- Email: [email protected]
Clinical Issues—March 2011
CLINICAL ISSUES
1.3 www.aorn.org/CE
This Month f f
First surgical hand scrub of the day Key words: alcohol-based surgical hand rub products, surgical hand antisepsis, standardized surgical hand rub protocol.
f f
The correct method for sterilizing towel clips Key words: ratcheted instruments, instrument hinges, bloodborne pathogens standard, glove tears, percutaneous punctures, instrument stringers.
f f
Patient abandonment Key words: patient abandonment, patient assignment, nurse-patient relationship.
f f
Determining shelf life Key words: event-related sterility, expiration dates, moisture-controlled environment, dustcontrolled environment, storage conditions, sterile storage, shelf life, sterile items.
f f
First surgical hand scrub of the day
QUESTION Our staff members have varying opinions regarding the necessity of performing a surgical hand scrub with a brush and water as the first scrub of the day before using surgical hand rub products. Do we need to scrub with water and a brush, or can we use the hand rub product for our first scrub of the day? ANSWER A traditional, standardized surgical hand scrub with an antimicrobial agent, nonabrasive sponge,
and water does not have to be the first surgical hand scrub of the day before an alcohol-based surgical hand rub product is used. The purpose of a surgical hand scrub is to reduce transient and resident flora, which also may reduce health care-associated infections.1 A standardized surgical hand scrub using an alcohol-based hand rub product will decrease transient and resident microorganisms on the hands and maintain the bacterial level below baseline.2 If a surgical hand rub is the preferred product selected for surgical hand antisepsis, personnel
indicates that continuing education contact hours are available for this activity. Earn the contact hours by reading this article, reviewing the purpose/goal and objectives, and completing the online Learner Evaluation at http://www.aorn.org/CE. The contact hours for this article expire March 31, 2014. doi: 10.1016/j.aorn.2010.12.003
© AORN, Inc, 2011
March 2011
Vol 93
No 3 ● AORN Journal
397
March 2011
Vol 93
should use an alcohol-based surgical hand rub product with demonstrated persistence and cumulative activity. The product also must have met US Food and Drug Administration regulatory requirements for surgical hand antisepsis. The perioperative manager should ensure that a standardized surgical hand rub protocol is developed that follows the manufacturer’s written instructions for use. The protocol should include the following steps:
f f
Before beginning surgical hand antisepsis, remove jewelry including rings, watches, and bracelets. Prewash hands and forearms with soap and water to remove any debris. Using a nail cleaner, clean the subungual areas of both hands under running water. Rinse the hands and forearms and dry them thoroughly with a paper towel. Following the manufacturer’s directions, dispense the recommended amount of the surgical hand rub product and apply it to hands and forearms. Repeat the product application process if required by the manufacturer’s directions. Rub hands together until they are completely dry.3-5
Although the skin can never be rendered sterile, it can be made surgically clean by reducing the number of microorganisms. The mechanical action associated with the friction of rubbing removes debris and microorganisms. Surgical hand antisepsis will only be effective if all surfaces are exposed to the mechanical cleaning and chemical antisepsis processes. MARY J. OGG MSN, RN, CNOR PERIOPERATIVE NURSING SPECIALIST AORN CENTER FOR NURSING PRACTICE References 1.
2.
3.
4.
5.
Centers for Disease Control and Prevention. Guideline for hand hygiene in health-care settings. MMWR. October 25, 2002;51(RR-16):1-44. Rotter ML, Kampf G, Suchomel M, Kundi M. Longterm effect of a 1.5 minute surgical hand rub with a propanolbased product on the resident hand flora. J Hosp Infect. 2007;66(1):84-85. WHO Guidelines on Hand Hygiene in Health Care. Geneva, Switzerland: World Health Organization; 2006. http://whqlibdoc.who.int/publications/2009/9789241597906_ eng.pdf. Accessed October 18, 2010. Recommended practices for hand hygiene in the perioperative setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2010: 75– 89. Hand hygiene. In: Underwood MA, ed. APIC Text of Infection Control and Epidemiology. Washington, DC: Association for Professionals in Infection Control and Epidemiology; 2005:19-1–19-7.
