Teaching the sterile start: a rapid scoping review and proposed START-OR competency model

Background Surgical hand preparation, patient skin antisepsis, draping readiness and sterile-table set-up are often taught as separate rituals, although delays and failures arise at their interfaces. Evidence also spans microbiology, infection prevention, human factors and education, making it difficult to define what learners should time, observe, communicate and re-check. Methods A rapid scoping review mapped global indexed evidence on three sterile-start processes: surgical hand preparation; the transition from skin antisepsis to draping or incision; and sterile-field or instrument-table set-up. Web of Science and Scopus were searched from inception to 2 August 2026. Records were deduplicated and subjected to a high-recall rule-assisted primary screen. All candidate records underwent eligibility verification, and the full text of every included source was confirmed, verified and analysed by the author team. Data were charted by domain, design, specialty, educational outcome and first indexed affiliation region. Findings were integrated into the proposed Surgical Timing and Aseptic Readiness Tool for the Operating Room (START-OR). Results Of 5747 imported records, 298 duplicates were removed, 747 candidates underwent structured eligibility verification and 143 full-text evidence sources were included after author-team confirmation and analysis. The map comprised 30 education, assessment or implementation sources; 44 surgical hand-preparation sources; 61 skin-preparation sources; and eight sterile-field or table sources. Evidence did not support one universal minute value across products and contexts. Instead, hand preparation required product-specific technique, complete coverage, specified duration and drying; skin preparation required complete visible drying, absence of pooling and fire-risk control before draping; and sterile-field management required minimizing unnecessary open exposure and re-validating integrity after delay. Educational studies identified recurrent gaps in timing accuracy, coverage, feedback, monitoring and shared responsibility. START-OR therefore separates team, patient and field clocks, then reunites them at a voiced sterile-start pause and seven readiness gates. Conclusions Perioperative education should replace memorized universal times with observable readiness criteria, interprofessional verification, simulation of delays and feedback linked to patient-safety outcomes. START-OR is a proposed, unvalidated curriculum and quality-improvement model that requires prospective multicentre testing before clinical adoption.