- Email: [email protected]
Clinical Issues—August 2014
CONTINUING EDUCATION Clinical Issues AMBER WOOD, MSN, RN, CNOR, CIC, CPN; RAMONA L. CONNER, MSN, RN, CNOR; MARK E. BRULEY, CCE; CHRIS LAVANCHY, BSME, BS; GAIL M. HORVATH, MSN, RN, CNOR, CRCST
1.9 www.aorn.org/CE
Continuing Education Contact Hours
Approvals
indicates that continuing education (CE) contact hours are available for this activity. Earn the CE contact hours by reading this article, reviewing the purpose/goal and objectives, and completing the online Learner Evaluation at http://www .aorn.org/CE. Each applicant who successfully completes this program can immediately print a certificate of completion.
This program meets criteria for CNOR and CRNFA recertification, as well as other CE requirements. AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this activity for relicensure.
Event: #14528 Session: #0001 Fee: Members $15.20, Nonmembers $30.40
Conflict of Interest Disclosures
The contact hours for this article expire August 31, 2017. Pricing is subject to change.
Purpose/Goal To provide the learner with knowledge of AORN’s recommended practices related to cyanoacrylate microbial sealants, enhanced environmental cleaning, antibiotic stewardship programs, and blanket-warming temperatures.
Objectives 1. Discuss practices that could jeopardize safety in the perioperative area. 2. Discuss common areas of concern that relate to perioperative best practices. 3. Describe implementation of evidence-based practice in relation to perioperative nursing care.
Amber Wood, MSN, RN, CNOR, CIC, CPN; Ramona L. Conner, MSN, RN, CNOR; Mark E. Bruley, CCE; Chris Lavanchy, BSME, BS; and Gail M. Horvath, MSN, RN, CNOR, CRCST, have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article. The behavioral objectives for this program were created by Helen Starbuck Pashley, MA, BSN, CNOR, clinical editor, with consultation from Susan Bakewell, MS, RN-BC, director, Perioperative Education. Ms Starbuck Pashley and Ms Bakewell have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article.
Sponsorship or Commercial Support No sponsorship or commercial support was received for this article.
Disclaimer Accreditation AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
AORN recognizes these activities as CE for RNs. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity.
http://dx.doi.org/10.1016/j.aorn.2014.05.008
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This Month Cyanoacrylate microbial sealants Key words: sealant, microbial sealant, surgical site infections, SSIs.
Enhanced environmental cleaning Key words: cleaning, enhanced cleaning, multidrug-resistant organisms, MDROs, infection transmission.
Antibiotic stewardship programs Key words: stewardship, stewardship programs, antibiotics, multidrug-resistant organisms, MDROs, Clostridium difficile, C diff.
Blanket-warming cabinet temperature settings Key words: blankets, warming, temperature settings, warming cabinets.
Cyanoacrylate microbial sealants QUESTION: Should cyanoacrylate microbial sealants be used to reduce the risk of surgical site infections (SSIs)? ANSWER: The US Food and Drug Administration (FDA) classifies cyanoacrylate microbial sealants as surgical drapes and drape accessories.1 Microbial sealants are applied to the skin after preoperative patient skin antisepsis. The purpose of using a sealant is to seal the skin and prevent skin flora and other bacteria from migrating to the surgical incision.2 The benefits of using cyanoacrylate microbial sealants might include a reduced microbial load on the skin before incision and a lower risk of developing an SSI.2 Possible harms of using
cyanoacrylate microbial sealants include allergic reaction or hypersensitivity to the product.2 There might also be a risk of wound contamination if the product flakes off and falls into the wound, cases of which have been reported to the FDA.3 A review of the literature shows that there is insufficient evidence to determine whether use of cyanoacrylate microbial sealants reduces the risk of SSIs. In a Cochrane Database review, the reviewers evaluated three randomized controlled trials of 524 patients undergoing clean surgery.2 Although they found significantly fewer SSIs in the group using microbial sealants (n ¼ 261) compared with the control group (n ¼ 274), the reviewers advised caution when interpreting their results because of the small sample sizes and low quality of the studies. The studies also were limited by the lack of http://dx.doi.org/10.1016/j.aorn.2014.05.008
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CLINICAL ISSUES statistical power to determine the sealants’ effect on SSI as an outcome. The reviewers recommended that additional, higher-quality studies be performed to determine the effect of using cyanoacrylate microbial sealants for reduction of SSI. To help determine whether these products merit use in a facility, a multidisciplinary team that includes perioperative nurses, surgeons, and infection preventionists could evaluate these FDA-cleared products for the prevention of SSI. The multidisciplinary team members should use the health care organization’s mechanism for evaluating and selecting existing and emerging products, including performing a risk/benefit/cost analysis and reviewing the literature. Use of a process for product selection, including evaluation of productspecific criteria (ie, safety, performance, evidencebased efficacy, financial impact analysis) is recommended in AORN’s “Recommended practices
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for product selection in perioperative practice settings.”4 AMBER WOOD MSN, RN, CNOR, CIC, CPN PERIOPERATIVE NURSING SPECIALIST AORN NURSING DEPARTMENT References 1. Product classification. US Food and Drug Administration. http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpcd/ classification.cfm?ID¼2519. Accessed April 2, 2014. 2. Lipp A, Phillips C, Harris P, Dowie I. Cyanoacrylate microbial sealants for skin preparation prior to surgery. Cochrane Database Syst Rev. 2013;8:CD008062. 3. MAUDE Adverse Event Report. Medlogic Global Limited Kimberly-Clark Integuseal Microbial Sealant Cyanoacrylate Based Sealant. US Food and Drug Administration. http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfmaude/ detail.cfm?mdrfoi__id¼909670. Accessed April 2, 2014. 4. Recommended practices for product selection in perioperative practice settings. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2014: 209-216.