The correct method for sterilizing towel clips
QUESTION What is the correct method for sterilizing towel clips? The OR staff members think that towel clips should be placed in the instrument set closed to prevent tearing of gloves during setup for a procedure. Sterile processing department personnel think towel clips should be sterilized open similar to the way any ratcheted instrument with a box lock is sterilized. ANSWER Instruments with hinges should be kept open and unlocked during the sterilization process by using instrument stringers, racks, or instrument pegs.1-3 398
CLINICAL ISSUES
No 3
AORN Journal
Sterilization occurs only on surfaces that have direct contact with the sterilant.2 Unlocking ratcheted instruments enables the sterilant to contact all surfaces.1 During handling of sharp instruments (eg, towel clips, scissors, skin hooks, retractors), there is the potential for glove tears and percutaneous injury. One tactic to prevent accidental tears and percutaneous injuries is to use tip protectors on the ends of sharp instruments. The tip protector should be used according to the manufacturer’s instructions, validated for use with the chosen method of sterilization, and loose fitting so that
CLINICAL ISSUES the sterilant can contact the surface to be sterilized.1 Educating staff members about correct handling of sharp instruments and double gloving helps decrease potential glove tears and sharps injuries. Another consideration is replacing sharp towel clips with blunt towel clips to prevent injuries to personnel and patients. Using blunt towel clips and tip protectors and double gloving would be considered engineering and work practice controls that are in compliance with the Occupational Safety and Health Administration bloodborne pathogen standard.4 The bloodborne pathogen standard requires facilities to institute work practice and engineering controls that eliminate occupational exposure or reduce it to the lowest feasible extent.4 Work practice controls reduce the likelihood of exposure by altering the manner in which a task is performed.4 Engineering controls help isolate or remove bloodborne pathogen hazards from the workplace.4 Engineering controls should be examined on a regular schedule to ensure their effectiveness and maintained or replaced as necessary.4 Sharp instruments present a challenge not only in the OR but also in the sterile processing department. Before the scrub person sends instruments to the sterile processing department, he or she should segregate sharp instruments from other instruments. Segregating sharp instruments minimizes the risk of injury to personnel handling the instruments during decontamination.1 The Occupational Safety and Health Administration prohibits processes that require employees to place their hands into basins of sharp instruments submerged in water because of the risk of a percutaneous exposure to bloodborne pathogens.4 Reusable f f
www.aornjournal.org
sharp instruments, including scissors, should be placed in a separate receptacle.1 Reusable scalpel handles should be considered sharp and placed in a receptacle designated for sharp instruments. Considering a reusable scalpel handle to be sharp minimizes the risk of injury if a blade has been inadvertently left on the handle.1 Reusable sharps must be placed in a puncture-proof container for transport.1,4 All hinged instruments should be opened and unlocked during the sterilization process to allow the sterilant to reach all surfaces of the instrument. Exercising additional precautions in the OR and sterile processing departments will help minimize sharps injuries and effectively sterilize sharp, hinged instruments. MARY J. OGG MSN, RN, CNOR PERIOPERATIVE NURSING SPECIALIST AORN CENTER FOR NURSING PRACTICE References 1.
2.
3.
4.
Recommended practices for cleaning and care of surgical instruments and powered equipment. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2010:421-446. Association for the Advancement of Medical Instrumentation. ANSI/AAMI ST79: 2006 Comprehensive Guide to Steam Sterilization and Sterility Assurance in Health Care Facilities. Arlington, VA: Association for the Advancement of Medical Instrumentation; 2009:65. Rutala WA, Weber DJ; Healthcare Infection Control Practices Advisory Committee. Guideline for Disinfection and Sterilization in Healthcare Facilities. Atlanta, GA: Centers for Disease Control and Prevention; 2008. http://www.cdc.gov/hicpac/pdf/guidelines/Disinfection _Nov_2008.pdf. Accessed November 15, 2010. Occupational Safety and Health Standards: Bloodborne pathogens. 56(235) Fed Regist. (December 6, 1991) 64004 (codified at 29 CFR §1910.1030). http://www .osha.gov/pls/oshaweb/owadisp.show_document? p_table⫽STANDARDS&p_id⫽10051. Accessed November 15, 2010.
Patient abandonment
QUESTION Recently, a scrub person had an altercation with the circulating nurse in the OR while a procedure was in progress. As the altercation
escalated, the charge nurse was contacted but before relief could be provided, the circulating nurse left the room, changed clothes, and left the facility. Is this considered abandonment? AORN Journal
399
March 2011
Vol 93
No 3
