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Changing scrub clothes; patient shaves, preps; hand-scrub policies; sterilization, high-level disinfection; environmental policies
AORN .JOURNAL
OCTOBER 1993. VOL 58. NO 4
Clinical Issues Changing scrub clothes; patient shaves, preps; hand-scrub policies; sterilization, high-level disinfection; environmental policies
Q
uestion: Our new infection control nurse has suggested that the scrub person and the circulating nurse change their scrubs between every case. We follow universal precautions; however, I did not think it was necessary to change clothes after every procedure. What does AORN say?
A
nswer: The AORN “Recommended practices for surgical attire” state that “scrub clothes should be changed whenever they become visibly soiled or wet.”’ A study reported in the May 1979 issue of Hospital Infection Control emphasizes the importance of changing wet or soiled scrub suits.* There is not enough information, however, to show the benefit of changing scrub clothes between every procedure if they are not visibly contaminated. Blood and other body fluids are capable of transmitting infectious disease. If scrub clothes become contaminated during the course of the day, it is necessary to change them as soon as possible. If scrub clothes remain clean and dry, however, it is not necessary to change them between procedures.
Q
uestion: At our institution, if the patient is to receive an abdominal shave, it is done in the OR after the patient is anesthetized. Should this shave be performed somewhere other than in the OR?
A
nswer: AORN recommended practices state that hair is best left on the operative site.3If a shave prep is needed, it should be per-
formed as close to the time of surgery as possible, and hair should be removed in an area outside the room where the procedure will be perf~rmed.~ Most shave preps are best performed in the holding area. During a shave, it is impossible to contain all the hair that is removed. Loose hair may become airborne and contaminate the sterile field. Certain shave procedures, however, may need to be done in the OR. A craniotomy shave on a child, for example, may be impossible to perform until the child is under anesthesia.
Q
uestion: My supervisor says that AORN recommends a five-minute prep for all procedures except orthopedic preps. She says that for orthopedic preps, AORN recommends a 10-minute prep. I have been unable to verify this information. Can you help?
A
nswer: AORN does not make any recommendation regarding the length of time for a patient prep. How long the prep should last must be determined by the surgeon’s preference and from information provided by the manufacturer of the skin preparation product. Manufacturers may recommend that a prep be performed for a specified time for best results with their products. This information, along with the surgeon’s preference, will determine the length of time for a patient skin prep.
Q
uestion: Two surgeons recently joined the staff at our hospital. They perform a 785
AORN JOURNAL
OCTOBER 1993, VOL 58, NO 4
Alcohol does not meet the objective of inhibiting rapid rebound growth of microorganisms. five-minute hand scrub for their first case of the day and then use a foam product on their hands between each of their subsequent cases. This is against our policy. Before these physicians discontinue their hand-scrub practice. however. they want to see a reference that indicates that their practice is incorrect. Can AORN provide information regarding this practice?
A
nswer: The objective of a surgical hand scrub with an antimicrobial agent is to leave a persistent chemical activity on the hands after a five-minute scrub.' What this means is that rebound microbial growth is suppressed after the person has finished the scrub and donned sterile gloves. Most foam products used on the hands contain alcohol. Alcohol does not leave a persistent chemical effect on the skin and does not meet the objective of inhibiting rapid rebound growth of microorganisms.6 If a person has a skin sensitivity to an antimicrobial skin scrub product, he or she could use a foam product in the following manner: wash first with a nonmedicated soap and rinse, 0 apply an alcohol-based hand cleanser (eg, foam), and 0 rub the hands together until the cleanser dries and repeat the application. The foam product should be reapplied for a total of five minutes. Foam hand cleansers can be used in the OR between patient contact. Hands should be washed first, however, before the foam product is applied.
Q
uestion: Our hospital just went through a state inspection. We received a deficiency rating for using a high-level disinfectant on our laparoscopes between patient use. It was my understanding that you should steam sterilize la6
parts of the laparoscope that can be sterilized and that it is acceptable to use high-level disinfection on heat-sensitive items. Has there been a change in this recommendation?
A
nswer: Laparoscopes and arthroscopes are considered critical items by the Centers for Disease Control and Prevention (CDC) because they enter sterile areas of the body. The sterility of these items is required. The CDC states that if sterilization of these scopes is not feasible, they should receive at least high-level di~infection.~ High-level disinfection of the heat-sensitive parts of laparoscopes is an acceptable standard across the country. If an item is not heat sensitive, it should be sterilized between patient use. An alternative to high-level disinfection is single-use laparoscopic equipment. By using disposable instruments, all of your patients would be receiving sterile instruments for every procedure, and the need to clean the difficultto-reach parts of reusable laparoscopes would be eliminated. Another advantage to single-use parts is that sharps can be disposed of at the point of use. Items such as trocars would not need to be handled for cleaning, thus avoiding possible injuries to personnel who decontaminate sharp items.
Q
uestion: I thought all metal instrument trays that weighed more than 16 Ibs needed to be flash sterilized for 10 minutes. I cannot find this statement in the new recommended practices for sterilization, however. Has this information changed?
