- Email: [email protected]
Clinical Issues—May 2013
CONTINUING EDUCATION Clinical Issues
2.0
AMBER WOOD, MSN, RN, CNOR, CIC, CPN; SHARON A. VAN WICKLIN, MSN, RN, CNOR, CRNFA, CPSN, PLNC
www.aorn.org/CE Continuing Education Contact Hours
Approvals
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 Examination and Learner Evaluation at http://www.aorn.org/CE. A score of 70% correct on the examination is required for credit. Participants receive feedback on incorrect answers. 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 continuing education 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: #13513 Session: #0001 Fee: Members $12, Nonmembers $24
Ms Wood and Ms Van Wicklin 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.
The contact hours for this article expire May 31, 2016.
Purpose/Goal The purpose of this activity is to provide the reader with knowledge of AORN recommended practices related to transmissible infections and surgical attire.
Conflict of Interest Disclosures
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.
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 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.
http://dx.doi.org/10.1016/j.aorn.2013.02.008
586 j AORN Journal
May 2013
Vol 97
No 5
Ó AORN, Inc, 2013
CLINICAL ISSUES
2.0
www.aorn.org/CE
This Month Immunization recommendations for perioperative observers Key words: immunization, vaccine, vaccination, perioperative observers, perioperative visitors.
Legislation related to the immunization of perioperative observers Key words: immunization, vaccine, vaccination, perioperative observers, perioperative visitors, students, immunization legislation, immunization regulation, immunization law.
Scrubbed personnel who are sneezing Key words: sneezing, coughing, saliva, mucus, surgical mask.
Length of time after which a surgical mask should be changed Key words: surgical masks, wet, soiled, filtration efficiency, microbial barrier.
Removing surgical head coverings Key words: surgical head coverings, perioperative areas, microbial dispersal.
Surgical wound classification change after glove perforation Key words: surgical wound classification, glove perforation, major break, sterile technique, wound contamination.
Immunization recommendations for perioperative observers QUESTION: What are the immunization recommendations for observers (eg, students, visiting physicians) in the OR or other invasive procedure rooms? ANSWER: Observers in the OR or other invasive procedure rooms should be immunized according to the health care organization’s policy regarding immunization for health care personnel. According to the Centers for Disease Control and Prevention (CDC)
“Immunization of health-care personnel: recommendations of the Advisory Committee on Immunization Practices (ACIP),” the term health care personnel refers to all paid and unpaid persons working in health care settings who have the potential for exposure to patients or infectious materials, including the patient’s environment and air.1 Therefore, all recommendations from the ACIP guidelines apply to observers in the OR or other areas where invasive procedures occur. Figure 1 provides a visual representation of the
http://dx.doi.org/10.1016/j.aorn.2013.02.008
Ó AORN, Inc, 2013
May 2013
Vol 97 No 5
AORN Journal j 587
May 2013
CLINICAL ISSUES
Vol 97 No 5
Figure 1. Advisory Committee on Immunization Practices recommendations for immunization of health care personnel as listed by vaccine-preventable diseases.1 1. Immunization of Health-care Personnel: Recommendations of the Advisory Committee on Immunization Practices (ACIP). Centers for Disease Control and Prevention. MMWR. November 25, 2011. 60(RR07):1-45. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6007a1.htm?s_cid¼rr6007a1_e. Accessed January 4, 2013.
ACIP recommendations for immunization of health care personnel. The ACIP guidelines recommend assessing the immunization status of health care personnel and administering vaccines for the following vaccinepreventable diseases: n
hepatitis B, n seasonal influenza, n measles,
588 j AORN Journal
n
mumps, rubella, n pertussis, and 1,2 n varicella. n
The ACIP guidelines recommend pertussis immunization in combination with tetanus and diphtheria toxoids vaccine (ie, Tdap) for health care personnel who do not have documented immunity to pertussis.1 Health care personnel who are
CLINICAL ISSUES immune to pertussis may still be required to be immunized against tetanus and diphtheria if this is required in the health care organization’s policy. The ACIP recommends that all qualifying adults, whether they are health care workers or not, receive the tetanus and diphtheria vaccine (ie, Td) in addition to the following vaccines: n
pneumococcal polysaccharide vaccine, human papillomavirus vaccine, n herpes zoster vaccine, and 1 n hepatitis A vaccine. n
In certain circumstances (eg, health condition of health care personnel, geographic location), health care organizations may extend the immunization program for health care personnel to include vaccines against meningococcal disease, typhoid fever, and polio.1 For example, health care personnel caring for patients undergoing neurosurgical procedures may be more likely to be exposed to meningococcal disease. In this situation, health care personnel may benefit from receiving the meningococcal disease vaccine, especially if those employees are immunocompromised. Health care organizations in the United States do not routinely require health care personnel to receive the following vaccinations: n n n n n n
hepatitis A, Japanese encephalitis, rabies, typhoid fever, yellow fever, or tuberculosis (ie, bacillus Calmette-Guerin [BCG] vaccine).1
However, health care personnel who are international travelers, including those who observe operative or other invasive procedures outside the United States, may be required to get these immunizations. The efficacy of the BCG vaccine against tuberculosis (TB) is controversial, and thus the BCG vaccine is typically not recommended in the United States.1 The CDC recommends that health care
www.aornjournal.org
organizations screen health care personnel for TB by using either the tuberculin skin test (ie, TST) or blood assay for Mycobacterium tuberculosis (ie, BAMT) (eg, QuantiFERONÒ-TB test, QuantiFERONÒ-TB Gold test).3 According to the CDC, health care personnel who qualify for TB screening are “all paid and unpaid persons working in health-care settings who have the potential for exposure to M. tuberculosis through air space shared with persons with infectious TB disease.”3(p3) Sharing air space with patients in an OR or an invasive procedure room may expose the observer to TB if he or she was present during a procedure involving a patient with an undiagnosed case of infectious TB. When possible, observers should not enter the OR or invasive procedure room of a patient with known or suspected infectious TB.4 Perioperative personnel should consult the health care organization’s policy for TB screening of observers to determine the organization’s requirements. When the organization’s policy does not clearly define TB screening requirements for observers, perioperative personnel should collaborate with members of the facility’s infection prevention committee to determine the procedure for TB screening of observers. The choice to require or recommend immunizations for observers is a decision health care organization leaders should make based on the specific needs of the health care personnel population at the facility. AMBER WOOD MSN, RN, CNOR, CIC, CPN PERIOPERATIVE NURSING SPECIALIST AORN CENTER FOR NURSING PRACTICE
Editor’s note: QuantiFERON is a registered trademark of Cellestis, Ltd, Carnegie, Australia. References 1. Centers for Disease Control and Prevention. Immunization of health-care personnel: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR. 2011;60(RR07):1-45. http://www.cdc.gov/mmwr/ preview/mmwrhtml/rr6007a1.htm?s_cid¼rr6007a1_e. Accessed January 4, 2013.