ANSWER Patient abandonment is a term being used by health care facilities, the nursing profession, health care regulatory agencies, and health care consumers.1,2 The Oregon Board of Nursing and the Connecticut Board of Examiners for Nursing have provided a definition for patient abandonment to ensure consistency throughout the health care system. The licensed person (ie, RN, licensed practical nurse) accepts an assignment for patient care for a specified period. The licensed person should provide care until the responsibility can be transferred to another licensed person.1,2 Patient abandonment has occurred if the licensed person has voluntarily removed herself or himself from the patient care setting during the previously agreed upon time period and a status report has not been given to another qualified licensed person.1,2 The Colorado Board of Nursing has similarly interpreted patient abandonment by describing the conditions that must be met to determine whether abandonment has occurred. The first is that a licensee has accepted a patient assignment. By accepting the assignment, a relationship is established with the patient. In the perioperative environment, this would mean that the nurse accepted the surgical case assignment. The second condition is that the patient relationship is severed without reasonable notice given to the appropriate person (eg, the charge nurse, manager, director) and without arrangements having been made for the continuation of care by someone else. In the situation described, the circulating nurse leaving the room before relief had been provided would be considered abandonment in the state of Colorado. For licensed personnel, this could lead to discipline by the appropriate state board with the possibility of suspension of the license to practice.3 Leaving the OR when the patient is in the room and no relief is available is another example of abandonment.4 Leaving the room to begin another procedure in a different room after the procedure is finished but before the patient has been transferred to the care of the postanesthesia care 400
AORN Journal
CLINICAL ISSUES RN is also considered abandonment.5 Potential consequences of abandonment to the patient include severe injury and death.4 A patient abandonment claim could also arise in a lawsuit brought by a plaintiff against the nurse. The court of law could award a monetary settlement for the abandonment, but the court has no jurisdiction to suspend or revoke the licensed person’s right to practice.6 Ultimately, the perioperative nurse’s primary commitment is to the patient.7 Perioperative nurses are responsible for nursing decisions that are not only clinically and technically sound but also morally appropriate and suitable for the specific problems of the patient being treated. The perioperative nurse, by virtue of the nurse-patient relationship, has an obligation to provide safe, professional, and ethical patient care. It is important that nurses know how to manage ethical decisions appropriately. AORN’s “Perioperative explications of the ANA Code of Ethics for Nurses” states that the perioperative RN acts as a patient advocate by protecting the patient from incompetent, unethical, or illegal practices; reports incompetent, unethical, or illegal practice to a responsible administrative person; consults with colleagues and supervisors to resolve concerns; complies with institutional policies in resolving problems; and intervenes appropriately to protect the patient.7 In this instance, the circulating nurse should have tried to de-escalate the situation; failing that, contacting the charge nurse or department director or manager and waiting for that person to respond was the next step. Your state board of nursing and your health care facility will need to determine whether the actions of the circulating nurse constituted patient abandonment. The board of nursing may discipline licensed professionals by suspending the license for a period of time.8 The employer may also discipline the employee whether or not action was taken by the board of nursing.8 The employer’s action can vary depending on their administrative policies and can range from counseling to suspension to termination.8 Contact your state board of nursing for your state’s
CLINICAL ISSUES interpretation of patient abandonment. Use the legislative map at http://www.aorn.org/PublicPolicy/ LegislativeMap to find the web site address for your state board of nursing. MARY J. OGG MSN, RN, CNOR PERIOPERATIVE NURSING SPECIALIST AORN CENTER FOR NURSING PRACTICE References Connecticut Board of Examiners for Nursing: patient abandonment guidelines for APRNs, RNs, and LPNs. CT.gov. http://www.ct.gov/dph/lib/dph/phho/nursing _board/guidelines/patient_aband.pdf. Accessed November 15, 2010. 2. OSBN board policy: patient abandonment. Oregon State Board of Nursing. http://www.oregon.gov/OSBN/pdfs/
www.aornjournal.org
3.
4. 5.
6. 7.
1.
f f
8.
policies/abandon.pdf?ga⫽t. Accessed November 15, 2010. Nursing board policy: patient abandonment. Colorado Board of Nursing. http://www.dora.state.co.us/nursing/ policies/20-01.pdf. Accessed November 15, 2010. Fuller JK. Surgical Technology: Principles and Practice. 5th ed. St Louis, MO: Saunders Elsevier; 2009:37-38. Phillips N. Berry and Kohn’s Operating Room Technique. 11th ed. St Louis, MO: Mosby Elsevier; 2007: 42-43. Blyth DA. Do you know what constitutes patient abandonment? Nurs Manage. 2007;38(8):8, 10. Exhibit B: Perioperative explications for the ANA Code of Ethics for Nurses. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2010:30-61. Westrick SJ. Refusing an assignment/patient abandonment. In: Westrick SJ, Dempski K, eds. Essentials of Nursing Law and Ethics. Sudbury, MA: Jones and Bartlett Publishers; 2009:37-44.