A
nswer: According to the Association for the Advancement of Medical Instrumentation (AAMI), the recommended minimum exposure time and temperature for loads containing only routine metal instruments is three
OCTOBER 1993, VOL 58, NO 4
minutes at 270” F (132’ C).8Metal instruments require surface sterilization only. If you add porous items (eg, towels, rubber, plastic items, any items with lumens), the time must be increased. In a gravity displacement sterilizer, this time should be 10 minute^.^ Because AAMI does not set a weight limit for flash sterilization, you may want to contact the manufacturer of your flash sterilizer for additional documentation.
Q
uestion: Our staff members were wondering what can be done to help the environment by recycling in the OR. We have some ideas of our own but wondered if AORN had any guidelines?
A
nswer: The AORN Board of Directors recently approved a recommended practice on environmental responsibility in the practice setting. It appeared as a proposed recommended practice in the April 1993 AORN Journal, and the final recommended practice appears in this issue of the Journal. This recommended practice should provide you with information about how to be environmentally responsible. You can have an effect on the OR environment by turning water off at the scrub sink unless you are rinsing your hands and by shutting off the lights in the OR when the room is empty. An additional recommendation is to open surgical supplies only when there is reasonable certainty that they will be used.’” This cuts down on the creation of waste materials. One way to decrease the amount of supply waste is to use custom packs, which eliminates the need for outer wrappers on many items contained within the pack and reduces the amount of unnecessarily opened products. Many operating rooms already use separate receptacles for infectious and noninfectious waste. The outer wrappers of packages that are opened and are not visibly contaminated can be thrown in the noninfectious waste receptacle. Color-coded, labeled bags can be used to visually segregate infectious waste from noninfectious waste in the OR.” Supporting a recycling program is something
AORN JOURNAL
that can be instituted by the entire hospital. Each area of the hospital can have recycling bins for aluminum cans, newspaper, and possibly glass containers. Have your hospital contact your local sanitation company for information. MARYO’NEALE,RN, MN, CNOR PERIOPERATIVE NURSING SPECIALIST
CENTER FOR NURSING PRACTICE Notes 1. “Recommended practices for surgical attire,” in AORN Standards and Recommended Practices (Denver: Association of Operating Room Nurses, Inc, 1993) 105. 2. S Goings, “Surgeon a clue in puzzle of unusual outbreak,” Hospital Infection Control 6 (May 1979) 57-59. 3. “Recommended practices for skin preparation of patients,” in AORN Standards and Recommended Practices (Denver: Association of Operating Room Nurses, Inc, 1993) 195. 4.Ibid, 196. 5. “Recommended practices for surgical hand scrubs,” in AORN Standards and Recommended Practices (Denver: Association of Operating Room Nurses, Inc, 1993) 130, 6. Ibid. 7. J S Garner, M S Favero, “Guideline for handwashing and hospital environmental control,” in Guidelines for Prevention and Control of Nosocomial Infection (Atlanta: Centers for Disease Control and Prevention, 1985) 12. 8. American National Standards Institute/ Association for the Advancement of Medical Instrumentation, Good Hospital Practice: Flash Sterilization-Stearn Sterilization of Patient Care Items f o r Immediate Use ST37 (Arlington,Va: American National Standards Institute/Association for the Advancement of Medical Instrumentation, 1992) 7. 9. Ibid. 10. “Proposed recommended practices: Environmental responsibility in the practice setting,” AORN Journal 57 (April 1993) 970-977. 11. Ibid, 972.
OCTOBER 1993. VOL 58. NO 4
Clinical Issues Changing scrub clothes; patient shaves, preps; hand-scrub policies; sterilization, high-level disinfection; environmental policies
Q
uestion: Our new infection control nurse has suggested that the scrub person and the circulating nurse change their scrubs between every case. We follow universal precautions; however, I did not think it was necessary to change clothes after every procedure. What does AORN say?
A
nswer: The AORN “Recommended practices for surgical attire” state that “scrub clothes should be changed whenever they become visibly soiled or wet.”’ A study reported in the May 1979 issue of Hospital Infection Control emphasizes the importance of changing wet or soiled scrub suits.* There is not enough information, however, to show the benefit of changing scrub clothes between every procedure if they are not visibly contaminated. Blood and other body fluids are capable of transmitting infectious disease. If scrub clothes become contaminated during the course of the day, it is necessary to change them as soon as possible. If scrub clothes remain clean and dry, however, it is not necessary to change them between procedures.
Q
uestion: At our institution, if the patient is to receive an abdominal shave, it is done in the OR after the patient is anesthetized. Should this shave be performed somewhere other than in the OR?
A
nswer: AORN recommended practices state that hair is best left on the operative site.3If a shave prep is needed, it should be per-
formed as close to the time of surgery as possible, and hair should be removed in an area outside the room where the procedure will be perf~rmed.~ Most shave preps are best performed in the holding area. During a shave, it is impossible to contain all the hair that is removed. Loose hair may become airborne and contaminate the sterile field. Certain shave procedures, however, may need to be done in the OR. A craniotomy shave on a child, for example, may be impossible to perform until the child is under anesthesia.