AORN Journal j 589
May 2013
Vol 97 No 5
2. Recommended practices for prevention of transmissible infections in the perioperative practice setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:331-363. 3. Centers for Disease Control and Prevention. Guidelines for preventing the transmission of Mycobacterium
CLINICAL ISSUES tuberculosis in health-care settings. MMWR. 2005; 54(RR17):1-141. http://www.cdc.gov/mmwr/preview/ mmwrhtml/rr5417a1.htm?s_cid¼rr5417a1_e. Accessed January 4, 2013. 4. Neil JA. Perioperative care of the patient with tuberculosis. AORN J. 2008;88(6):942-960.
Legislation related to the immunization of perioperative observers QUESTION: Is there any legislation requiring immunization for observers (eg, students, visiting physicians) in the OR or in other invasive procedure rooms? If immunizations are required, who is responsible for paying for the immunizations? ANSWER: There are currently no federal laws mandating immunization of observers in the OR or in other invasive procedure rooms or requiring health care organizations to pay for the immunization of observers.1 State and local regulations may require health care organizations to pay for these immunizations, although the definition of health care personnel varies among states and may or may not include observers. State legislation on immunization requirements for health care personnel varies by assessment of the health care worker’s immunization status and the responsibility of the organization to provide immunizations at no cost.2 Table 1 provides information about which states have legislation regarding immunization of health care personnel. Although there are no federal immunization laws about immunization of observers, there are federal regulations related to the immunization of health care personnel. After a bill is passed by Congress and becomes federal law, regulatory agencies, such as the Occupational Safety and Health Administration (OSHA) and the Centers for Medicare & Medicaid Services (CMS), are responsible for putting the law into action by developing specific federal regulations to enforce the law.3 For example, the OSHA Act of 1970 was amended in 1991 to include a requirement for the development
590 j AORN Journal
of a bloodborne pathogens standard.4 The law does not list the specific details of the bloodborne pathogens standard; this information is provided in the Code of Federal Regulations 1910.1030 of the Occupational Safety and Health Standards, Bloodborne Pathogens section.5 Hepatitis B immunization is regulated by OSHA under the Bloodborne Pathogens Standard.5 As part of the Bloodborne Pathogens Standard, OSHA requires health care organizations to make the hepatitis B vaccine available at no cost to personnel upon hire and in the event of an exposure, but this does not apply to unpaid health care personnel, such as observers in the OR or in other invasive procedure rooms.5 In 2007, the National Quality Forum launched an influenza and pneumococcal immunization initiative for patients and health care personnel.6 As part of a provision to the Medicare Improvements for Patients and Providers Act of 2008, the US Department of Health and Human Services entered into a contract with the National Quality Forum to develop quality and efficiency measures.7 Initiatives from the National Quality Forum influenza and pneumococcal immunization program led to the creation of CMS regulatory measure IM-015-07 regarding influenza immunization of health care personnel.6 Measure IM-015-07 requires a health care organization’s infection preventionist, employee health personnel, or quality personnel to calculate the percentage of all health care personnel, including those who are unpaid (eg, observers), who receive the influenza vaccine. This calculation is federally regulated by CMS. As of January 2013, CMS requires that health care organizations report this calculation to the Centers for
CLINICAL ISSUES
www.aornjournal.org
TABLE 1. Federal and State Requirements for Immunization of Health Care Personnel
Immunization
Federal regulation
State law mandating*
State law offeringy
State with other legislationz
Alaska Maine2
Arizona Arkansas California Connecticut Hawaii Illinois Michigan Minnesota Missouri New York Oklahoma Oregon Rhode Island South Dakota Texas Vermont Washington2
Alabama District of Columbia Georgia Virginia2
Alabama New Hampshire2
California Illinois Maine Maryland Massachusetts Nebraska Oklahoma Rhode Island Tennessee2
District of Columbia Oregon Virginia2
Hepatitis B
Occupational Safety and Health Administration (does not include unpaid health care personnel)1
Influenza
Centers for Medicare and Medicaid Services (includes unpaid health care personnel)3
Measles mumps rubella (MMR)
None4
Arkansas Illinois Maine Maryland Massachusetts New Mexico New York Oklahoma Rhode Island Wisconsin2
California New Jersey2
Alabama District of Columbia New Hampshire Oregon Virginia2
Varicella
None4
Maine Oklahoma Rhode Island2
California2
Alabama District of Columbia Illinois Oregon Virginia2
* States with legislation mandating immunization for hospital personnel, unless the person has a medical, religious, or philosophical exemption to the law.1 States with legislation requiring that health care organizations offer immunization or make it available to hospital personnel.1 z States (including the District of Columbia) with other legislation language related to immunization of health care personnel.1 y
1. 29 CFR 1910.1030. Occupational exposure. Bloodborne pathogens. 2009. Occupational Safety & Health Administration. http://www.osha.gov/pls/osha web/owadisp.show_document?p_table¼STANDARDS&p_id¼1005. Accessed January 4, 2013. 2. State vaccination requirements. 2011. Centers for Disease Control and Prevention. http://www.cdc.gov/vaccines/vac-gen/laws/state-reqs.htm. Accessed January 4, 2013. 3. Influenza and pneumococcal immunizations: national voluntary consensus standards for influenza and pneumococcal immunizations. 2008. National Quality Forum. http://www.qualityforum.org/Projects/i-m/Influenza_and_Pneumococcal_Immunizations/Influenza_and_Pneumococcal_Immunizations.aspx. Accessed January 4, 2013. 4. Vaccines & immunizations. 2012. Centers for Disease Control and Prevention. http://www.cdc.gov/vaccines/hcp.htm. Accessed January 4, 2013.
AORN Journal j 591
May 2013
CLINICAL ISSUES
Vol 97 No 5
Disease Control and Prevention and the National Healthcare Safety Network to monitor compliance with measure IM-015-07.6 Accreditation organizations, such as The Joint Commission, also may specify the immunizations to be provided to health care personnel.8 Health care organizations should refer to the accrediting organization’s standards regarding immunization of health care personnel, including observers. AMBER WOOD MSN, RN, CNOR, CIC, CPN PERIOPERATIVE NURSING SPECIALIST AORN CENTER FOR NURSING PRACTICE References 1. Vaccines & immunizations. Centers for Disease Control and Prevention. http://www.cdc.gov/vaccines/hcp.htm. Accessed January 4, 2013. 2. State vaccination requirements. Centers for Disease Control and Prevention. http://www.cdc.gov/vaccines/vacgen/laws/state-reqs.htm. Accessed January 4, 2013.