Determining shelf life
QUESTION We are very confused about sterile items, expiration dates, and shelf life. Personnel in our ambulatory surgery center have been placing 30-day expiration dates on all sterilized items based on the Centers for Medicare & Medicaid Services (CMS) requirements. The inpatient sterile processing department’s policy is event related. Which process is correct? ANSWER Sterilized materials should be packaged, labeled, and stored in a manner that ensures sterility.1 AORN and the Association for the Advancement of Medical Instrumentation (AAMI) recommend the event-related process to determine the shelf life of sterilized items.1,2 The confusion around the CMS requirements arises from a variance in its earlier State Operations Manuals for ambulatory surgical services and hospitals. The 2004 State Operations Manual for ambulatory surgical services stated that “Sterilized materials should be packaged, labeled, and stored in a manner to ensure sterility and that each item is marked with the expiration date.”3 The 2008 State Operations Manual for hospitals states, “That sterilized materials are packaged, handled, labeled, and stored in
a manner that ensures sterility (eg, in a moistureand dust-controlled environment) and policies and procedures for expiration dates have been developed and are followed in accordance with accepted standards of practice.”4 This requirement is now stated the same way in the 2009 State Operations Manual for ambulatory surgical services.5 The important point to consider here is that policies and procedures are developed in accordance with accepted standards of practice, such as those provided by AORN and AAMI. AORN recommendations are consistent with the AAMI standards and the Centers for Disease Control and Prevention Healthcare Infection Control Practices Advisory Committee guidelines.1,6 AORN’s recommended practices for sterilization2 and AAMI’s Comprehensive Guide to Steam Sterilization and Sterility Assurance in Health Care Facilities1 recommend that the following be included in the health care facility’s policy and procedure for event-related sterility. The shelf life of a packaged sterile item should be considered event related. An event must occur to compromise package content sterility. Events that may compromise the sterility of a package include, but are not limited to, repeated handling that leads to seal breakage or loss of AORN Journal
401
March 2011
Vol 93
CLINICAL ISSUES
No 3
package integrity, moisture penetration, and exposure to airborne contaminants.1,2 Limiting exposure to moisture, dust, excessive light, handling, and temperature and humidity extremes decreases the risk of contamination of sterilized items.1,2 Perioperative managers should evaluate the adequacy and quality of storage space and conditions before writing policies and procedures on event-related sterility for perioperative practice settings.1 Sterile packages should be stored under environmentally controlled conditions that reduce the risk of contamination.7 Managers should ensure that the temperature in the sterile storage areas does not exceed 24° C (75° F), four air exchanges per hour occur in the storage area, and the relative humidity is controlled and does not exceed 70%. Traffic should be controlled to limit access to those trained in handling sterile supplies. Managers should also ensure that supplies are stored in a manner that allows adequate air circulation, ease of cleaning, and compliance with local fire codes; sterile items are stored at least 8 to 10 inches above the floor, at least 18 inches below sprinkler heads, and at least 2 inches from outside walls; outside shipping containers are not allowed in the sterile storage area because they serve as generators of and reservoirs for dust; and all stored items are rotated according to the principle of “first in, first out.”2,7
Commission, the Accreditation Association for Ambulatory Health Care, the American Association for Accreditation of Ambulatory Surgery Facilities) with which the surgical facility is affiliated. MARY J. OGG MSN, RN, CNOR PERIOPERATIVE NURSING SPECIALIST AORN CENTER FOR NURSING PRACTICE References 1.
2.
3.
When you are creating or reviewing policies for event-related sterility, shelf life, and sterile storage, check specific state and local regulations for your practice setting (eg, hospital, ambulatory surgery center, office-based surgery center). The policies should be based on national standards (eg, AORN, AAMI) and accreditation agencies (eg, the Joint
4.
5.
6.
7.
ANSI/AAMI ST79:2006 —Comprehensive Guide to Steam Sterilization and Sterility Assurance in Health Care Facilities. Arlington, VA: Association for the Advancement of Medical Instrumentation; 2006:73. Recommended practices for sterilization in the perioperative practice setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2010:457-480. Appendix A §482.51. Survey protocol, regulations and interpretive guidelines for hospitals. Condition of participation: surgical services. In: State Operations Manual. US Department of Health and Human Services; Centers for Medicaid and Medicare Services (CMS). http://www.cms .gov/manuals/Downloads/som107ap_a_hospitals.pdf. Accessed November 15, 2010. Appendix A §482.51. Survey protocol, regulations and interpretive guidelines for hospitals. Survey procedures. In: State Operations Manual. US Department of Health and Human Services; Centers for Medicaid and Medicare Services (CMS). http://www.cms.gov/manuals/ downloads/som107ap_a_hospitals.pdf. Accessed November 15, 2010. Appendix L §416.44(a)(3) and §416.51. Ambulatory surgical centers (ASC) comprehensive revision. In: State Operations Manual. US Department of Health and Human Services; Centers for Medicaid and Medicare Services (CMS). http://www1.cms.gov/SurveyCertification GenInfo/PMSR/itemdetail.asp?filterType⫽none&filter ByDID⫽0&sortByDID⫽4&sortOrder⫽descending&item ID⫽CMS1222613&intNumPerPage⫽20 Accessed November 15, 2010. Rutala WA, Weber DJ; Healthcare Infection Control Practice Advisory Committee. Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008. Atlanta, GA: Centers for Disease Control and Prevention; 2008. http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/ Disinfection_Nov_2008.pdf. Accessed October 19, 2010. Recommended practices for cleaning and care of surgical instruments and powered equipment. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2010:421-446.
The author of this column has no declared affiliations that could be perceived as posing a potential conflict of interest in the publication of this article.
402
AORN Journal
LEARNER EVALUATION CONTINUING EDUCATION PROGRAM
1.3
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 Learner Evaluation online at http://www.aorn.org/CE. Rate the items as described below. PURPOSE/GOAL To educate perioperative nurses about providing safe nursing care throughout the perioperative continuum. 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 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
www.aorn.org/CE
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 1.3 continuing education contact hour (78-minute) program: _____
This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements. 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 continuing education for registered nurses. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity. 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: #11005; Session: #4058; Fee: Members $6.50, Nonmembers $13 The deadline for this program is March 31, 2014. Each applicant who successfully completes this program can immediately print a certificate of completion.