Enhanced environmental cleaning QUESTION: When should enhanced environmental cleaning be performed, and what does it involve? ANSWER: Enhanced environmental cleaning should be performed after the care of patients who are infected or colonized with multidrug-resistant organisms (MDROs), such as methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococcus (VRE), carbapenem-resistant Enterobacteriaceae, and extended-spectrum betalactamaseeproducing organisms.1,2 Enhanced environmental cleaning is defined as cleaning practices that are implemented to prevent the spread or outbreak of infections and that promote consistent and standardized cleaning procedures that extend beyond routine cleaning. 1 The purpose of enhanced environmental cleaning is to decrease environmental contamination on high-touch surfaces, whether the surface has a high risk (eg, OR bed) or low risk (eg, light
switch) of transmitting pathogens to another patient. The results of a nonexperimental study demonstrated that environmental contamination was the main reason for transmission of MDROs to health care workers’ clothing, gloves, and gowns.3 Researchers have shown that removing MDROs from environmental surfaces is important in the prevention of MDRO transmission to health care workers. A quasi-experimental study showed that enhanced cleaning reduced environmental contamination with MRSA and VRE and decreased the risk of transmission among patients from the room’s previous occupant.4 Comparatively, in a randomized controlled trial of intense cleaning procedures in intensive care unit rooms after occupancy by patients with MRSA and multidrug-resistant Acinetobacter, researchers did not find a significant difference between intense and standard cleaning procedures in reducing contamination of health care workers’ gowns and gloves.5 Although researchers conducted these studies in inpatient units, AORN Journal j 215
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the results have implications for the perioperative setting where personnel have frequent hand contact with patients and environmental surfaces during patient care activities. Despite the different findings between studies, the evidence supporting enhanced environmental cleaning is sufficient for AORN to recommend enhanced environmental cleaning after treating patients with MDROs as a minimum standard of care. The status of a patient colonized or infected with MDROs may not be known at the time care is provided. Unlike bloodborne pathogens, however, preventing the spread of MDROs by cleaning practices is not currently supported in the literature as a universal approach for all patients; rather, the current recommendation to prevent the spread of MDROs is using a targeted approach. As part of targeted efforts to control the spread of MDROs, enhanced cleaning and isolation precautions should be performed when caring for patients who are suspected or confirmed to be colonized or infected with an MDRO. Based on an evaluation of emerging literature, some facilities may not perform special cleaning processes or use isolation precautions for patients with an MDRO unless the facility is experiencing an outbreak. The Centers for Disease Control and Prevention does not currently address this practice but recommends using isolation precautions and intensified cleaning to control the spread of MDROs.6 The multidisciplinary team at a facility may either implement no special cleaning practices for patients with MDROs or apply enhanced cleaning for all patients regardless of their infective status. Choosing not to use special cleaning practices is not in alignment with the current AORN recommendation for enhanced environmental cleaning. In deciding on a cleaning process, the multidisciplinary team should conduct a risk/ benefit/cost analysis to determine the most effective method based on their infection control plan. Routine environmental cleaning in the perioperative setting involves cleaning contaminated objects and some high-touch objects that are a high risk of transmitting microorganisms to patients. In 216 j AORN Journal
contrast, enhanced environmental cleaning involves cleaning all touched objects regardless of contamination. For example, routine cleaning after every patient in the OR does not typically include cleaning light switches and door handles because there is a low risk of transferring pathogens between patients, but these items should be cleaned as part of enhanced cleaning to control the spread of MDROs. Personnel should perform enhanced environmental cleaning after the patient leaves the room or area (eg, bay).1,5 Personnel who perform environmental cleaning and disinfection should wear an isolation gown and gloves when cleaning areas where patients who are infected or colonized with an MDRO have received care.1,2 As part of routine cleaning procedures in the operating or procedure room, perioperative team members should clean and disinfect any items and high-touch objects that were used, soiled, or potentially soiled with splash, spray, or splatter. Cleaning team members also should remove trash and used linen from receptacles in the room. High-touch objects with a high risk of transmitting microorganisms to a patient in the OR include the anesthesia cart and equipment, anesthesia machine, patient monitors, OR bed, and safety strap. During routine cleaning, all items that are used for patient care should be cleaned, including n n
n n n n
OR bed attachments (eg, arm boards, stirrups, head rests), positioning devices (eg, gel rolls, circular padded headrest, vacuum pack positioning devices), patient transfer devices (eg, roll boards), overhead procedure lights, tables and Mayo stands, and equipment that may be either mobile or mounted (eg, suction regulator, medical gas regulator, imaging viewer, viewing monitors, radiology equipment, electrosurgical unit, microscope, robot, laser).
High-touch objects in the perioperative area include privacy curtains, patient monitors, patient
CLINICAL ISSUES beds, over-the-bed tables, television remote controls, and call lights. To extend routine cleaning procedures into enhanced environmental cleaning, team members should use a US Environmental Protection Agency (EPA)-registered disinfectant to clean and disinfect all high-touch objects, even if they have a low risk of transmitting infection to a patient (eg, control panels, switches, knobs, work areas, handles, door push plates, telephones, computers, chairs, receptacle lids), as well as specific items or surfaces that have been touched by the patient with the MDRO or personnel in the course of patient care.1,5 Team members should mop the floor with an EPA-registered disinfectant after the patient leaves the room or bay if the floor is soiled or was potentially soiled with splash, spray, or splatter during the procedure or patient care activities. Items that contact patients who are infected or colonized with MDROs are considered to be contaminated with MDROs. If any item or article of linen that was previously in contact with the patient touches the floor, the floor should be disinfected. Team members should mop any soiled, potentially soiled, or contaminated areas of the floor, including the adjacent surrounding areas, taking care to mop the cleanest areas first to avoid cross-contamination from dirty areas. The cleanest area may be determined by visible soil or proximity to the area of patient care. Cleaning personnel should inspect all
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areas of the floor for cleanliness, including under the OR bed and areas exposed to contamination during the procedure or patient care activities. If the area of potential soil or contamination is unknown, team members should mop the entire floor. AMBER WOOD MSN, RN, CNOR, CIC, CPN PERIOPERATIVE NURSING SPECIALIST AORN NURSING DEPARTMENT References 1. Recommended practices for prevention of transmissible infections in the perioperative practice setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2014:385-420. 2. Recommended practices for environmental cleaning. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2014:255-276. 3. Morgan DJ, Rogawski E, Thom KA, et al. Transfer of multidrug-resistant bacteria to healthcare workers’ gloves and gowns after patient contact increases with environmental contamination. Crit Care Med. 2012;40(4): 1045-1051. 4. Datta R, Platt R, Yokoe DS, Huang SS. Environmental cleaning intervention and risk of acquiring multidrugresistant organisms from prior room occupants. Arch Intern Med. 2011;171(6):491-494. 5. Hess AS, Shardell M, Johnson JK, et al. A randomized controlled trial of enhanced cleaning to reduce contamination of healthcare worker gowns and gloves with multidrug-resistant bacteria. Infect Control Hosp Epidemiol. 2013;34(5):487-493. 6. Siegel JD, Rhinehart E, Jackson M, Chiarello L; Healthcare Infection Control Practices Advisory Committee. Management of Multidrug-Resistant Organisms in Healthcare Settings, 2006. Atlanta, GA: Centers for Disease Control and Prevention; 2006.
Antibiotic stewardship programs QUESTION: Our infection prevention committee is creating an antibiotic stewardship program in collaboration with members of the pharmacy department. What is antibiotic stewardship, and how does it affect perioperative RNs? ANSWER: Antibiotic stewardship programs have emerged in the literature as a mechanism to improve antibiotic use, optimize treatment of infections, and reduce
adverse events associated with antibiotic use (eg, Clostridium difficile infection, antibiotic resistance).1 These programs may improve patient care from a quality and safety perspective by increasing cures from infections, reducing treatment failure, helping to ensure correct prescribing of antibiotic therapy for both treatment and prophylaxis, and reducing health care costs.1 In 2014, the Centers for Disease Control and Prevention (CDC) recommended that all acute care hospitals implement antibiotic stewardship programs.1 AORN Journal j 217
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Antibiotic stewardship programs measure compliance with the program goals through process and outcome measures. For processes, the antibiotic stewardship team should determine whether the facility’s policies and clinical practice guidelines are being followed. When evaluating outcomes (eg, morbidity and mortality, use of antibiotics), the team should assess interventions to determine whether they resulted in improvements in patient outcomes. The CDC recommends that nurses participate in antibiotic stewardship programs by verifying that cultures are performed before starting antibiotics (ie, except when used for surgical prophylaxis); reviewing antibiotic medications; and prompting discussions with medical team members about antibiotic treatment, indication, and duration of treatment.1 In the perioperative setting, process measures for antibiotic stewardship programs focus on developing and implementing facility-specific treatment recommendations for surgical antibiotic prophylaxis based on clinical practice guidelines, facility antibiograms (ie, charts of bacteria antibiotic susceptibilities), and formulary options.1 Process development measures may result in establishing order sets for preoperative antibiotic prophylaxis. When using order sets as a process measure, the antibiotic stewardship program team should monitor compliance with selection of antibiotics on the order sets that are facility approved.