3. Federal regulations. Answers.USA.gov. http://answers.usa .gov/system/selfservice.controller?CONFIGURATION¼ 1000&PARTITION_ID¼1&TIMEZONE_OFFSET¼2520 0000&CMD¼VIEW_ARTICLE&ARTICLE_ID¼10430& SIDE_LINK_TOPIC_ID¼&SIDE_LINK_SUB_TOPIC _ID¼&EXPANDED_TOPIC_TREE_NODES¼&TOPIC _ID¼. Accessed January 4, 2013. 4. OSHA Act of 1970. Historical notes. Occupational Safety & Health Administration. http://www.osha.gov/pls/oshawe b/owadisp.show_document?p_table¼OSHACT&p_id¼ 3389. Accessed January 4, 2013. 5. 29 CFR 1910.1030. Occupational exposure. Bloodborne pathogens. 2009. Occupational Safety & Health Administration. http://www.osha.gov/pls/oshaweb/owadisp.sho w_document?p_table¼STANDARDS&p_id¼10051. Accessed January 4, 2013. 6. Influenza and pneumococcal vaccinations: national voluntary consensus standards for influenza and pneumococcal immunizations. National Quality Forum. http:// www.qualityforum.org/Projects/i-m/Influenza_and_Pneu mococcal_Immunizations/Influenza_and_Pneumococcal _Immunizations.aspx. Accessed January 4, 2013. 7. HHS performance measurement. National Quality Forum. http://www.qualityforum.org/About_NQF/HHS _Performance_Measurement.aspx. Accessed January 25, 2013. 8. Infection control. The Joint Commission. http://www .jointcommission.org/infection_control.aspx. Accessed January 25, 2013.
Scrubbed personnel who are sneezing QUESTION: What actions should be taken when a scrubbed person sneezes during an operative or other invasive procedure? ANSWER: If possible, scrubbed team members should step away from the sterile field to sneeze. After sneezing, the perioperative team member should remove his or her sterile gown and gloves and leave the room to discard his or her mask, wash his or her hands, apply a clean surgical mask, and perform a surgical hand scrub. After returning to the OR, the team member should don a clean sterile gown and gloves. According to the AORN “Recommended practices for surgical attire,” a surgical mask should be changed whenever it becomes wet or soiled because the filtering efficiency of a surgical mask may be compromised by moisture.1 During
592 j AORN Journal
coughing, sneezing, or speaking, particles of saliva and mucus are emitted.2 Research on this subject has been conducted for more than 50 years. Researchers in one 1946 study demonstrated that large numbers of saliva particles are expelled from the mouth during sneezing, and many fewer particles are expelled during breathing, talking, and coughing.3 The researchers found that a sneeze produced an average of 73,000 bacteria-carrying particles, a cough produced approximately 710 particles, and loud talking produced approximately 36 particles for every 100 words spoken.3 According to the researchers, sneezing released 200fold more particles than coughing, with 50-fold more particles released during three sneezes than during 12 coughs.3 Louden and Roberts4 in 1967 found only 470 particles were produced per cough, and Papineni and Rosenthal5 in 1997 found 420 particles per cough, indicating that the number of particles produced during coughing may actually
CLINICAL ISSUES be closer to 450 particles than to 710 particles. In another 1946 study, researchers found a 95-fold increase in airborne bacteria during sneezing.6 In 2006, researchers using volumetric air sampling to study histamine-induced sneezing found a 4.7-fold increase in airborne dispersal of Staphylococcus aureus, a 1.4-fold increase in coagulasenegative staphylococci, and a 3.9-fold increase in other bacteria during sneezing.7 One possible explanation for the markedly increased numbers of particles associated with sneezing is that more saliva is typically expelled from the mouth during sneezing than during coughing because during coughing the fluid is expelled from the back of the pharynx and has a greater distance to travel before expulsion.2 In a 2009 prospective study of orthopedic surgeons, researchers assessed the potential for contamination of the sterile field from sneezes by perioperative team members wearing masks and showed that although surgical masks significantly reduced bacterial counts after sneezing, they did not eliminate the potential for contamination of the surgical site.8 The researchers recommended that, if possible, perioperative team members distance themselves from the surgical site while sneezing
www.aornjournal.org
and that they change into a clean sterile gown, gloves, and mask after sneezing.8 SHARON A. VAN WICKLIN MSN, RN, CNOR, CRNFA, CPSN, PLNC PERIOPERATIVE NURSING SPECIALIST AORN CENTER FOR NURSING PRACTICE References 1. Recommended practices for surgical attire. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:51-62. 2. Nicas M, Nazaroff WW, Hubbard A. Toward understanding the risk of secondary airborne infection: emission of respirable pathogens. J Occup Environ Hyg. 2005;2(3): 143-154. 3. Duguid JP. The size and duration of air carriage of respiratory droplets and droplet nuclei. J Hygiene (Lond). 1946;44(6):471-479. 4. Louden RG, Roberts RM. Droplet expulsion from the respiratory tract. Am Rev Respir Dis. 1967;95(3):435-442. 5. Papineni RS, Rosenthal FS. The size distribution of droplets in the exhaled breath of healthy human subjects. J Aerosol Med. 1997;10(2):105-116. 6. Hare R, Mackenzie DM. The source and transmission of nasopharyngeal infections due to certain bacteria and viruses. Br Med J. 1946;8(June):865-870. 7. Bischoff WE, Wallis ML, Tucker BK, et al. “Gesundheit!” sneezing, common colds, allergies, and Staphylococcus aureus dispersion. J Infect Dis. 2006;194(8): 1119-1126. 8. Graham D, Parkinson B, Evans M, Keijzers G, Derrington P. Nothing to sneeze at! A study into intra-operative contamination. ANZ J Surg. 2009;79(12):909-912.
Length of time after which a surgical mask should be changed QUESTION: Is there a particular length of time after which a surgical mask should be changed? ANSWER: AORN does not have any specific recommendations as to the length of time a surgical mask should be worn before it is changed. According to the AORN “Recommended practices for surgical attire,” a surgical mask should be replaced whenever it becomes wet or soiled.1 In a controlled, quasi-experimental study to determine whether the filtration efficiency of surgical masks decreased with the length of time
the mask was worn, researchers evaluated 32 individuals wearing surgical masks and 32 individuals without masks.2 The surgical masks used in the experiment had a bacterial filtration efficiency of 95%. The researchers conducted the experiment in positive pressure ORs in which temperatures were maintained between 66 F and 75 F (19 C and 24 C) and the humidity level was maintained between 45% and 60%. Participants read aloud continuously for two minutes, stopped, and then repeated the two-minute reading at 15-minute intervals during a six-hour period. Researchers took air samples from the site of the OR bed at one, two, four, and six hours. The results
AORN Journal j 593
May 2013
CLINICAL ISSUES
Vol 97 No 5
showed an increase in contamination after four hours, and the researchers concluded that the microbial barrier of surgical masks decreases significantly after four hours.2 Based on the evidence provided by this study, although there is no specific recommendation for practice regarding changing masks at specific time periods, perioperative team members may want to consider changing masks that have been worn continuously for longer than four hours.