© AORN, Inc, 2011
March 2011
Vol 93
No 3 ● AORN Journal
403
1.3 www.aorn.org/CE
This Month f f
First surgical hand scrub of the day Key words: alcohol-based surgical hand rub products, surgical hand antisepsis, standardized surgical hand rub protocol.
f f
The correct method for sterilizing towel clips Key words: ratcheted instruments, instrument hinges, bloodborne pathogens standard, glove tears, percutaneous punctures, instrument stringers.
f f
Patient abandonment Key words: patient abandonment, patient assignment, nurse-patient relationship.
f f
Determining shelf life Key words: event-related sterility, expiration dates, moisture-controlled environment, dustcontrolled environment, storage conditions, sterile storage, shelf life, sterile items.
f f
First surgical hand scrub of the day
QUESTION Our staff members have varying opinions regarding the necessity of performing a surgical hand scrub with a brush and water as the first scrub of the day before using surgical hand rub products. Do we need to scrub with water and a brush, or can we use the hand rub product for our first scrub of the day? ANSWER A traditional, standardized surgical hand scrub with an antimicrobial agent, nonabrasive sponge,
and water does not have to be the first surgical hand scrub of the day before an alcohol-based surgical hand rub product is used. The purpose of a surgical hand scrub is to reduce transient and resident flora, which also may reduce health care-associated infections.1 A standardized surgical hand scrub using an alcohol-based hand rub product will decrease transient and resident microorganisms on the hands and maintain the bacterial level below baseline.2 If a surgical hand rub is the preferred product selected for surgical hand antisepsis, personnel
indicates that continuing education contact hours are available for this activity. Earn the contact hours by reading this article, reviewing the purpose/goal and objectives, and completing the online Learner Evaluation at http://www.aorn.org/CE. The contact hours for this article expire March 31, 2014. doi: 10.1016/j.aorn.2010.12.003
© AORN, Inc, 2011
March 2011
Vol 93
No 3 ● AORN Journal
397
March 2011
Vol 93
should use an alcohol-based surgical hand rub product with demonstrated persistence and cumulative activity. The product also must have met US Food and Drug Administration regulatory requirements for surgical hand antisepsis. The perioperative manager should ensure that a standardized surgical hand rub protocol is developed that follows the manufacturer’s written instructions for use. The protocol should include the following steps:
f f
Before beginning surgical hand antisepsis, remove jewelry including rings, watches, and bracelets. Prewash hands and forearms with soap and water to remove any debris. Using a nail cleaner, clean the subungual areas of both hands under running water. Rinse the hands and forearms and dry them thoroughly with a paper towel. Following the manufacturer’s directions, dispense the recommended amount of the surgical hand rub product and apply it to hands and forearms. Repeat the product application process if required by the manufacturer’s directions. Rub hands together until they are completely dry.3-5
Although the skin can never be rendered sterile, it can be made surgically clean by reducing the number of microorganisms. The mechanical action associated with the friction of rubbing removes debris and microorganisms. Surgical hand antisepsis will only be effective if all surfaces are exposed to the mechanical cleaning and chemical antisepsis processes. MARY J. OGG MSN, RN, CNOR PERIOPERATIVE NURSING SPECIALIST AORN CENTER FOR NURSING PRACTICE References 1.
2.
3.
4.
5.
Centers for Disease Control and Prevention. Guideline for hand hygiene in health-care settings. MMWR. October 25, 2002;51(RR-16):1-44. Rotter ML, Kampf G, Suchomel M, Kundi M. Longterm effect of a 1.5 minute surgical hand rub with a propanolbased product on the resident hand flora. J Hosp Infect. 2007;66(1):84-85. WHO Guidelines on Hand Hygiene in Health Care. Geneva, Switzerland: World Health Organization; 2006. http://whqlibdoc.who.int/publications/2009/9789241597906_ eng.pdf. Accessed October 18, 2010. Recommended practices for hand hygiene in the perioperative setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2010: 75– 89. Hand hygiene. In: Underwood MA, ed. APIC Text of Infection Control and Epidemiology. Washington, DC: Association for Professionals in Infection Control and Epidemiology; 2005:19-1–19-7.