Perioperative RNs can support the antibiotic stewardship program by identifying barriers to compliance with selection of facility-approved antibiotics and discussing these barriers with the program team members as well as suggesting ways to improve antibiotic stewardship compliance. When administering surgical antibiotic prophylaxis, perioperative RNs may encounter automatic time-sensitive stop orders, which are another strategy for antibiotic stewardship. A core element of hospital antibiotic stewardship programs is regular reporting of information regarding antibiotic use and resistance to physicians, nurses, and clinical personnel by the antibiotic stewardship team. Perioperative RNs should be familiar with the mission of the antibiotic stewardship program at their facility, watch for reports from the antibiotic stewardship program team, participate in program initiatives, and provide constructive feedback to the team on the barriers and successes of the program implementation in the perioperative setting. AMBER WOOD MSN, RN, CNOR, CIC, CPN PERIOPERATIVE NURSING SPECIALIST AORN NURSING DEPARTMENT Reference 1. CDC core elements of hospital antibiotic stewardship programs. Centers for Disease Control and Prevention. http://www.cdc.gov/getsmart/healthcare/implementation/ core-elements.html. Accessed April 2, 2014.
Blanket warming cabinet temperature settings QUESTION: A recent letter to the AORN Journal editor1 discussed research that does not appear to support the blanket warming temperature recommendations in the AORN “Recommended practices for a safe environment of care”2 and the ECRI Institute recommendations.3 Considering this new evidence, should we change our policy for the blanket warming cabinet maximum temperature setting?
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ANSWER: AORN encourages perioperative RNs to use evidence-based practice as the foundation on which to base patient care. As new compelling evidence arises, health care organization personnel may determine that it is appropriate to change a practice or policy based on this new evidence. Not all research articles, however, warrant a change in practice, and any change in practice should be made only after careful and systematic evaluation
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of the evidence. This includes appraising the level and quality of evidence and considering any limitations of the studies. The 2009 article by Bujdoso4 was cited by Kelly et al5 as evidence for reconsidering the AORN recommended maximum temperature limit of 130 F (54.4 C) for blanket warming cabinets. Bujdoso’s study examined patient safety and comfort issues associated with blankets from warming cabinets set to different temperatures; however, the study has significant limitations that render it insufficient as evidence for reconsidering the current recommended temperature limit noted in the “Recommended practices for a safe environment of care.”2 The limitations include the following: The article4 states that irrigation solution bags should be stored at a temperature lower than 150 F (65.6 C) but fails to point out that patients can be burned in a matter of seconds at skin temperatures below that. A classic extensive human study published in 19476 shows that, for example, irrigation solution warmed to 145 F (62.8 C) can burn human skin in less than five seconds. 4 n The study does not address the potential burn risks of using an overly heated, unfolded blanket on an unconscious or insensate patient. n
TABLE 1. Summary of Data
n
Bujdoso4 incorrectly states that Moritz and Henriques6 found that thermal damage can occur when skin is heated to a temperature of 117 F (47.2 C) to 119 F (48.3 C). The Moritz and Henriques6 study actually showed that burns can occur at a temperature as low as 111 F (43.9 ).
Table 1 presents a summary of the human data from the study by Moritz and Henriques.6 Although comfort, which was the focus of the research by Bujdoso,4 is clinically important for patient care and satisfaction, it is not a reliable metric for assessing the thermal safety of a warmed product, including a folded or rolled blanket, especially for use on unconscious or insensate patients. Bujdoso4 focused on the recommendation of a maximum temperature limit of 110 F (43.3 C) for fluid and blanket warming cabinets initially published by the ECRI Institute in 2005.3 In 2009, based on increased clinical awareness of the hazard of patient burns and to better accommodate patient comfort, the ECRI Institute published updated recommendations for temperature settings on blanket warming cabinets, stating that 130 F (54.4 C) was appropriate as a maximum setting. 7 The ECRI Institute continues to recommend that cabinets used to heat solutions be limited to 110 F (43.3 C).8
1
Temperature
Minimum exposure time for first-degree burn
Maximum exposure time for second- or third-degree burns
111 113 119 121 123 131 140
5 hours 2 hours 15 minutes 2 minutes 30 seconds 20 seconds 3 seconds
6 hours 3 hours 15 minutes 4 minutes 30 seconds 30 seconds 5 seconds
F F F F F F F
(43.9 (45.0 (48.3 (49.4 (50.6 (55.0 (60.0
C) C) C)a C) C)a C) C)
N ¼ 8 human subjects. a
The minimum exposures times until burning for first-degree and second- or third-degree burns are correctly shown. The times are the same for 119 F (48.3 C) and 123 F (50.6 C) because they are minimums for the eight test subjects, some of whom were more or less sensitive to the applied temperature.
1. Moritz AR, Henriques FC. Studies of thermal injury, II: the relative importance of time and surface temperature in the causation of cutaneous burns. Am J Pathol. 1947;23(5):695-720.
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Additional studies that have added recently to the discussion of appropriate blanket temperatures are by Kelly et al5 and Sutton et al.9 The authors of these two studies examined outcomes of using higher blanket temperatures than are recommended by AORN. The prospective, comparative, descriptive study by Kelly et al5 examined the thermal comfort and safety of warmed cotton blankets. The study was performed in a single setting and involved 20 healthy, alert, female participants who were provided blankets from warmers that were set to 130 F (54.4 C) or 200 F (93.3 C). The participants were then asked to rate their thermal comfort as ‘‘too warm,” “too cool,” or “just right.” The researchers also measured the participants’ skin temperature on the arm, abdomen, and lower leg after blanket application. The authors found that no participants had skin temperatures that approached the levels necessary to cause skin burns, and based on the higher thermal comfort rating, they recommended that blankets from a warmer set at 200 F (93.3 C) should be used. Using the AORN Evidence Appraisal tool, this article was appraised and given a score of III for level of evidence because it is a prospective, comparative, descriptive study. The quality of the article was appraised and scored as level C because the sample size was small and homogeneous. A complete description of the AORN evidence rating method is provided in AORN’s Perioperative Standards and Recommended Practices.10 In addition, a limitation of the study not identified by Kelly et al5 was that the blanket warmers were set at 130 F (54.4 C) and 200 F (93.3 C) but the in-cabinet blanket temperature only reached 109.4 F (43.0 C) to 118 F (47.8 C) with a mean of 112.8 F (44.9 C) and 158 F (70.0 C) to 183.6 F (84.2 C) with a mean of 168.7 F (75.9 C), respectively. This is a limitation because the participants never received a blanket that had been warmed to the set temperatures as reported. The quasi-experimental study by Sutton et al9 was conducted in a 26-bed postanesthesia care unit 220 j AORN Journal
CLINICAL ISSUES located in a 384-bed metropolitan hospital. The study had a sample size of 156, which the authors determined was large enough to render the results generalizable. The researchers divided the participants into two groups. Participants in the intervention group (n ¼ 76) received blankets warmed to 155 F (68.3 C), and participants in the control group (n ¼ 80) received blankets warmed to 110 F (43.3 C). The researchers measured the participants’ thermal comfort, which was reported on a scale of 0 to 10 (10 being most comfortable), and their oral and skin temperatures. The researchers found that the average skin temperatures increased from the first time measured (ie, baseline) and the end of sampling (ie, 10 minutes later) in both groups. Based on these results, the authors concluded that the blankets, independent of the temperature to which they were warmed, exerted similar warming effects on the skin. The participants in the intervention group reported a higher thermal comfort level throughout the 10-minute data collection period with only slightly higher skin temperatures. The article was appraised and scored as a II for level of evidence and B for quality of evidence because of its limitations. The authors did not report any limitations of the study, but AORN2 and the ECRI Institute8 consider the use of a temperature that is higher than the current recommendations from the ECRI Institute and AORN to be a limitation. The authors of these studies5,9 did not adequately address the issue of potential risk of thermal injuries, ranging from minor skin irritation (eg, redness) to partial- or full-thickness burns, from the increased temperature setting when blankets were folded or rolled against the skin of semiconscious individuals. The ECRI Institute recently reiterated such risks in an organizational opinion statement, noting that increased temperature settings might lead to unintended consequences, highlighting the multiple stages of injury related to thermal mechanics and describing heat transference.8 Another consideration is blanket material. Studies4,5,9 that have investigated blanket temperature presumed that blankets were made of cotton;
