CSCT cheat sheet

Sterile field: only sterile-draped surfaces and sterile-gowned team members are sterile; the outer edge of a wrapper is considered nonsterile (usually ~2.5 cm / 1 inch border).

A sterile person must stay within the sterile field; below the level of the sterile field or table edge is considered contaminated.

Gowns are sterile only from chest to waist level and sleeve to cuff; back, shoulders, and below waist are nonsterile.

Gloved hands are sterile; once a sterile glove touches a nonsterile surface it is contaminated and must be changed.

Movement rule: sterile personnel pass face-to-face or back-to-back; never turn the back to a sterile field.

Airborne contamination: keep talking, movement, and door traffic minimal; the sterile team should not sneeze or cough over the field.

A break in sterile technique is corrected by re-draping or re-gloving, not by wiping the area with a sponge.

Room air handling: positive-pressure ORs with HEPA filtration typically achieve ≥15 air exchanges per hour (≥20 for ortho/transplant in many guidelines).

Scrub technique: surgical scrub removes transient flora and reduces resident flora; alcohol-based rubs require pre-wash and dry time per manufacturer.

Spaulding classification: critical items (enter sterile tissue/body cavity) require sterilization; semicritical (contact mucous membranes) require high-level disinfection; noncritical (intact skin) require low-level disinfection.

Steam sterilization: 121°C (250°F) at 15 psi for ~30 min, or 132–134°C (270°F) at ~27–30 psi for ~4 min (gravity displacement); pre-vacuum cycles are shorter.

Sterilization parameters are temperature, pressure, and time; monitoring uses mechanical, chemical (indicators), and biological (spore) methods.

Biological indicators: Geobacillus stearothermophilus for steam; Bacillus atrophaeus for ethylene oxide and dry heat.

Sterile storage: wrapped sterile items remain sterile indefinitely if package integrity is maintained and storage is clean, dry, and controlled; event-related sterility replaces arbitrary shelf-life dates.

Instrument decontamination order: point-of-use treatment, transport in closed container, cleaning (manual/ultrasonic), rinsing, drying, inspection, packaging, sterilization, storage.

High-level disinfectants: glutaraldehyde, ortho-phthalaldehyde (OPA), hydrogen peroxide, peracetic acid; require appropriate contact time and employee exposure controls.

Flash sterilization/IMPRES is for emergencies only; it bypasses packaging and shelf life and requires immediate use.

Universal protocol: verify patient identity, procedure, and site; mark the site; conduct a time-out with the full team before incision.

Surgical site marking is required for procedures involving laterality, multiple structures, or levels; the mark is made by the surgeon and remains visible after prep.

Preop skin prep: cleanse with approved antiseptic (chlorhexidine-alcohol or povidone-iodine); allow full dry time; do not blot; prep from clean to dirty (incision site outward).

Hair removal, if required, is done with clippers immediately before surgery; razors increase SSI risk.

Positioning principles: maintain body alignment, protect pressure points, pad bony prominences, prevent shearing, and secure the patient before draping.

Common positions: supine, Trendelenburg (head down), reverse Trendelenburg (head up), lithotomy, prone, lateral, Fowler, and Kraske (jackknife).

Pressure injury risk: interface pressure, immobility, moisture, and duration; document skin assessment and padding before and after positioning.

Safe transport: verify identity, procedure, consent, allergies, NPO status, and side rails; ensure adequate personnel and monitoring during transfer.

Anesthesia safety: confirm NPO status (typically 2 h clear liquids, 6 h light meal, 8 h fatty meal per ASA), allergies, and preop checklist before induction.

Team roles: surgeon, first assistant (retraction, hemostasis, suturing), scrub person (sterile field, instruments, counts), circulator (nonsterile, documentation, supply, patient advocate).

Instrument passes: pass with the handle toward the surgeon; sharp instruments are passed in a neutral or protected manner; never pass a scalpel by the blade.

Suture handling: identify suture type, size, and needle; keep needle on needle driver; account for all needles and suture ends.

Sponge/supply handling: keep sponges and small items on the field accounted; never leave loose sponges in the wound.

Suction and irrigation: maintain suction patency; irrigation is typically normal saline; document volume and type.

Electrosurgery safety: active electrode kept in holster when not in use; avoid pooling of prep solution; ensure return electrode (grounding pad) has full skin contact.

Hemostasis and counts: anticipate needs, keep the field dry, and communicate changes in patient condition to the team.

Documentation: record supplies used, implants, drains, and any deviations from plan; the circulator maintains the intraoperative record.

Specimen labeling: label at the point of collection with patient identifiers, specimen type, site, and laterality; verify with the surgeon before leaving the room.

Fixative: formalin (10% neutral buffered) for routine tissue; normal saline for fresh/frozen or microbiology; never place a specimen in formalin if frozen section or culture is needed.