The correct method for sterilizing towel clips
QUESTION What is the correct method for sterilizing towel clips? The OR staff members think that towel clips should be placed in the instrument set closed to prevent tearing of gloves during setup for a procedure. Sterile processing department personnel think towel clips should be sterilized open similar to the way any ratcheted instrument with a box lock is sterilized. ANSWER Instruments with hinges should be kept open and unlocked during the sterilization process by using instrument stringers, racks, or instrument pegs.1-3 398
CLINICAL ISSUES
No 3
AORN Journal
Sterilization occurs only on surfaces that have direct contact with the sterilant.2 Unlocking ratcheted instruments enables the sterilant to contact all surfaces.1 During handling of sharp instruments (eg, towel clips, scissors, skin hooks, retractors), there is the potential for glove tears and percutaneous injury. One tactic to prevent accidental tears and percutaneous injuries is to use tip protectors on the ends of sharp instruments. The tip protector should be used according to the manufacturer’s instructions, validated for use with the chosen method of sterilization, and loose fitting so that
CLINICAL ISSUES the sterilant can contact the surface to be sterilized.1 Educating staff members about correct handling of sharp instruments and double gloving helps decrease potential glove tears and sharps injuries. Another consideration is replacing sharp towel clips with blunt towel clips to prevent injuries to personnel and patients. Using blunt towel clips and tip protectors and double gloving would be considered engineering and work practice controls that are in compliance with the Occupational Safety and Health Administration bloodborne pathogen standard.4 The bloodborne pathogen standard requires facilities to institute work practice and engineering controls that eliminate occupational exposure or reduce it to the lowest feasible extent.4 Work practice controls reduce the likelihood of exposure by altering the manner in which a task is performed.4 Engineering controls help isolate or remove bloodborne pathogen hazards from the workplace.4 Engineering controls should be examined on a regular schedule to ensure their effectiveness and maintained or replaced as necessary.4 Sharp instruments present a challenge not only in the OR but also in the sterile processing department. Before the scrub person sends instruments to the sterile processing department, he or she should segregate sharp instruments from other instruments. Segregating sharp instruments minimizes the risk of injury to personnel handling the instruments during decontamination.1 The Occupational Safety and Health Administration prohibits processes that require employees to place their hands into basins of sharp instruments submerged in water because of the risk of a percutaneous exposure to bloodborne pathogens.4 Reusable f f
www.aornjournal.org
sharp instruments, including scissors, should be placed in a separate receptacle.1 Reusable scalpel handles should be considered sharp and placed in a receptacle designated for sharp instruments. Considering a reusable scalpel handle to be sharp minimizes the risk of injury if a blade has been inadvertently left on the handle.1 Reusable sharps must be placed in a puncture-proof container for transport.1,4 All hinged instruments should be opened and unlocked during the sterilization process to allow the sterilant to reach all surfaces of the instrument. Exercising additional precautions in the OR and sterile processing departments will help minimize sharps injuries and effectively sterilize sharp, hinged instruments. MARY J. OGG MSN, RN, CNOR PERIOPERATIVE NURSING SPECIALIST AORN CENTER FOR NURSING PRACTICE References 1.
2.
3.
4.
Recommended practices for cleaning and care of surgical instruments and powered equipment. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2010:421-446. Association for the Advancement of Medical Instrumentation. ANSI/AAMI ST79: 2006 Comprehensive Guide to Steam Sterilization and Sterility Assurance in Health Care Facilities. Arlington, VA: Association for the Advancement of Medical Instrumentation; 2009:65. Rutala WA, Weber DJ; Healthcare Infection Control Practices Advisory Committee. Guideline for Disinfection and Sterilization in Healthcare Facilities. Atlanta, GA: Centers for Disease Control and Prevention; 2008. http://www.cdc.gov/hicpac/pdf/guidelines/Disinfection _Nov_2008.pdf. Accessed November 15, 2010. Occupational Safety and Health Standards: Bloodborne pathogens. 56(235) Fed Regist. (December 6, 1991) 64004 (codified at 29 CFR §1910.1030). http://www .osha.gov/pls/oshaweb/owadisp.show_document? p_table⫽STANDARDS&p_id⫽10051. Accessed November 15, 2010.
Patient abandonment
QUESTION Recently, a scrub person had an altercation with the circulating nurse in the OR while a procedure was in progress. As the altercation
escalated, the charge nurse was contacted but before relief could be provided, the circulating nurse left the room, changed clothes, and left the facility. Is this considered abandonment? AORN Journal
399
March 2011
Vol 93
No 3