CLINICAL ISSUES however, the opportunity exists for noncotton blankets to be present, and little is known about the risk of heating semisynthetic fiber blankets. The issue of having a warmed blanket that exceeds the recommendations in AORN’s recommended practices raises the question of safety versus comfort. Although patient comfort is an important patient care consideration, safety should be the priority consideration. The collective limitations of the studies5,9 included the failure to consider folded or rolled blankets; the failure to consider unconscious or insensate patients; use of only awake, healthy, volunteer test subjects; small sample sizes; and thermal comfort measured on different scales. Thermal comfort measures are subjective measurements, and the researchers5,9 established no direct relationship to patient outcomes. Including folded blankets is important because the folded blanket does not lose its heat as fast as an unfolded blanket.6 The inclusion of only awake patients is a limitation because many of the patients in a perioperative setting are not awake and therefore cannot report whether the blanket is too hot. The collective benefits of the studies5,9 were that the participants’ skin temperatures increased only slightly and that the reported thermal comfort rating rose with the warmer blankets. The risk of patient burn may still exist, especially with the use of a rolled blanket on an unconscious patient. The collective evidence does not support a change in the current recommendation because the benefits of the change are not great enough to outweigh the risks. Changes in practice should be carefully considered and should not be based on studies that have serious limitations or are of low levels of evidence or quality. In this instance, the most serious limitation is that these studies5,9 do not address the application of very hot rolled or folded blankets from warming cabinets to unconscious or insensate patients. The ECRI Institute recommendation of a maximum temperature of 130 F (54.4 C) for
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blankets is based on evidence from firsthand, detailed, in-hospital clinical accident investigations of multiple cases of patient burns at four facilities during a 10-year period.8,11 This evidence is more detailed than, but somewhat analogous to, that derived from a closed claims analysis of insurance files,11 on which other clinical policies and procedures are based. The ECRI Institute recently republished its updated recommendations and presented more detailed information about its investigations of burn accidents involving patients that led to the 130 F (54.4 C) recommended temperature limit.8 The fundamental patient safety issue warranting a 130 F (54.4 C) limit is that there is no way to reliably prevent folded or rolled blankets that come out of an overly heated warming cabinet from being applied to unconscious or insensate patients. AORN2 and the ECRI Institute8 continue to recommend an upper temperature limit of 130 F (54.4 C) for blanket warming cabinets. RAMONA L. CONNER MSN, RN, CNOR MANAGER, STANDARDS AND RECOMMENDED PRACTICES AORN NURSING DEPARTMENT
MARK E. BRULEY CCE VICE PRESIDENT ACCIDENT AND FORENSIC INVESTIGATION ECRI INSTITUTE CHRIS LAVANCHY BSME, BS ENGINEERING DIRECTOR HEALTH DEVICES GROUP ECRI INSTITUTE GAIL M. HORVATH MSN, RN, CNOR, CRCST PATIENT SAFETY ANALYST/CONSULTANT III ECRI INSTITUTE PSO HEALTHCARE QUALITY & INSIGHT ASSESSMENT SERVICES RISK MANAGEMENT ECRI INSTITUTE
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References 1. Morse E, Sands T, Kelly P, Krogh M. Reconsidering recommendations for blanket warming [Letter to the Editor]. AORN J. 2014;99(3):353-355. 2. Recommended practices for a safe environment of care. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2014:229-253. 3. ECRI Institute. Limiting temperature settings on blanket and solution warming cabinets can prevent patient burns. Health Devices. 2005;34(5):168-171. 4. Bujdoso PJ. Blanket warming: comfort and safety. AORN J. 2009;89(4):717-722. 5. Kelly PA, Cooper SK, Krogh ML, et al. Thermal comfort and safety of cotton blankets warmed at 130 F and 200 F. J Perianesth Nurs. 2013;28(6):337-346. 6. Moritz AR, Henriques FC. Studies of thermal injury, II: the relative importance of time and surface temperature in the causation of cutaneous burns. Am J Pathol. 1947; 23(5):695-720. http://www.ncbi.nlm.nih.gov/pmc/articles/ PMC1934304/pdf/amjpathol00502-0018.pdf. Accessed May 6, 2014.
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CLINICAL ISSUES 7. ECRI Institute. Hazard report update. ECRI Institute revises its recommendation for temperature limits on blanket warmers. Health Devices. 2009;38(7):230-231. 8. ECRI Institute. H0225: Normal Priority Medical Device Alert. ECRI Institute Continues To Recommend Maximum Temperature Setting of 130 F for Blanket Warming Cabinets. Health Devices Alerts. Plymouth Meeting, PA: ECRI Institute; 2014. https://www.ecri.org/Documents/ Health_Devices/Blanket_warming_cabinets_130F_ Hazard(Health_Devices_Alerts).pdf. Accessed May 14, 2014. 9. Sutton LT, Baker FS, Faile NJ, Tavakoli A. A quasi experimental study examining the safety profile and comfort provided by two different blanket temperatures. J Perianesth Nurs. 2012;27(3):181-192. 10. Introduction to the AORN recommended practices. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2014:43-48. 11. Cheney FW, Posner KL, Caplan RA, Gild WM. Burns from warming devices in anesthesia. A closed claims analysis. Anesthesiology. 1994;80(4):806-810.
LEARNER EVALUATION
1.9
CONTINUING EDUCATION PROGRAM
Clinical Issues
T
his evaluation is used to determine the extent to which this continuing education program met your learning needs. The evaluation is printed here for your convenience. To receive continuing education credit, you must complete the online Learner Evaluation at http://www.aorn.org/CE. Rate the items as described below. PURPOSE/GOAL To provide the learner with knowledge of AORN’s recommended practices related to cyanoacrylate microbial sealants, enhanced environmental cleaning, antibiotic stewardship programs, and blanket-warming temperatures. OBJECTIVES To what extent were the following objectives of this continuing education program achieved? 1. Discuss practices that could jeopardize safety in the perioperative area. Low 1. 2. 3. 4. 5. High 2. Discuss common areas of concern that relate to perioperative best practices. Low 1. 2. 3. 4. 5. High 3. Describe implementation of evidence-based practice in relation to perioperative nursing care. Low 1. 2. 3. 4. 5. High CONTENT 4. To what extent did this article increase your knowledge of the subject matter? Low 1. 2. 3. 4. 5. High
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5. To what extent were your individual objectives met? Low 1. 2. 3. 4. 5. High 6. Will you be able to use the information from this article in your work setting? 1. Yes 2. No 7. Will you change your practice as a result of reading this article? (If yes, answer question #7A. If no, answer question #7B.) 7A. How will you change your practice? (Select all that apply) 1. I will provide education to my team regarding why change is needed. 2. I will work with management to change/ implement a policy and procedure. 3. I will plan an informational meeting with physicians to seek their input and acceptance of the need for change. 4. I will implement change and evaluate the effect of the change at regular intervals until the change is incorporated as best practice. 5. Other: ________________________________ 7B. If you will not change your practice as a result of reading this article, why? (Select all that apply) 1. The content of the article is not relevant to my practice. 2. I do not have enough time to teach others about the purpose of the needed change. 3. I do not have management support to make a change. 4. Other: ________________________________ 8. Our accrediting body requires that we verify the time you needed to complete the 1.9 continuing education contact hour (114-minute) program: _______________________________
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Continuing Education Contact Hours
Approvals
indicates that continuing education (CE) contact hours are available for this activity. Earn the CE contact hours by reading this article, reviewing the purpose/goal and objectives, and completing the online Learner Evaluation at http://www .aorn.org/CE. Each applicant who successfully completes this program can immediately print a certificate of completion.
