reports11 suggest that donning surgical gloves using the 2-person technique can minimize the probability of gown contamination.
Service type and stage of rotation did not affect the frequency of APBs. We noted that APBs were high across all services but could be considered as being most worrisome for orthopedic procedures due to the use of permanent implants and difficulty with managing orthopedic infections. We hypothesized that students on the orthopedic rotation would be more mindful of APBs, as the clinicians on the orthopedic service typically emphasize the importance of stringent aseptic techniques; however, the results suggest that such priming to these students was ineffective. Our study also highlighted that increased gowning and gloving times were noted with APBs. One possible explanation is that students lacking confidence or familiarity with SGG required more time and were also more susceptible to APBs. Finally, we could not identify any influence of prior experience and APBs, which could be explained by the nature of the study. By only including yes or no as a possible answer, those who responded “yes” to having surgical experience may still have been very inexperienced.
The limitations of this study were due to the nature of a single person observing the participants. Students could not be observed from multiple angles, and therefore, some APBs may not have been recorded. Due to the limitations regarding participant consent and study design, our study utilized an in-person observation of the technique instead of video recordings, which precluded the opportunity for reobservation. Similarly, we described each observation of technique as an individual event instead of noting each separate student to comply with ethics standards.
We conclude that APBs were common among veterinary students during SGG for surgery in an academic teaching hospital, and most errors were associated with contamination of the hand towel and gown. Our findings could be useful for efforts to maximize adherence to proper asepsis, such as improving the teaching of veterinary students and modifications to SGG techniques.
Acknowledgments
None reported.
Disclosures
The authors have nothing to disclose. No AI-assisted technologies were used in the composition of this manuscript.
Funding
This study was funded by a generous gift provided by Edward DeBartolo to the University of Florida.
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