ANSWER Patient abandonment is a term being used by health care facilities, the nursing profession, health care regulatory agencies, and health care consumers.1,2 The Oregon Board of Nursing and the Connecticut Board of Examiners for Nursing have provided a definition for patient abandonment to ensure consistency throughout the health care system. The licensed person (ie, RN, licensed practical nurse) accepts an assignment for patient care for a specified period. The licensed person should provide care until the responsibility can be transferred to another licensed person.1,2 Patient abandonment has occurred if the licensed person has voluntarily removed herself or himself from the patient care setting during the previously agreed upon time period and a status report has not been given to another qualified licensed person.1,2 The Colorado Board of Nursing has similarly interpreted patient abandonment by describing the conditions that must be met to determine whether abandonment has occurred. The first is that a licensee has accepted a patient assignment. By accepting the assignment, a relationship is established with the patient. In the perioperative environment, this would mean that the nurse accepted the surgical case assignment. The second condition is that the patient relationship is severed without reasonable notice given to the appropriate person (eg, the charge nurse, manager, director) and without arrangements having been made for the continuation of care by someone else. In the situation described, the circulating nurse leaving the room before relief had been provided would be considered abandonment in the state of Colorado. For licensed personnel, this could lead to discipline by the appropriate state board with the possibility of suspension of the license to practice.3 Leaving the OR when the patient is in the room and no relief is available is another example of abandonment.4 Leaving the room to begin another procedure in a different room after the procedure is finished but before the patient has been transferred to the care of the postanesthesia care 400
AORN Journal
CLINICAL ISSUES RN is also considered abandonment.5 Potential consequences of abandonment to the patient include severe injury and death.4 A patient abandonment claim could also arise in a lawsuit brought by a plaintiff against the nurse. The court of law could award a monetary settlement for the abandonment, but the court has no jurisdiction to suspend or revoke the licensed person’s right to practice.6 Ultimately, the perioperative nurse’s primary commitment is to the patient.7 Perioperative nurses are responsible for nursing decisions that are not only clinically and technically sound but also morally appropriate and suitable for the specific problems of the patient being treated. The perioperative nurse, by virtue of the nurse-patient relationship, has an obligation to provide safe, professional, and ethical patient care. It is important that nurses know how to manage ethical decisions appropriately. AORN’s “Perioperative explications of the ANA Code of Ethics for Nurses” states that the perioperative RN acts as a patient advocate by protecting the patient from incompetent, unethical, or illegal practices; reports incompetent, unethical, or illegal practice to a responsible administrative person; consults with colleagues and supervisors to resolve concerns; complies with institutional policies in resolving problems; and intervenes appropriately to protect the patient.7 In this instance, the circulating nurse should have tried to de-escalate the situation; failing that, contacting the charge nurse or department director or manager and waiting for that person to respond was the next step. Your state board of nursing and your health care facility will need to determine whether the actions of the circulating nurse constituted patient abandonment. The board of nursing may discipline licensed professionals by suspending the license for a period of time.8 The employer may also discipline the employee whether or not action was taken by the board of nursing.8 The employer’s action can vary depending on their administrative policies and can range from counseling to suspension to termination.8 Contact your state board of nursing for your state’s
CLINICAL ISSUES interpretation of patient abandonment. Use the legislative map at http://www.aorn.org/PublicPolicy/ LegislativeMap to find the web site address for your state board of nursing. MARY J. OGG MSN, RN, CNOR PERIOPERATIVE NURSING SPECIALIST AORN CENTER FOR NURSING PRACTICE References Connecticut Board of Examiners for Nursing: patient abandonment guidelines for APRNs, RNs, and LPNs. CT.gov. http://www.ct.gov/dph/lib/dph/phho/nursing _board/guidelines/patient_aband.pdf. Accessed November 15, 2010. 2. OSBN board policy: patient abandonment. Oregon State Board of Nursing. http://www.oregon.gov/OSBN/pdfs/
www.aornjournal.org
3.
4. 5.
6. 7.
1.
f f
8.
policies/abandon.pdf?ga⫽t. Accessed November 15, 2010. Nursing board policy: patient abandonment. Colorado Board of Nursing. http://www.dora.state.co.us/nursing/ policies/20-01.pdf. Accessed November 15, 2010. Fuller JK. Surgical Technology: Principles and Practice. 5th ed. St Louis, MO: Saunders Elsevier; 2009:37-38. Phillips N. Berry and Kohn’s Operating Room Technique. 11th ed. St Louis, MO: Mosby Elsevier; 2007: 42-43. Blyth DA. Do you know what constitutes patient abandonment? Nurs Manage. 2007;38(8):8, 10. Exhibit B: Perioperative explications for the ANA Code of Ethics for Nurses. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2010:30-61. Westrick SJ. Refusing an assignment/patient abandonment. In: Westrick SJ, Dempski K, eds. Essentials of Nursing Law and Ethics. Sudbury, MA: Jones and Bartlett Publishers; 2009:37-44.