This program meets criteria for CNOR and CRNFA recertification, as well as other CE requirements. AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this activity for relicensure.
Event: #14528 Session: #0001 Fee: Members $15.20, Nonmembers $30.40
Conflict of Interest Disclosures
The contact hours for this article expire August 31, 2017. Pricing is subject to change.
Purpose/Goal To provide the learner with knowledge of AORN’s recommended practices related to cyanoacrylate microbial sealants, enhanced environmental cleaning, antibiotic stewardship programs, and blanket-warming temperatures.
Objectives 1. Discuss practices that could jeopardize safety in the perioperative area. 2. Discuss common areas of concern that relate to perioperative best practices. 3. Describe implementation of evidence-based practice in relation to perioperative nursing care.
Amber Wood, MSN, RN, CNOR, CIC, CPN; Ramona L. Conner, MSN, RN, CNOR; Mark E. Bruley, CCE; Chris Lavanchy, BSME, BS; and Gail M. Horvath, MSN, RN, CNOR, CRCST, have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article. The behavioral objectives for this program were created by Helen Starbuck Pashley, MA, BSN, CNOR, clinical editor, with consultation from Susan Bakewell, MS, RN-BC, director, Perioperative Education. Ms Starbuck Pashley and Ms Bakewell have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article.
Sponsorship or Commercial Support No sponsorship or commercial support was received for this article.
Disclaimer Accreditation AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
AORN recognizes these activities as CE for RNs. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity.
http://dx.doi.org/10.1016/j.aorn.2014.05.008
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This Month Cyanoacrylate microbial sealants Key words: sealant, microbial sealant, surgical site infections, SSIs.
Enhanced environmental cleaning Key words: cleaning, enhanced cleaning, multidrug-resistant organisms, MDROs, infection transmission.
Antibiotic stewardship programs Key words: stewardship, stewardship programs, antibiotics, multidrug-resistant organisms, MDROs, Clostridium difficile, C diff.
Blanket-warming cabinet temperature settings Key words: blankets, warming, temperature settings, warming cabinets.
Cyanoacrylate microbial sealants QUESTION: Should cyanoacrylate microbial sealants be used to reduce the risk of surgical site infections (SSIs)? ANSWER: The US Food and Drug Administration (FDA) classifies cyanoacrylate microbial sealants as surgical drapes and drape accessories.1 Microbial sealants are applied to the skin after preoperative patient skin antisepsis. The purpose of using a sealant is to seal the skin and prevent skin flora and other bacteria from migrating to the surgical incision.2 The benefits of using cyanoacrylate microbial sealants might include a reduced microbial load on the skin before incision and a lower risk of developing an SSI.2 Possible harms of using
cyanoacrylate microbial sealants include allergic reaction or hypersensitivity to the product.2 There might also be a risk of wound contamination if the product flakes off and falls into the wound, cases of which have been reported to the FDA.3 A review of the literature shows that there is insufficient evidence to determine whether use of cyanoacrylate microbial sealants reduces the risk of SSIs. In a Cochrane Database review, the reviewers evaluated three randomized controlled trials of 524 patients undergoing clean surgery.2 Although they found significantly fewer SSIs in the group using microbial sealants (n ¼ 261) compared with the control group (n ¼ 274), the reviewers advised caution when interpreting their results because of the small sample sizes and low quality of the studies. The studies also were limited by the lack of http://dx.doi.org/10.1016/j.aorn.2014.05.008
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CLINICAL ISSUES statistical power to determine the sealants’ effect on SSI as an outcome. The reviewers recommended that additional, higher-quality studies be performed to determine the effect of using cyanoacrylate microbial sealants for reduction of SSI. To help determine whether these products merit use in a facility, a multidisciplinary team that includes perioperative nurses, surgeons, and infection preventionists could evaluate these FDA-cleared products for the prevention of SSI. The multidisciplinary team members should use the health care organization’s mechanism for evaluating and selecting existing and emerging products, including performing a risk/benefit/cost analysis and reviewing the literature. Use of a process for product selection, including evaluation of productspecific criteria (ie, safety, performance, evidencebased efficacy, financial impact analysis) is recommended in AORN’s “Recommended practices
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for product selection in perioperative practice settings.”4 AMBER WOOD MSN, RN, CNOR, CIC, CPN PERIOPERATIVE NURSING SPECIALIST AORN NURSING DEPARTMENT References 1. Product classification. US Food and Drug Administration. http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpcd/ classification.cfm?ID¼2519. Accessed April 2, 2014. 2. Lipp A, Phillips C, Harris P, Dowie I. Cyanoacrylate microbial sealants for skin preparation prior to surgery. Cochrane Database Syst Rev. 2013;8:CD008062. 3. MAUDE Adverse Event Report. Medlogic Global Limited Kimberly-Clark Integuseal Microbial Sealant Cyanoacrylate Based Sealant. US Food and Drug Administration. http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfmaude/ detail.cfm?mdrfoi__id¼909670. Accessed April 2, 2014. 4. Recommended practices for product selection in perioperative practice settings. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2014: 209-216.