SHARON A. VAN WICKLIN MSN, RN, CNOR, CRNFA, CPSN, PLNC PERIOPERATIVE NURSING SPECIALIST AORN CENTER FOR NURSING PRACTICE
References 1. Recommended practices for surgical attire. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:51-62. 2. Barbosa MH, Graziano KU. Influence of wearing time on efficacy of disposable surgical masks as microbial barrier. Braz J Microbiol. 2006;37(3):216-217.
Removing surgical head coverings QUESTION: Is it necessary to remove surgical head coverings when leaving perioperative areas? ANSWER: It is not recommended or necessary that health care workers leaving perioperative areas remove surgical head coverings; however, surgical attire (including head coverings) should be removed when the health care worker leaves the health care facility or when he or she travels between buildings located on separate campuses.1 Although surgical head coverings are part of the surgical attire that is worn in perioperative areas, they do not provide protection against hazards and do not qualify as personal protective equipment.2 The purpose of the head covering is to contain hair and minimize microbial dispersal.1 When the head covering is removed, hair and microbes may be shed onto surgical attire; therefore, a disposable or reusable
head covering should only be removed at the end of the day or when it is contaminated.1 A used, singleuse head covering should be discarded in a designated receptacle.1 Reusable head coverings should be laundered daily after each use in a health careaccredited laundry facility.1
SHARON A. VAN WICKLIN MSN, RN, CNOR, CRNFA, CPSN, PLNC PERIOPERATIVE NURSING SPECIALIST AORN CENTER FOR NURSING PRACTICE
References 1. Recommended practices for surgical attire. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:51-62. 2. 29 CFR 1910.1030. Occupational exposure. Bloodborne pathogens. 2009. Occupational Safety & Health Administration. http://www.osha.gov/pls/oshaweb/owadisp.sho w_document?p_table¼STANDARDS&p_id¼10051. Accessed January 4, 2013.
Surgical wound classification change after glove perforation QUESTION: If a scrubbed person discovers a perforation in his or her glove during an operative procedure, should the Centers for Disease Control and Prevention (CDC) surgical wound classification be changed from a class I to a class II?
594 j AORN Journal
ANSWER: In most cases, the CDC surgical wound classification should not be changed because of a perforation in a scrubbed person’s glove. According to the CDC, wounds should be classified according to the likelihood and degree of wound
CLINICAL ISSUES contamination at the time of surgery.1 The following are the CDC definitions for wound classifications: n
[Class 1] Clean wounds: These are uninfected operative wounds in which no inflammation is encountered and the respiratory, alimentary, genital, or uninfected urinary tracts are not entered. In addition, clean wounds are primarily closed, and if necessary, drained with closed drainage. Operative incisional wounds that follow nonpenetrating (blunt) trauma should be included in this category if they meet the criteria. n [Class 2] Clean-contaminated wounds: These are operative wounds in which the respiratory, alimentary, genital, or urinary tract is entered under controlled conditions and without unusual contamination. Specifically, operations involving the biliary tract, appendix, vagina, and oropharynx are included in this category, provided no evidence of infection or major break in technique is encountered. n [Class 3] Contaminated wounds: These include open, fresh, accidental wounds, operations with major breaks in sterile technique (eg, open cardiac massage) or gross spillage from the gastrointestinal tract, and incisions in which acute, nonpurulent inflammation is encountered. n [Class 4] Dirty or infected wounds: These include old traumatic wounds with retained devitalized tissue and those that involve existing clinical infection or perforated viscera. This definition suggests that the organisms causing postoperative infection were present in the operative field before the operation.1 A wound classification should not be changed from a class I to a class II if a scrubbed person’s glove perforates because the class II assignment is strictly for situations in which the respiratory, alimentary, or genitourinary tract is entered. If the wound classification must be changed because of a break in technique, the classification would
www.aornjournal.org
change from a class I to a class III. According to the CDC, however, a class III assignment is to be used only for surgical procedures in which there is “a major break in technique.”1 The CDC provides the example of open cardiac massage to describe a major break in technique.1 Open cardiac massage is a very traumatic event and indicates a break in sterile technique that presents a risk of much greater contamination than a glove perforation. Another example of a class III wound situation would be during a total joint procedure in which midway through the procedure the surgical team discovers that the instruments have not been properly sterilized. A full discussion of the recommended practices for documentation of the CDC surgical wound classification as well as an educational tool to assist with accurate identification of wound classification can be found in the AORN “Recommended practices for prevention of transmissible infections in the perioperative practice setting.”2 The factors associated with a break in sterile technique require thoughtful assessment and the application of informed clinical judgment to determine whether a wound classification should be changed, and there may be special circumstances that necessitate changing the wound classification (eg, significant sharps injury to a scrubbed person who perforates both layers of gloves and skin).2 When special circumstances arise that may indicate the need to change the wound classification, the surgical team should consult the facility’s infection prevention personnel. Determining the correct wound classification presents an excellent opportunity for communication and collaboration with the surgeon and other perioperative team members regarding the degree of wound contamination and the potential for subsequent wound infection. SHARON A. VAN WICKLIN MSN, RN, CNOR, CRNFA, CPSN, PLNC PERIOPERATIVE NURSING SPECIALIST AORN CENTER FOR NURSING PRACTICE
AORN Journal j 595
May 2013
Vol 97 No 5
References 1. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Hospital Infection Control Practices Advisory Committee. Guidelines for prevention of surgical site infection, 1999. Infect Control Epidemiol. 1999;20(4):247-278. http://www.cdc.gov/
596 j AORN Journal
CLINICAL ISSUES ncidod/dhqp/pdf/guidelines/SSI.pdf. Accessed December 13, 2012. 2. Recommended practices for prevention of transmissible infections in the perioperative practice setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:331-363.