Determining shelf life
QUESTION We are very confused about sterile items, expiration dates, and shelf life. Personnel in our ambulatory surgery center have been placing 30-day expiration dates on all sterilized items based on the Centers for Medicare & Medicaid Services (CMS) requirements. The inpatient sterile processing department’s policy is event related. Which process is correct? ANSWER Sterilized materials should be packaged, labeled, and stored in a manner that ensures sterility.1 AORN and the Association for the Advancement of Medical Instrumentation (AAMI) recommend the event-related process to determine the shelf life of sterilized items.1,2 The confusion around the CMS requirements arises from a variance in its earlier State Operations Manuals for ambulatory surgical services and hospitals. The 2004 State Operations Manual for ambulatory surgical services stated that “Sterilized materials should be packaged, labeled, and stored in a manner to ensure sterility and that each item is marked with the expiration date.”3 The 2008 State Operations Manual for hospitals states, “That sterilized materials are packaged, handled, labeled, and stored in
a manner that ensures sterility (eg, in a moistureand dust-controlled environment) and policies and procedures for expiration dates have been developed and are followed in accordance with accepted standards of practice.”4 This requirement is now stated the same way in the 2009 State Operations Manual for ambulatory surgical services.5 The important point to consider here is that policies and procedures are developed in accordance with accepted standards of practice, such as those provided by AORN and AAMI. AORN recommendations are consistent with the AAMI standards and the Centers for Disease Control and Prevention Healthcare Infection Control Practices Advisory Committee guidelines.1,6 AORN’s recommended practices for sterilization2 and AAMI’s Comprehensive Guide to Steam Sterilization and Sterility Assurance in Health Care Facilities1 recommend that the following be included in the health care facility’s policy and procedure for event-related sterility. The shelf life of a packaged sterile item should be considered event related. An event must occur to compromise package content sterility. Events that may compromise the sterility of a package include, but are not limited to, repeated handling that leads to seal breakage or loss of AORN Journal
401
March 2011
Vol 93
CLINICAL ISSUES
No 3
package integrity, moisture penetration, and exposure to airborne contaminants.1,2 Limiting exposure to moisture, dust, excessive light, handling, and temperature and humidity extremes decreases the risk of contamination of sterilized items.1,2 Perioperative managers should evaluate the adequacy and quality of storage space and conditions before writing policies and procedures on event-related sterility for perioperative practice settings.1 Sterile packages should be stored under environmentally controlled conditions that reduce the risk of contamination.7 Managers should ensure that the temperature in the sterile storage areas does not exceed 24° C (75° F), four air exchanges per hour occur in the storage area, and the relative humidity is controlled and does not exceed 70%. Traffic should be controlled to limit access to those trained in handling sterile supplies. Managers should also ensure that supplies are stored in a manner that allows adequate air circulation, ease of cleaning, and compliance with local fire codes; sterile items are stored at least 8 to 10 inches above the floor, at least 18 inches below sprinkler heads, and at least 2 inches from outside walls; outside shipping containers are not allowed in the sterile storage area because they serve as generators of and reservoirs for dust; and all stored items are rotated according to the principle of “first in, first out.”2,7
Commission, the Accreditation Association for Ambulatory Health Care, the American Association for Accreditation of Ambulatory Surgery Facilities) with which the surgical facility is affiliated. MARY J. OGG MSN, RN, CNOR PERIOPERATIVE NURSING SPECIALIST AORN CENTER FOR NURSING PRACTICE References 1.
2.
3.
When you are creating or reviewing policies for event-related sterility, shelf life, and sterile storage, check specific state and local regulations for your practice setting (eg, hospital, ambulatory surgery center, office-based surgery center). The policies should be based on national standards (eg, AORN, AAMI) and accreditation agencies (eg, the Joint
4.
5.
6.
7.
ANSI/AAMI ST79:2006 —Comprehensive Guide to Steam Sterilization and Sterility Assurance in Health Care Facilities. Arlington, VA: Association for the Advancement of Medical Instrumentation; 2006:73. Recommended practices for sterilization in the perioperative practice setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2010:457-480. Appendix A §482.51. Survey protocol, regulations and interpretive guidelines for hospitals. Condition of participation: surgical services. In: State Operations Manual. US Department of Health and Human Services; Centers for Medicaid and Medicare Services (CMS). http://www.cms .gov/manuals/Downloads/som107ap_a_hospitals.pdf. Accessed November 15, 2010. Appendix A §482.51. Survey protocol, regulations and interpretive guidelines for hospitals. Survey procedures. In: State Operations Manual. US Department of Health and Human Services; Centers for Medicaid and Medicare Services (CMS). http://www.cms.gov/manuals/ downloads/som107ap_a_hospitals.pdf. Accessed November 15, 2010. Appendix L §416.44(a)(3) and §416.51. Ambulatory surgical centers (ASC) comprehensive revision. In: State Operations Manual. US Department of Health and Human Services; Centers for Medicaid and Medicare Services (CMS). http://www1.cms.gov/SurveyCertification GenInfo/PMSR/itemdetail.asp?filterType⫽none&filter ByDID⫽0&sortByDID⫽4&sortOrder⫽descending&item ID⫽CMS1222613&intNumPerPage⫽20 Accessed November 15, 2010. Rutala WA, Weber DJ; Healthcare Infection Control Practice Advisory Committee. Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008. Atlanta, GA: Centers for Disease Control and Prevention; 2008. http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/ Disinfection_Nov_2008.pdf. Accessed October 19, 2010. Recommended practices for cleaning and care of surgical instruments and powered equipment. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2010:421-446.
The author of this column has no declared affiliations that could be perceived as posing a potential conflict of interest in the publication of this article.
402
AORN Journal
LEARNER EVALUATION CONTINUING EDUCATION PROGRAM
1.3
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 Learner Evaluation online at http://www.aorn.org/CE. Rate the items as described below. PURPOSE/GOAL To educate perioperative nurses about providing safe nursing care throughout the perioperative continuum. 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 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
www.aorn.org/CE
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 1.3 continuing education contact hour (78-minute) program: _____
This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements. 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 continuing education for registered nurses. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity. 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: #11005; Session: #4058; Fee: Members $6.50, Nonmembers $13 The deadline for this program is March 31, 2014. Each applicant who successfully completes this program can immediately print a certificate of completion.
© AORN, Inc, 2011
March 2011
Vol 93
No 3 ● AORN Journal
403