Enhanced environmental cleaning QUESTION: When should enhanced environmental cleaning be performed, and what does it involve? ANSWER: Enhanced environmental cleaning should be performed after the care of patients who are infected or colonized with multidrug-resistant organisms (MDROs), such as methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococcus (VRE), carbapenem-resistant Enterobacteriaceae, and extended-spectrum betalactamaseeproducing organisms.1,2 Enhanced environmental cleaning is defined as cleaning practices that are implemented to prevent the spread or outbreak of infections and that promote consistent and standardized cleaning procedures that extend beyond routine cleaning. 1 The purpose of enhanced environmental cleaning is to decrease environmental contamination on high-touch surfaces, whether the surface has a high risk (eg, OR bed) or low risk (eg, light
switch) of transmitting pathogens to another patient. The results of a nonexperimental study demonstrated that environmental contamination was the main reason for transmission of MDROs to health care workers’ clothing, gloves, and gowns.3 Researchers have shown that removing MDROs from environmental surfaces is important in the prevention of MDRO transmission to health care workers. A quasi-experimental study showed that enhanced cleaning reduced environmental contamination with MRSA and VRE and decreased the risk of transmission among patients from the room’s previous occupant.4 Comparatively, in a randomized controlled trial of intense cleaning procedures in intensive care unit rooms after occupancy by patients with MRSA and multidrug-resistant Acinetobacter, researchers did not find a significant difference between intense and standard cleaning procedures in reducing contamination of health care workers’ gowns and gloves.5 Although researchers conducted these studies in inpatient units, AORN Journal j 215
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the results have implications for the perioperative setting where personnel have frequent hand contact with patients and environmental surfaces during patient care activities. Despite the different findings between studies, the evidence supporting enhanced environmental cleaning is sufficient for AORN to recommend enhanced environmental cleaning after treating patients with MDROs as a minimum standard of care. The status of a patient colonized or infected with MDROs may not be known at the time care is provided. Unlike bloodborne pathogens, however, preventing the spread of MDROs by cleaning practices is not currently supported in the literature as a universal approach for all patients; rather, the current recommendation to prevent the spread of MDROs is using a targeted approach. As part of targeted efforts to control the spread of MDROs, enhanced cleaning and isolation precautions should be performed when caring for patients who are suspected or confirmed to be colonized or infected with an MDRO. Based on an evaluation of emerging literature, some facilities may not perform special cleaning processes or use isolation precautions for patients with an MDRO unless the facility is experiencing an outbreak. The Centers for Disease Control and Prevention does not currently address this practice but recommends using isolation precautions and intensified cleaning to control the spread of MDROs.6 The multidisciplinary team at a facility may either implement no special cleaning practices for patients with MDROs or apply enhanced cleaning for all patients regardless of their infective status. Choosing not to use special cleaning practices is not in alignment with the current AORN recommendation for enhanced environmental cleaning. In deciding on a cleaning process, the multidisciplinary team should conduct a risk/ benefit/cost analysis to determine the most effective method based on their infection control plan. Routine environmental cleaning in the perioperative setting involves cleaning contaminated objects and some high-touch objects that are a high risk of transmitting microorganisms to patients. In 216 j AORN Journal
contrast, enhanced environmental cleaning involves cleaning all touched objects regardless of contamination. For example, routine cleaning after every patient in the OR does not typically include cleaning light switches and door handles because there is a low risk of transferring pathogens between patients, but these items should be cleaned as part of enhanced cleaning to control the spread of MDROs. Personnel should perform enhanced environmental cleaning after the patient leaves the room or area (eg, bay).1,5 Personnel who perform environmental cleaning and disinfection should wear an isolation gown and gloves when cleaning areas where patients who are infected or colonized with an MDRO have received care.1,2 As part of routine cleaning procedures in the operating or procedure room, perioperative team members should clean and disinfect any items and high-touch objects that were used, soiled, or potentially soiled with splash, spray, or splatter. Cleaning team members also should remove trash and used linen from receptacles in the room. High-touch objects with a high risk of transmitting microorganisms to a patient in the OR include the anesthesia cart and equipment, anesthesia machine, patient monitors, OR bed, and safety strap. During routine cleaning, all items that are used for patient care should be cleaned, including n n
n n n n
OR bed attachments (eg, arm boards, stirrups, head rests), positioning devices (eg, gel rolls, circular padded headrest, vacuum pack positioning devices), patient transfer devices (eg, roll boards), overhead procedure lights, tables and Mayo stands, and equipment that may be either mobile or mounted (eg, suction regulator, medical gas regulator, imaging viewer, viewing monitors, radiology equipment, electrosurgical unit, microscope, robot, laser).
High-touch objects in the perioperative area include privacy curtains, patient monitors, patient
CLINICAL ISSUES beds, over-the-bed tables, television remote controls, and call lights. To extend routine cleaning procedures into enhanced environmental cleaning, team members should use a US Environmental Protection Agency (EPA)-registered disinfectant to clean and disinfect all high-touch objects, even if they have a low risk of transmitting infection to a patient (eg, control panels, switches, knobs, work areas, handles, door push plates, telephones, computers, chairs, receptacle lids), as well as specific items or surfaces that have been touched by the patient with the MDRO or personnel in the course of patient care.1,5 Team members should mop the floor with an EPA-registered disinfectant after the patient leaves the room or bay if the floor is soiled or was potentially soiled with splash, spray, or splatter during the procedure or patient care activities. Items that contact patients who are infected or colonized with MDROs are considered to be contaminated with MDROs. If any item or article of linen that was previously in contact with the patient touches the floor, the floor should be disinfected. Team members should mop any soiled, potentially soiled, or contaminated areas of the floor, including the adjacent surrounding areas, taking care to mop the cleanest areas first to avoid cross-contamination from dirty areas. The cleanest area may be determined by visible soil or proximity to the area of patient care. Cleaning personnel should inspect all
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areas of the floor for cleanliness, including under the OR bed and areas exposed to contamination during the procedure or patient care activities. If the area of potential soil or contamination is unknown, team members should mop the entire floor. AMBER WOOD MSN, RN, CNOR, CIC, CPN PERIOPERATIVE NURSING SPECIALIST AORN NURSING DEPARTMENT References 1. Recommended practices for prevention of transmissible infections in the perioperative practice setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2014:385-420. 2. Recommended practices for environmental cleaning. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2014:255-276. 3. Morgan DJ, Rogawski E, Thom KA, et al. Transfer of multidrug-resistant bacteria to healthcare workers’ gloves and gowns after patient contact increases with environmental contamination. Crit Care Med. 2012;40(4): 1045-1051. 4. Datta R, Platt R, Yokoe DS, Huang SS. Environmental cleaning intervention and risk of acquiring multidrugresistant organisms from prior room occupants. Arch Intern Med. 2011;171(6):491-494. 5. Hess AS, Shardell M, Johnson JK, et al. A randomized controlled trial of enhanced cleaning to reduce contamination of healthcare worker gowns and gloves with multidrug-resistant bacteria. Infect Control Hosp Epidemiol. 2013;34(5):487-493. 6. Siegel JD, Rhinehart E, Jackson M, Chiarello L; Healthcare Infection Control Practices Advisory Committee. Management of Multidrug-Resistant Organisms in Healthcare Settings, 2006. Atlanta, GA: Centers for Disease Control and Prevention; 2006.
Antibiotic stewardship programs QUESTION: Our infection prevention committee is creating an antibiotic stewardship program in collaboration with members of the pharmacy department. What is antibiotic stewardship, and how does it affect perioperative RNs? ANSWER: Antibiotic stewardship programs have emerged in the literature as a mechanism to improve antibiotic use, optimize treatment of infections, and reduce
adverse events associated with antibiotic use (eg, Clostridium difficile infection, antibiotic resistance).1 These programs may improve patient care from a quality and safety perspective by increasing cures from infections, reducing treatment failure, helping to ensure correct prescribing of antibiotic therapy for both treatment and prophylaxis, and reducing health care costs.1 In 2014, the Centers for Disease Control and Prevention (CDC) recommended that all acute care hospitals implement antibiotic stewardship programs.1 AORN Journal j 217
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Antibiotic stewardship programs measure compliance with the program goals through process and outcome measures. For processes, the antibiotic stewardship team should determine whether the facility’s policies and clinical practice guidelines are being followed. When evaluating outcomes (eg, morbidity and mortality, use of antibiotics), the team should assess interventions to determine whether they resulted in improvements in patient outcomes. The CDC recommends that nurses participate in antibiotic stewardship programs by verifying that cultures are performed before starting antibiotics (ie, except when used for surgical prophylaxis); reviewing antibiotic medications; and prompting discussions with medical team members about antibiotic treatment, indication, and duration of treatment.1 In the perioperative setting, process measures for antibiotic stewardship programs focus on developing and implementing facility-specific treatment recommendations for surgical antibiotic prophylaxis based on clinical practice guidelines, facility antibiograms (ie, charts of bacteria antibiotic susceptibilities), and formulary options.1 Process development measures may result in establishing order sets for preoperative antibiotic prophylaxis. When using order sets as a process measure, the antibiotic stewardship program team should monitor compliance with selection of antibiotics on the order sets that are facility approved.