LEARNER EVALUATION
2.0
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 Learner Evaluation online at http://www.aorn.org/CE. Rate the items as described below. PURPOSE/GOAL The purpose of this activity is to provide the reader with knowledge of AORN recommended practices related to transmissible infections and surgical attire. 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
Ó AORN, Inc, 2013
www.aorn.org/CE
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 2.0 continuing education contact hour (120-minute) program: ________________________________
May 2013
Vol 97 No 5
AORN Journal j 597
2.0
AMBER WOOD, MSN, RN, CNOR, CIC, CPN; SHARON A. VAN WICKLIN, MSN, RN, CNOR, CRNFA, CPSN, PLNC
www.aorn.org/CE Continuing Education Contact Hours
Approvals
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 Examination and Learner Evaluation at http://www.aorn.org/CE. A score of 70% correct on the examination is required for credit. Participants receive feedback on incorrect answers. 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 continuing education 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: #13513 Session: #0001 Fee: Members $12, Nonmembers $24
Ms Wood and Ms Van Wicklin 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.
The contact hours for this article expire May 31, 2016.
Purpose/Goal The purpose of this activity is to provide the reader with knowledge of AORN recommended practices related to transmissible infections and surgical attire.
Conflict of Interest Disclosures
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.
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 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.
http://dx.doi.org/10.1016/j.aorn.2013.02.008
586 j AORN Journal
May 2013
Vol 97
No 5
Ó AORN, Inc, 2013
CLINICAL ISSUES
2.0
www.aorn.org/CE
This Month Immunization recommendations for perioperative observers Key words: immunization, vaccine, vaccination, perioperative observers, perioperative visitors.
Legislation related to the immunization of perioperative observers Key words: immunization, vaccine, vaccination, perioperative observers, perioperative visitors, students, immunization legislation, immunization regulation, immunization law.
Scrubbed personnel who are sneezing Key words: sneezing, coughing, saliva, mucus, surgical mask.
Length of time after which a surgical mask should be changed Key words: surgical masks, wet, soiled, filtration efficiency, microbial barrier.
Removing surgical head coverings Key words: surgical head coverings, perioperative areas, microbial dispersal.
Surgical wound classification change after glove perforation Key words: surgical wound classification, glove perforation, major break, sterile technique, wound contamination.
Immunization recommendations for perioperative observers QUESTION: What are the immunization recommendations for observers (eg, students, visiting physicians) in the OR or other invasive procedure rooms? ANSWER: Observers in the OR or other invasive procedure rooms should be immunized according to the health care organization’s policy regarding immunization for health care personnel. According to the Centers for Disease Control and Prevention (CDC)
“Immunization of health-care personnel: recommendations of the Advisory Committee on Immunization Practices (ACIP),” the term health care personnel refers to all paid and unpaid persons working in health care settings who have the potential for exposure to patients or infectious materials, including the patient’s environment and air.1 Therefore, all recommendations from the ACIP guidelines apply to observers in the OR or other areas where invasive procedures occur. Figure 1 provides a visual representation of the
http://dx.doi.org/10.1016/j.aorn.2013.02.008
Ó AORN, Inc, 2013
May 2013
Vol 97 No 5
AORN Journal j 587
May 2013
CLINICAL ISSUES
Vol 97 No 5
Figure 1. Advisory Committee on Immunization Practices recommendations for immunization of health care personnel as listed by vaccine-preventable diseases.1 1. Immunization of Health-care Personnel: Recommendations of the Advisory Committee on Immunization Practices (ACIP). Centers for Disease Control and Prevention. MMWR. November 25, 2011. 60(RR07):1-45. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6007a1.htm?s_cid¼rr6007a1_e. Accessed January 4, 2013.
ACIP recommendations for immunization of health care personnel. The ACIP guidelines recommend assessing the immunization status of health care personnel and administering vaccines for the following vaccinepreventable diseases: n
hepatitis B, n seasonal influenza, n measles,
588 j AORN Journal
n
mumps, rubella, n pertussis, and 1,2 n varicella. n
The ACIP guidelines recommend pertussis immunization in combination with tetanus and diphtheria toxoids vaccine (ie, Tdap) for health care personnel who do not have documented immunity to pertussis.1 Health care personnel who are
CLINICAL ISSUES immune to pertussis may still be required to be immunized against tetanus and diphtheria if this is required in the health care organization’s policy. The ACIP recommends that all qualifying adults, whether they are health care workers or not, receive the tetanus and diphtheria vaccine (ie, Td) in addition to the following vaccines: n
pneumococcal polysaccharide vaccine, human papillomavirus vaccine, n herpes zoster vaccine, and 1 n hepatitis A vaccine. n
In certain circumstances (eg, health condition of health care personnel, geographic location), health care organizations may extend the immunization program for health care personnel to include vaccines against meningococcal disease, typhoid fever, and polio.1 For example, health care personnel caring for patients undergoing neurosurgical procedures may be more likely to be exposed to meningococcal disease. In this situation, health care personnel may benefit from receiving the meningococcal disease vaccine, especially if those employees are immunocompromised. Health care organizations in the United States do not routinely require health care personnel to receive the following vaccinations: n n n n n n
hepatitis A, Japanese encephalitis, rabies, typhoid fever, yellow fever, or tuberculosis (ie, bacillus Calmette-Guerin [BCG] vaccine).1
However, health care personnel who are international travelers, including those who observe operative or other invasive procedures outside the United States, may be required to get these immunizations. The efficacy of the BCG vaccine against tuberculosis (TB) is controversial, and thus the BCG vaccine is typically not recommended in the United States.1 The CDC recommends that health care
www.aornjournal.org
organizations screen health care personnel for TB by using either the tuberculin skin test (ie, TST) or blood assay for Mycobacterium tuberculosis (ie, BAMT) (eg, QuantiFERONÒ-TB test, QuantiFERONÒ-TB Gold test).3 According to the CDC, health care personnel who qualify for TB screening are “all paid and unpaid persons working in health-care settings who have the potential for exposure to M. tuberculosis through air space shared with persons with infectious TB disease.”3(p3) Sharing air space with patients in an OR or an invasive procedure room may expose the observer to TB if he or she was present during a procedure involving a patient with an undiagnosed case of infectious TB. When possible, observers should not enter the OR or invasive procedure room of a patient with known or suspected infectious TB.4 Perioperative personnel should consult the health care organization’s policy for TB screening of observers to determine the organization’s requirements. When the organization’s policy does not clearly define TB screening requirements for observers, perioperative personnel should collaborate with members of the facility’s infection prevention committee to determine the procedure for TB screening of observers. The choice to require or recommend immunizations for observers is a decision health care organization leaders should make based on the specific needs of the health care personnel population at the facility. AMBER WOOD MSN, RN, CNOR, CIC, CPN PERIOPERATIVE NURSING SPECIALIST AORN CENTER FOR NURSING PRACTICE
Editor’s note: QuantiFERON is a registered trademark of Cellestis, Ltd, Carnegie, Australia. References 1. Centers for Disease Control and Prevention. Immunization of health-care personnel: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR. 2011;60(RR07):1-45. http://www.cdc.gov/mmwr/ preview/mmwrhtml/rr6007a1.htm?s_cid¼rr6007a1_e. Accessed January 4, 2013.