Specimen transport: place in a leakproof container, secure the lid, and transport per policy; biohazard labeling is required.

Counted items: sponges, sharps (needles, blades), instruments, and miscellaneous items (e.g., umbilical tape, vessel loops).

Count timing: initial count before incision, count at wound closure, and final count before skin closure/end of procedure; also count on any cavity closure and at shift change.

Count discrepancy: recount; if unresolved, notify the surgeon, search the field and room, and consider intraoperative imaging (x-ray) before closure.

Documentation: record counts, any discrepancy, resolution, and notification in the intraoperative record; the count must be verified by two people.

Never remove a counted item from the room without documenting and communicating to the team.

Standard precautions apply to all patients: hand hygiene, gloves, gown, mask, eye protection based on exposure risk.

Hand hygiene: use alcohol-based rub for routine decontamination; wash with soap and water when hands are visibly soiled or after C. difficile exposure.

PPE sequence (donning): gown, mask, goggles/face shield, gloves; doffing removes gloves first, then goggles, gown, mask, with hand hygiene after.

Sharps safety: never recap needles by hand; use a one-handed scoop or safety device; dispose in puncture-resistant sharps container at point of use.

Needlestick exposure: wash the site with soap and water, report immediately, and follow post-exposure prophylaxis protocol; do not squeeze or use bleach.

Bloodborne pathogens: HBV, HCV, and HIV are the primary concerns; HBV vaccination is recommended for healthcare workers.

Surgical smoke: electrosurgery and lasers produce smoke that may contain infectious and toxic material; use smoke evacuation.

Waste segregation: sharps in sharps containers; biohazard waste in red bags; regular waste in clear/black bags per facility policy.

Occupational safety: report all exposures; follow facility injury and exposure reporting requirements.

Malignant hyperthermia: triggered by volatile anesthetics and succinylcholine; signs include hypercarbia, tachycardia, rigidity, and hyperthermia; treat with dantrolene and supportive measures.

Anaphylaxis: epinephrine is first-line; recognize airway, breathing, and circulation compromise; call for help.

Cardiac arrest in the OR: initiate CPR, defibrillate if indicated, and follow ACLS; the sterile field may need to be broken to allow effective resuscitation.

Fire safety (RACE): Rescue, Alarm, Contain, Extinguish/Evacuate; in the OR, remove the patient from the source of fire and stop the flow of oxygen.

Surgical fire triad: oxidizer (oxygen), ignition source (electrosurgery/laser), and fuel (drapes, prep solution, hair); prevent by allowing prep to dry and managing oxygen.

Sentinel event: an unexpected occurrence involving death or serious injury; requires immediate investigation and root cause analysis.

Patient safety: use the time-out, verify site/side, and speak up for any safety concern; a culture of safety encourages reporting without blame.

Emergency equipment: know location of code cart, defibrillator, and fire extinguishers; verify functionality per policy.

Scope of practice: perform only tasks within your training, certification, and state/facility policy; ask for help when unsure.

Consent: informed consent must be obtained by the provider performing the procedure; verify the consent is signed and matches the procedure before the time-out.

Confidentiality: protected health information is shared only on a need-to-know basis; HIPAA applies in all settings, including hallways and elevators.

Documentation: record objectively and contemporaneously; include patient identifiers, procedure, counts, specimens, implants, and any unusual events.

Never alter or falsify a record; late entries are marked as such with date and time; correct errors with a single line and initials, not by erasing.

Advocacy: the surgical technologist advocates for patient safety, dignity, and privacy; speak up about unsafe practices.

Professionalism: maintain competence through continuing education; follow sterile technique and ethical standards; report impaired colleagues.

Chain of custody: for legal or forensic specimens, maintain an unbroken documented chain of custody.

Team communication: use closed-loop communication and SBAR for handoffs to reduce errors.

Scope of practice: perform only tasks within your training, certification, and state/facility policy; ask for help when unsure.

Consent: informed consent must be obtained by the provider performing the procedure; verify the consent is signed and matches the procedure before the time-out.

Confidentiality: protected health information is shared only on a need-to-know basis; HIPAA applies in all settings, including hallways and elevators.

Documentation: record objectively and contemporaneously; include patient identifiers, procedure, counts, specimens, implants, and any unusual events.

Never alter or falsify a record; late entries are marked as such with date and time; correct errors with a single line and initials, not by erasing.

Advocacy: the surgical technologist advocates for patient safety, dignity, and privacy; speak up about unsafe practices.

Professionalism: maintain competence through continuing education; follow sterile technique and ethical standards; report impaired colleagues.

Chain of custody: for legal or forensic specimens, maintain an unbroken documented chain of custody.

Team communication: use closed-loop communication and SBAR for handoffs to reduce errors.