Perioperative RNs can support the antibiotic stewardship program by identifying barriers to compliance with selection of facility-approved antibiotics and discussing these barriers with the program team members as well as suggesting ways to improve antibiotic stewardship compliance. When administering surgical antibiotic prophylaxis, perioperative RNs may encounter automatic time-sensitive stop orders, which are another strategy for antibiotic stewardship. A core element of hospital antibiotic stewardship programs is regular reporting of information regarding antibiotic use and resistance to physicians, nurses, and clinical personnel by the antibiotic stewardship team. Perioperative RNs should be familiar with the mission of the antibiotic stewardship program at their facility, watch for reports from the antibiotic stewardship program team, participate in program initiatives, and provide constructive feedback to the team on the barriers and successes of the program implementation in the perioperative setting. AMBER WOOD MSN, RN, CNOR, CIC, CPN PERIOPERATIVE NURSING SPECIALIST AORN NURSING DEPARTMENT Reference 1. CDC core elements of hospital antibiotic stewardship programs. Centers for Disease Control and Prevention. http://www.cdc.gov/getsmart/healthcare/implementation/ core-elements.html. Accessed April 2, 2014.
Blanket warming cabinet temperature settings QUESTION: A recent letter to the AORN Journal editor1 discussed research that does not appear to support the blanket warming temperature recommendations in the AORN “Recommended practices for a safe environment of care”2 and the ECRI Institute recommendations.3 Considering this new evidence, should we change our policy for the blanket warming cabinet maximum temperature setting?
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ANSWER: AORN encourages perioperative RNs to use evidence-based practice as the foundation on which to base patient care. As new compelling evidence arises, health care organization personnel may determine that it is appropriate to change a practice or policy based on this new evidence. Not all research articles, however, warrant a change in practice, and any change in practice should be made only after careful and systematic evaluation
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of the evidence. This includes appraising the level and quality of evidence and considering any limitations of the studies. The 2009 article by Bujdoso4 was cited by Kelly et al5 as evidence for reconsidering the AORN recommended maximum temperature limit of 130 F (54.4 C) for blanket warming cabinets. Bujdoso’s study examined patient safety and comfort issues associated with blankets from warming cabinets set to different temperatures; however, the study has significant limitations that render it insufficient as evidence for reconsidering the current recommended temperature limit noted in the “Recommended practices for a safe environment of care.”2 The limitations include the following: The article4 states that irrigation solution bags should be stored at a temperature lower than 150 F (65.6 C) but fails to point out that patients can be burned in a matter of seconds at skin temperatures below that. A classic extensive human study published in 19476 shows that, for example, irrigation solution warmed to 145 F (62.8 C) can burn human skin in less than five seconds. 4 n The study does not address the potential burn risks of using an overly heated, unfolded blanket on an unconscious or insensate patient. n
TABLE 1. Summary of Data
n
Bujdoso4 incorrectly states that Moritz and Henriques6 found that thermal damage can occur when skin is heated to a temperature of 117 F (47.2 C) to 119 F (48.3 C). The Moritz and Henriques6 study actually showed that burns can occur at a temperature as low as 111 F (43.9 ).
Table 1 presents a summary of the human data from the study by Moritz and Henriques.6 Although comfort, which was the focus of the research by Bujdoso,4 is clinically important for patient care and satisfaction, it is not a reliable metric for assessing the thermal safety of a warmed product, including a folded or rolled blanket, especially for use on unconscious or insensate patients. Bujdoso4 focused on the recommendation of a maximum temperature limit of 110 F (43.3 C) for fluid and blanket warming cabinets initially published by the ECRI Institute in 2005.3 In 2009, based on increased clinical awareness of the hazard of patient burns and to better accommodate patient comfort, the ECRI Institute published updated recommendations for temperature settings on blanket warming cabinets, stating that 130 F (54.4 C) was appropriate as a maximum setting. 7 The ECRI Institute continues to recommend that cabinets used to heat solutions be limited to 110 F (43.3 C).8
1
Temperature
Minimum exposure time for first-degree burn
Maximum exposure time for second- or third-degree burns
111 113 119 121 123 131 140
5 hours 2 hours 15 minutes 2 minutes 30 seconds 20 seconds 3 seconds
6 hours 3 hours 15 minutes 4 minutes 30 seconds 30 seconds 5 seconds
F F F F F F F
(43.9 (45.0 (48.3 (49.4 (50.6 (55.0 (60.0
C) C) C)a C) C)a C) C)
N ¼ 8 human subjects. a
The minimum exposures times until burning for first-degree and second- or third-degree burns are correctly shown. The times are the same for 119 F (48.3 C) and 123 F (50.6 C) because they are minimums for the eight test subjects, some of whom were more or less sensitive to the applied temperature.
1. Moritz AR, Henriques FC. Studies of thermal injury, II: the relative importance of time and surface temperature in the causation of cutaneous burns. Am J Pathol. 1947;23(5):695-720.
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Additional studies that have added recently to the discussion of appropriate blanket temperatures are by Kelly et al5 and Sutton et al.9 The authors of these two studies examined outcomes of using higher blanket temperatures than are recommended by AORN. The prospective, comparative, descriptive study by Kelly et al5 examined the thermal comfort and safety of warmed cotton blankets. The study was performed in a single setting and involved 20 healthy, alert, female participants who were provided blankets from warmers that were set to 130 F (54.4 C) or 200 F (93.3 C). The participants were then asked to rate their thermal comfort as ‘‘too warm,” “too cool,” or “just right.” The researchers also measured the participants’ skin temperature on the arm, abdomen, and lower leg after blanket application. The authors found that no participants had skin temperatures that approached the levels necessary to cause skin burns, and based on the higher thermal comfort rating, they recommended that blankets from a warmer set at 200 F (93.3 C) should be used. Using the AORN Evidence Appraisal tool, this article was appraised and given a score of III for level of evidence because it is a prospective, comparative, descriptive study. The quality of the article was appraised and scored as level C because the sample size was small and homogeneous. A complete description of the AORN evidence rating method is provided in AORN’s Perioperative Standards and Recommended Practices.10 In addition, a limitation of the study not identified by Kelly et al5 was that the blanket warmers were set at 130 F (54.4 C) and 200 F (93.3 C) but the in-cabinet blanket temperature only reached 109.4 F (43.0 C) to 118 F (47.8 C) with a mean of 112.8 F (44.9 C) and 158 F (70.0 C) to 183.6 F (84.2 C) with a mean of 168.7 F (75.9 C), respectively. This is a limitation because the participants never received a blanket that had been warmed to the set temperatures as reported. The quasi-experimental study by Sutton et al9 was conducted in a 26-bed postanesthesia care unit 220 j AORN Journal
CLINICAL ISSUES located in a 384-bed metropolitan hospital. The study had a sample size of 156, which the authors determined was large enough to render the results generalizable. The researchers divided the participants into two groups. Participants in the intervention group (n ¼ 76) received blankets warmed to 155 F (68.3 C), and participants in the control group (n ¼ 80) received blankets warmed to 110 F (43.3 C). The researchers measured the participants’ thermal comfort, which was reported on a scale of 0 to 10 (10 being most comfortable), and their oral and skin temperatures. The researchers found that the average skin temperatures increased from the first time measured (ie, baseline) and the end of sampling (ie, 10 minutes later) in both groups. Based on these results, the authors concluded that the blankets, independent of the temperature to which they were warmed, exerted similar warming effects on the skin. The participants in the intervention group reported a higher thermal comfort level throughout the 10-minute data collection period with only slightly higher skin temperatures. The article was appraised and scored as a II for level of evidence and B for quality of evidence because of its limitations. The authors did not report any limitations of the study, but AORN2 and the ECRI Institute8 consider the use of a temperature that is higher than the current recommendations from the ECRI Institute and AORN to be a limitation. The authors of these studies5,9 did not adequately address the issue of potential risk of thermal injuries, ranging from minor skin irritation (eg, redness) to partial- or full-thickness burns, from the increased temperature setting when blankets were folded or rolled against the skin of semiconscious individuals. The ECRI Institute recently reiterated such risks in an organizational opinion statement, noting that increased temperature settings might lead to unintended consequences, highlighting the multiple stages of injury related to thermal mechanics and describing heat transference.8 Another consideration is blanket material. Studies4,5,9 that have investigated blanket temperature presumed that blankets were made of cotton;