AORN Journal j 589
May 2013
Vol 97 No 5
2. Recommended practices for prevention of transmissible infections in the perioperative practice setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:331-363. 3. Centers for Disease Control and Prevention. Guidelines for preventing the transmission of Mycobacterium
CLINICAL ISSUES tuberculosis in health-care settings. MMWR. 2005; 54(RR17):1-141. http://www.cdc.gov/mmwr/preview/ mmwrhtml/rr5417a1.htm?s_cid¼rr5417a1_e. Accessed January 4, 2013. 4. Neil JA. Perioperative care of the patient with tuberculosis. AORN J. 2008;88(6):942-960.
Legislation related to the immunization of perioperative observers QUESTION: Is there any legislation requiring immunization for observers (eg, students, visiting physicians) in the OR or in other invasive procedure rooms? If immunizations are required, who is responsible for paying for the immunizations? ANSWER: There are currently no federal laws mandating immunization of observers in the OR or in other invasive procedure rooms or requiring health care organizations to pay for the immunization of observers.1 State and local regulations may require health care organizations to pay for these immunizations, although the definition of health care personnel varies among states and may or may not include observers. State legislation on immunization requirements for health care personnel varies by assessment of the health care worker’s immunization status and the responsibility of the organization to provide immunizations at no cost.2 Table 1 provides information about which states have legislation regarding immunization of health care personnel. Although there are no federal immunization laws about immunization of observers, there are federal regulations related to the immunization of health care personnel. After a bill is passed by Congress and becomes federal law, regulatory agencies, such as the Occupational Safety and Health Administration (OSHA) and the Centers for Medicare & Medicaid Services (CMS), are responsible for putting the law into action by developing specific federal regulations to enforce the law.3 For example, the OSHA Act of 1970 was amended in 1991 to include a requirement for the development
590 j AORN Journal
of a bloodborne pathogens standard.4 The law does not list the specific details of the bloodborne pathogens standard; this information is provided in the Code of Federal Regulations 1910.1030 of the Occupational Safety and Health Standards, Bloodborne Pathogens section.5 Hepatitis B immunization is regulated by OSHA under the Bloodborne Pathogens Standard.5 As part of the Bloodborne Pathogens Standard, OSHA requires health care organizations to make the hepatitis B vaccine available at no cost to personnel upon hire and in the event of an exposure, but this does not apply to unpaid health care personnel, such as observers in the OR or in other invasive procedure rooms.5 In 2007, the National Quality Forum launched an influenza and pneumococcal immunization initiative for patients and health care personnel.6 As part of a provision to the Medicare Improvements for Patients and Providers Act of 2008, the US Department of Health and Human Services entered into a contract with the National Quality Forum to develop quality and efficiency measures.7 Initiatives from the National Quality Forum influenza and pneumococcal immunization program led to the creation of CMS regulatory measure IM-015-07 regarding influenza immunization of health care personnel.6 Measure IM-015-07 requires a health care organization’s infection preventionist, employee health personnel, or quality personnel to calculate the percentage of all health care personnel, including those who are unpaid (eg, observers), who receive the influenza vaccine. This calculation is federally regulated by CMS. As of January 2013, CMS requires that health care organizations report this calculation to the Centers for
CLINICAL ISSUES
www.aornjournal.org
TABLE 1. Federal and State Requirements for Immunization of Health Care Personnel
Immunization
Federal regulation
State law mandating*
State law offeringy
State with other legislationz
Alaska Maine2
Arizona Arkansas California Connecticut Hawaii Illinois Michigan Minnesota Missouri New York Oklahoma Oregon Rhode Island South Dakota Texas Vermont Washington2
Alabama District of Columbia Georgia Virginia2
Alabama New Hampshire2
California Illinois Maine Maryland Massachusetts Nebraska Oklahoma Rhode Island Tennessee2
District of Columbia Oregon Virginia2
Hepatitis B
Occupational Safety and Health Administration (does not include unpaid health care personnel)1
Influenza
Centers for Medicare and Medicaid Services (includes unpaid health care personnel)3
Measles mumps rubella (MMR)
None4
Arkansas Illinois Maine Maryland Massachusetts New Mexico New York Oklahoma Rhode Island Wisconsin2
California New Jersey2
Alabama District of Columbia New Hampshire Oregon Virginia2
Varicella
None4
Maine Oklahoma Rhode Island2
California2
Alabama District of Columbia Illinois Oregon Virginia2
* States with legislation mandating immunization for hospital personnel, unless the person has a medical, religious, or philosophical exemption to the law.1 States with legislation requiring that health care organizations offer immunization or make it available to hospital personnel.1 z States (including the District of Columbia) with other legislation language related to immunization of health care personnel.1 y
1. 29 CFR 1910.1030. Occupational exposure. Bloodborne pathogens. 2009. Occupational Safety & Health Administration. http://www.osha.gov/pls/osha web/owadisp.show_document?p_table¼STANDARDS&p_id¼1005. Accessed January 4, 2013. 2. State vaccination requirements. 2011. Centers for Disease Control and Prevention. http://www.cdc.gov/vaccines/vac-gen/laws/state-reqs.htm. Accessed January 4, 2013. 3. Influenza and pneumococcal immunizations: national voluntary consensus standards for influenza and pneumococcal immunizations. 2008. National Quality Forum. http://www.qualityforum.org/Projects/i-m/Influenza_and_Pneumococcal_Immunizations/Influenza_and_Pneumococcal_Immunizations.aspx. Accessed January 4, 2013. 4. Vaccines & immunizations. 2012. Centers for Disease Control and Prevention. http://www.cdc.gov/vaccines/hcp.htm. Accessed January 4, 2013.
AORN Journal j 591
May 2013
CLINICAL ISSUES
Vol 97 No 5
Disease Control and Prevention and the National Healthcare Safety Network to monitor compliance with measure IM-015-07.6 Accreditation organizations, such as The Joint Commission, also may specify the immunizations to be provided to health care personnel.8 Health care organizations should refer to the accrediting organization’s standards regarding immunization of health care personnel, including observers. AMBER WOOD MSN, RN, CNOR, CIC, CPN PERIOPERATIVE NURSING SPECIALIST AORN CENTER FOR NURSING PRACTICE References 1. Vaccines & immunizations. Centers for Disease Control and Prevention. http://www.cdc.gov/vaccines/hcp.htm. Accessed January 4, 2013. 2. State vaccination requirements. Centers for Disease Control and Prevention. http://www.cdc.gov/vaccines/vacgen/laws/state-reqs.htm. Accessed January 4, 2013.
3. Federal regulations. Answers.USA.gov. http://answers.usa .gov/system/selfservice.controller?CONFIGURATION¼ 1000&PARTITION_ID¼1&TIMEZONE_OFFSET¼2520 0000&CMD¼VIEW_ARTICLE&ARTICLE_ID¼10430& SIDE_LINK_TOPIC_ID¼&SIDE_LINK_SUB_TOPIC _ID¼&EXPANDED_TOPIC_TREE_NODES¼&TOPIC _ID¼. Accessed January 4, 2013. 4. OSHA Act of 1970. Historical notes. Occupational Safety & Health Administration. http://www.osha.gov/pls/oshawe b/owadisp.show_document?p_table¼OSHACT&p_id¼ 3389. Accessed January 4, 2013. 5. 29 CFR 1910.1030. Occupational exposure. Bloodborne pathogens. 2009. Occupational Safety & Health Administration. http://www.osha.gov/pls/oshaweb/owadisp.sho w_document?p_table¼STANDARDS&p_id¼10051. Accessed January 4, 2013. 6. Influenza and pneumococcal vaccinations: national voluntary consensus standards for influenza and pneumococcal immunizations. National Quality Forum. http:// www.qualityforum.org/Projects/i-m/Influenza_and_Pneu mococcal_Immunizations/Influenza_and_Pneumococcal _Immunizations.aspx. Accessed January 4, 2013. 7. HHS performance measurement. National Quality Forum. http://www.qualityforum.org/About_NQF/HHS _Performance_Measurement.aspx. Accessed January 25, 2013. 8. Infection control. The Joint Commission. http://www .jointcommission.org/infection_control.aspx. Accessed January 25, 2013.
Scrubbed personnel who are sneezing QUESTION: What actions should be taken when a scrubbed person sneezes during an operative or other invasive procedure? ANSWER: If possible, scrubbed team members should step away from the sterile field to sneeze. After sneezing, the perioperative team member should remove his or her sterile gown and gloves and leave the room to discard his or her mask, wash his or her hands, apply a clean surgical mask, and perform a surgical hand scrub. After returning to the OR, the team member should don a clean sterile gown and gloves. According to the AORN “Recommended practices for surgical attire,” a surgical mask should be changed whenever it becomes wet or soiled because the filtering efficiency of a surgical mask may be compromised by moisture.1 During
592 j AORN Journal
coughing, sneezing, or speaking, particles of saliva and mucus are emitted.2 Research on this subject has been conducted for more than 50 years. Researchers in one 1946 study demonstrated that large numbers of saliva particles are expelled from the mouth during sneezing, and many fewer particles are expelled during breathing, talking, and coughing.3 The researchers found that a sneeze produced an average of 73,000 bacteria-carrying particles, a cough produced approximately 710 particles, and loud talking produced approximately 36 particles for every 100 words spoken.3 According to the researchers, sneezing released 200fold more particles than coughing, with 50-fold more particles released during three sneezes than during 12 coughs.3 Louden and Roberts4 in 1967 found only 470 particles were produced per cough, and Papineni and Rosenthal5 in 1997 found 420 particles per cough, indicating that the number of particles produced during coughing may actually
CLINICAL ISSUES be closer to 450 particles than to 710 particles. In another 1946 study, researchers found a 95-fold increase in airborne bacteria during sneezing.6 In 2006, researchers using volumetric air sampling to study histamine-induced sneezing found a 4.7-fold increase in airborne dispersal of Staphylococcus aureus, a 1.4-fold increase in coagulasenegative staphylococci, and a 3.9-fold increase in other bacteria during sneezing.7 One possible explanation for the markedly increased numbers of particles associated with sneezing is that more saliva is typically expelled from the mouth during sneezing than during coughing because during coughing the fluid is expelled from the back of the pharynx and has a greater distance to travel before expulsion.2 In a 2009 prospective study of orthopedic surgeons, researchers assessed the potential for contamination of the sterile field from sneezes by perioperative team members wearing masks and showed that although surgical masks significantly reduced bacterial counts after sneezing, they did not eliminate the potential for contamination of the surgical site.8 The researchers recommended that, if possible, perioperative team members distance themselves from the surgical site while sneezing
www.aornjournal.org
and that they change into a clean sterile gown, gloves, and mask after sneezing.8 SHARON A. VAN WICKLIN MSN, RN, CNOR, CRNFA, CPSN, PLNC PERIOPERATIVE NURSING SPECIALIST AORN CENTER FOR NURSING PRACTICE References 1. Recommended practices for surgical attire. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:51-62. 2. Nicas M, Nazaroff WW, Hubbard A. Toward understanding the risk of secondary airborne infection: emission of respirable pathogens. J Occup Environ Hyg. 2005;2(3): 143-154. 3. Duguid JP. The size and duration of air carriage of respiratory droplets and droplet nuclei. J Hygiene (Lond). 1946;44(6):471-479. 4. Louden RG, Roberts RM. Droplet expulsion from the respiratory tract. Am Rev Respir Dis. 1967;95(3):435-442. 5. Papineni RS, Rosenthal FS. The size distribution of droplets in the exhaled breath of healthy human subjects. J Aerosol Med. 1997;10(2):105-116. 6. Hare R, Mackenzie DM. The source and transmission of nasopharyngeal infections due to certain bacteria and viruses. Br Med J. 1946;8(June):865-870. 7. Bischoff WE, Wallis ML, Tucker BK, et al. “Gesundheit!” sneezing, common colds, allergies, and Staphylococcus aureus dispersion. J Infect Dis. 2006;194(8): 1119-1126. 8. Graham D, Parkinson B, Evans M, Keijzers G, Derrington P. Nothing to sneeze at! A study into intra-operative contamination. ANZ J Surg. 2009;79(12):909-912.
Length of time after which a surgical mask should be changed QUESTION: Is there a particular length of time after which a surgical mask should be changed? ANSWER: AORN does not have any specific recommendations as to the length of time a surgical mask should be worn before it is changed. According to the AORN “Recommended practices for surgical attire,” a surgical mask should be replaced whenever it becomes wet or soiled.1 In a controlled, quasi-experimental study to determine whether the filtration efficiency of surgical masks decreased with the length of time
the mask was worn, researchers evaluated 32 individuals wearing surgical masks and 32 individuals without masks.2 The surgical masks used in the experiment had a bacterial filtration efficiency of 95%. The researchers conducted the experiment in positive pressure ORs in which temperatures were maintained between 66 F and 75 F (19 C and 24 C) and the humidity level was maintained between 45% and 60%. Participants read aloud continuously for two minutes, stopped, and then repeated the two-minute reading at 15-minute intervals during a six-hour period. Researchers took air samples from the site of the OR bed at one, two, four, and six hours. The results
AORN Journal j 593
May 2013
CLINICAL ISSUES
Vol 97 No 5
showed an increase in contamination after four hours, and the researchers concluded that the microbial barrier of surgical masks decreases significantly after four hours.2 Based on the evidence provided by this study, although there is no specific recommendation for practice regarding changing masks at specific time periods, perioperative team members may want to consider changing masks that have been worn continuously for longer than four hours.