CLINICAL ISSUES however, the opportunity exists for noncotton blankets to be present, and little is known about the risk of heating semisynthetic fiber blankets. The issue of having a warmed blanket that exceeds the recommendations in AORN’s recommended practices raises the question of safety versus comfort. Although patient comfort is an important patient care consideration, safety should be the priority consideration. The collective limitations of the studies5,9 included the failure to consider folded or rolled blankets; the failure to consider unconscious or insensate patients; use of only awake, healthy, volunteer test subjects; small sample sizes; and thermal comfort measured on different scales. Thermal comfort measures are subjective measurements, and the researchers5,9 established no direct relationship to patient outcomes. Including folded blankets is important because the folded blanket does not lose its heat as fast as an unfolded blanket.6 The inclusion of only awake patients is a limitation because many of the patients in a perioperative setting are not awake and therefore cannot report whether the blanket is too hot. The collective benefits of the studies5,9 were that the participants’ skin temperatures increased only slightly and that the reported thermal comfort rating rose with the warmer blankets. The risk of patient burn may still exist, especially with the use of a rolled blanket on an unconscious patient. The collective evidence does not support a change in the current recommendation because the benefits of the change are not great enough to outweigh the risks. Changes in practice should be carefully considered and should not be based on studies that have serious limitations or are of low levels of evidence or quality. In this instance, the most serious limitation is that these studies5,9 do not address the application of very hot rolled or folded blankets from warming cabinets to unconscious or insensate patients. The ECRI Institute recommendation of a maximum temperature of 130 F (54.4 C) for
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blankets is based on evidence from firsthand, detailed, in-hospital clinical accident investigations of multiple cases of patient burns at four facilities during a 10-year period.8,11 This evidence is more detailed than, but somewhat analogous to, that derived from a closed claims analysis of insurance files,11 on which other clinical policies and procedures are based. The ECRI Institute recently republished its updated recommendations and presented more detailed information about its investigations of burn accidents involving patients that led to the 130 F (54.4 C) recommended temperature limit.8 The fundamental patient safety issue warranting a 130 F (54.4 C) limit is that there is no way to reliably prevent folded or rolled blankets that come out of an overly heated warming cabinet from being applied to unconscious or insensate patients. AORN2 and the ECRI Institute8 continue to recommend an upper temperature limit of 130 F (54.4 C) for blanket warming cabinets. RAMONA L. CONNER MSN, RN, CNOR MANAGER, STANDARDS AND RECOMMENDED PRACTICES AORN NURSING DEPARTMENT
MARK E. BRULEY CCE VICE PRESIDENT ACCIDENT AND FORENSIC INVESTIGATION ECRI INSTITUTE CHRIS LAVANCHY BSME, BS ENGINEERING DIRECTOR HEALTH DEVICES GROUP ECRI INSTITUTE GAIL M. HORVATH MSN, RN, CNOR, CRCST PATIENT SAFETY ANALYST/CONSULTANT III ECRI INSTITUTE PSO HEALTHCARE QUALITY & INSIGHT ASSESSMENT SERVICES RISK MANAGEMENT ECRI INSTITUTE
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References 1. Morse E, Sands T, Kelly P, Krogh M. Reconsidering recommendations for blanket warming [Letter to the Editor]. AORN J. 2014;99(3):353-355. 2. Recommended practices for a safe environment of care. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2014:229-253. 3. ECRI Institute. Limiting temperature settings on blanket and solution warming cabinets can prevent patient burns. Health Devices. 2005;34(5):168-171. 4. Bujdoso PJ. Blanket warming: comfort and safety. AORN J. 2009;89(4):717-722. 5. Kelly PA, Cooper SK, Krogh ML, et al. Thermal comfort and safety of cotton blankets warmed at 130 F and 200 F. J Perianesth Nurs. 2013;28(6):337-346. 6. Moritz AR, Henriques FC. Studies of thermal injury, II: the relative importance of time and surface temperature in the causation of cutaneous burns. Am J Pathol. 1947; 23(5):695-720. http://www.ncbi.nlm.nih.gov/pmc/articles/ PMC1934304/pdf/amjpathol00502-0018.pdf. Accessed May 6, 2014.
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CLINICAL ISSUES 7. ECRI Institute. Hazard report update. ECRI Institute revises its recommendation for temperature limits on blanket warmers. Health Devices. 2009;38(7):230-231. 8. ECRI Institute. H0225: Normal Priority Medical Device Alert. ECRI Institute Continues To Recommend Maximum Temperature Setting of 130 F for Blanket Warming Cabinets. Health Devices Alerts. Plymouth Meeting, PA: ECRI Institute; 2014. https://www.ecri.org/Documents/ Health_Devices/Blanket_warming_cabinets_130F_ Hazard(Health_Devices_Alerts).pdf. Accessed May 14, 2014. 9. Sutton LT, Baker FS, Faile NJ, Tavakoli A. A quasi experimental study examining the safety profile and comfort provided by two different blanket temperatures. J Perianesth Nurs. 2012;27(3):181-192. 10. Introduction to the AORN recommended practices. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2014:43-48. 11. Cheney FW, Posner KL, Caplan RA, Gild WM. Burns from warming devices in anesthesia. A closed claims analysis. Anesthesiology. 1994;80(4):806-810.
LEARNER EVALUATION
1.9
CONTINUING EDUCATION PROGRAM
Clinical Issues
T
his evaluation is used to determine the extent to which this continuing education program met your learning needs. The evaluation is printed here for your convenience. To receive continuing education credit, you must complete the online Learner Evaluation at http://www.aorn.org/CE. Rate the items as described below. PURPOSE/GOAL To provide the learner with knowledge of AORN’s recommended practices related to cyanoacrylate microbial sealants, enhanced environmental cleaning, antibiotic stewardship programs, and blanket-warming temperatures. OBJECTIVES To what extent were the following objectives of this continuing education program achieved? 1. Discuss practices that could jeopardize safety in the perioperative area. Low 1. 2. 3. 4. 5. High 2. Discuss common areas of concern that relate to perioperative best practices. Low 1. 2. 3. 4. 5. High 3. Describe implementation of evidence-based practice in relation to perioperative nursing care. Low 1. 2. 3. 4. 5. High CONTENT 4. To what extent did this article increase your knowledge of the subject matter? Low 1. 2. 3. 4. 5. High
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5. To what extent were your individual objectives met? Low 1. 2. 3. 4. 5. High 6. Will you be able to use the information from this article in your work setting? 1. Yes 2. No 7. Will you change your practice as a result of reading this article? (If yes, answer question #7A. If no, answer question #7B.) 7A. How will you change your practice? (Select all that apply) 1. I will provide education to my team regarding why change is needed. 2. I will work with management to change/ implement a policy and procedure. 3. I will plan an informational meeting with physicians to seek their input and acceptance of the need for change. 4. I will implement change and evaluate the effect of the change at regular intervals until the change is incorporated as best practice. 5. Other: ________________________________ 7B. If you will not change your practice as a result of reading this article, why? (Select all that apply) 1. The content of the article is not relevant to my practice. 2. I do not have enough time to teach others about the purpose of the needed change. 3. I do not have management support to make a change. 4. Other: ________________________________ 8. Our accrediting body requires that we verify the time you needed to complete the 1.9 continuing education contact hour (114-minute) program: _______________________________
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