SHARON A. VAN WICKLIN MSN, RN, CNOR, CRNFA, CPSN, PLNC PERIOPERATIVE NURSING SPECIALIST AORN CENTER FOR NURSING PRACTICE
References 1. Recommended practices for surgical attire. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:51-62. 2. Barbosa MH, Graziano KU. Influence of wearing time on efficacy of disposable surgical masks as microbial barrier. Braz J Microbiol. 2006;37(3):216-217.
Removing surgical head coverings QUESTION: Is it necessary to remove surgical head coverings when leaving perioperative areas? ANSWER: It is not recommended or necessary that health care workers leaving perioperative areas remove surgical head coverings; however, surgical attire (including head coverings) should be removed when the health care worker leaves the health care facility or when he or she travels between buildings located on separate campuses.1 Although surgical head coverings are part of the surgical attire that is worn in perioperative areas, they do not provide protection against hazards and do not qualify as personal protective equipment.2 The purpose of the head covering is to contain hair and minimize microbial dispersal.1 When the head covering is removed, hair and microbes may be shed onto surgical attire; therefore, a disposable or reusable
head covering should only be removed at the end of the day or when it is contaminated.1 A used, singleuse head covering should be discarded in a designated receptacle.1 Reusable head coverings should be laundered daily after each use in a health careaccredited laundry facility.1
SHARON A. VAN WICKLIN MSN, RN, CNOR, CRNFA, CPSN, PLNC PERIOPERATIVE NURSING SPECIALIST AORN CENTER FOR NURSING PRACTICE
References 1. Recommended practices for surgical attire. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:51-62. 2. 29 CFR 1910.1030. Occupational exposure. Bloodborne pathogens. 2009. Occupational Safety & Health Administration. http://www.osha.gov/pls/oshaweb/owadisp.sho w_document?p_table¼STANDARDS&p_id¼10051. Accessed January 4, 2013.
Surgical wound classification change after glove perforation QUESTION: If a scrubbed person discovers a perforation in his or her glove during an operative procedure, should the Centers for Disease Control and Prevention (CDC) surgical wound classification be changed from a class I to a class II?
594 j AORN Journal
ANSWER: In most cases, the CDC surgical wound classification should not be changed because of a perforation in a scrubbed person’s glove. According to the CDC, wounds should be classified according to the likelihood and degree of wound
CLINICAL ISSUES contamination at the time of surgery.1 The following are the CDC definitions for wound classifications: n
[Class 1] Clean wounds: These are uninfected operative wounds in which no inflammation is encountered and the respiratory, alimentary, genital, or uninfected urinary tracts are not entered. In addition, clean wounds are primarily closed, and if necessary, drained with closed drainage. Operative incisional wounds that follow nonpenetrating (blunt) trauma should be included in this category if they meet the criteria. n [Class 2] Clean-contaminated wounds: These are operative wounds in which the respiratory, alimentary, genital, or urinary tract is entered under controlled conditions and without unusual contamination. Specifically, operations involving the biliary tract, appendix, vagina, and oropharynx are included in this category, provided no evidence of infection or major break in technique is encountered. n [Class 3] Contaminated wounds: These include open, fresh, accidental wounds, operations with major breaks in sterile technique (eg, open cardiac massage) or gross spillage from the gastrointestinal tract, and incisions in which acute, nonpurulent inflammation is encountered. n [Class 4] Dirty or infected wounds: These include old traumatic wounds with retained devitalized tissue and those that involve existing clinical infection or perforated viscera. This definition suggests that the organisms causing postoperative infection were present in the operative field before the operation.1 A wound classification should not be changed from a class I to a class II if a scrubbed person’s glove perforates because the class II assignment is strictly for situations in which the respiratory, alimentary, or genitourinary tract is entered. If the wound classification must be changed because of a break in technique, the classification would
www.aornjournal.org
change from a class I to a class III. According to the CDC, however, a class III assignment is to be used only for surgical procedures in which there is “a major break in technique.”1 The CDC provides the example of open cardiac massage to describe a major break in technique.1 Open cardiac massage is a very traumatic event and indicates a break in sterile technique that presents a risk of much greater contamination than a glove perforation. Another example of a class III wound situation would be during a total joint procedure in which midway through the procedure the surgical team discovers that the instruments have not been properly sterilized. A full discussion of the recommended practices for documentation of the CDC surgical wound classification as well as an educational tool to assist with accurate identification of wound classification can be found in the AORN “Recommended practices for prevention of transmissible infections in the perioperative practice setting.”2 The factors associated with a break in sterile technique require thoughtful assessment and the application of informed clinical judgment to determine whether a wound classification should be changed, and there may be special circumstances that necessitate changing the wound classification (eg, significant sharps injury to a scrubbed person who perforates both layers of gloves and skin).2 When special circumstances arise that may indicate the need to change the wound classification, the surgical team should consult the facility’s infection prevention personnel. Determining the correct wound classification presents an excellent opportunity for communication and collaboration with the surgeon and other perioperative team members regarding the degree of wound contamination and the potential for subsequent wound infection. SHARON A. VAN WICKLIN MSN, RN, CNOR, CRNFA, CPSN, PLNC PERIOPERATIVE NURSING SPECIALIST AORN CENTER FOR NURSING PRACTICE
AORN Journal j 595
May 2013
Vol 97 No 5
References 1. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Hospital Infection Control Practices Advisory Committee. Guidelines for prevention of surgical site infection, 1999. Infect Control Epidemiol. 1999;20(4):247-278. http://www.cdc.gov/
596 j AORN Journal
CLINICAL ISSUES ncidod/dhqp/pdf/guidelines/SSI.pdf. Accessed December 13, 2012. 2. Recommended practices for prevention of transmissible infections in the perioperative practice setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:331-363.
LEARNER EVALUATION
2.0
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 Learner Evaluation online at http://www.aorn.org/CE. Rate the items as described below. PURPOSE/GOAL The purpose of this activity is to provide the reader with knowledge of AORN recommended practices related to transmissible infections and surgical attire. 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
Ó AORN, Inc, 2013
www.aorn.org/CE
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 2.0 continuing education contact hour (120-minute) program: ________________________________
May 2013
Vol 97 No 5
AORN Journal j 597