Q
uestion: My supervisor says that AORN recommends a five-minute prep for all procedures except orthopedic preps. She says that for orthopedic preps, AORN recommends a 10-minute prep. I have been unable to verify this information. Can you help?
A
nswer: AORN does not make any recommendation regarding the length of time for a patient prep. How long the prep should last must be determined by the surgeon’s preference and from information provided by the manufacturer of the skin preparation product. Manufacturers may recommend that a prep be performed for a specified time for best results with their products. This information, along with the surgeon’s preference, will determine the length of time for a patient skin prep.
Q
uestion: Two surgeons recently joined the staff at our hospital. They perform a 785
AORN JOURNAL
OCTOBER 1993, VOL 58, NO 4
Alcohol does not meet the objective of inhibiting rapid rebound growth of microorganisms. five-minute hand scrub for their first case of the day and then use a foam product on their hands between each of their subsequent cases. This is against our policy. Before these physicians discontinue their hand-scrub practice. however. they want to see a reference that indicates that their practice is incorrect. Can AORN provide information regarding this practice?
A
nswer: The objective of a surgical hand scrub with an antimicrobial agent is to leave a persistent chemical activity on the hands after a five-minute scrub.' What this means is that rebound microbial growth is suppressed after the person has finished the scrub and donned sterile gloves. Most foam products used on the hands contain alcohol. Alcohol does not leave a persistent chemical effect on the skin and does not meet the objective of inhibiting rapid rebound growth of microorganisms.6 If a person has a skin sensitivity to an antimicrobial skin scrub product, he or she could use a foam product in the following manner: wash first with a nonmedicated soap and rinse, 0 apply an alcohol-based hand cleanser (eg, foam), and 0 rub the hands together until the cleanser dries and repeat the application. The foam product should be reapplied for a total of five minutes. Foam hand cleansers can be used in the OR between patient contact. Hands should be washed first, however, before the foam product is applied.
Q
uestion: Our hospital just went through a state inspection. We received a deficiency rating for using a high-level disinfectant on our laparoscopes between patient use. It was my understanding that you should steam sterilize la6
parts of the laparoscope that can be sterilized and that it is acceptable to use high-level disinfection on heat-sensitive items. Has there been a change in this recommendation?
A
nswer: Laparoscopes and arthroscopes are considered critical items by the Centers for Disease Control and Prevention (CDC) because they enter sterile areas of the body. The sterility of these items is required. The CDC states that if sterilization of these scopes is not feasible, they should receive at least high-level di~infection.~ High-level disinfection of the heat-sensitive parts of laparoscopes is an acceptable standard across the country. If an item is not heat sensitive, it should be sterilized between patient use. An alternative to high-level disinfection is single-use laparoscopic equipment. By using disposable instruments, all of your patients would be receiving sterile instruments for every procedure, and the need to clean the difficultto-reach parts of reusable laparoscopes would be eliminated. Another advantage to single-use parts is that sharps can be disposed of at the point of use. Items such as trocars would not need to be handled for cleaning, thus avoiding possible injuries to personnel who decontaminate sharp items.
Q
uestion: I thought all metal instrument trays that weighed more than 16 Ibs needed to be flash sterilized for 10 minutes. I cannot find this statement in the new recommended practices for sterilization, however. Has this information changed?
A
nswer: According to the Association for the Advancement of Medical Instrumentation (AAMI), the recommended minimum exposure time and temperature for loads containing only routine metal instruments is three
OCTOBER 1993, VOL 58, NO 4
minutes at 270” F (132’ C).8Metal instruments require surface sterilization only. If you add porous items (eg, towels, rubber, plastic items, any items with lumens), the time must be increased. In a gravity displacement sterilizer, this time should be 10 minute^.^ Because AAMI does not set a weight limit for flash sterilization, you may want to contact the manufacturer of your flash sterilizer for additional documentation.
Q
uestion: Our staff members were wondering what can be done to help the environment by recycling in the OR. We have some ideas of our own but wondered if AORN had any guidelines?
A
nswer: The AORN Board of Directors recently approved a recommended practice on environmental responsibility in the practice setting. It appeared as a proposed recommended practice in the April 1993 AORN Journal, and the final recommended practice appears in this issue of the Journal. This recommended practice should provide you with information about how to be environmentally responsible. You can have an effect on the OR environment by turning water off at the scrub sink unless you are rinsing your hands and by shutting off the lights in the OR when the room is empty. An additional recommendation is to open surgical supplies only when there is reasonable certainty that they will be used.’” This cuts down on the creation of waste materials. One way to decrease the amount of supply waste is to use custom packs, which eliminates the need for outer wrappers on many items contained within the pack and reduces the amount of unnecessarily opened products. Many operating rooms already use separate receptacles for infectious and noninfectious waste. The outer wrappers of packages that are opened and are not visibly contaminated can be thrown in the noninfectious waste receptacle. Color-coded, labeled bags can be used to visually segregate infectious waste from noninfectious waste in the OR.” Supporting a recycling program is something
AORN JOURNAL
that can be instituted by the entire hospital. Each area of the hospital can have recycling bins for aluminum cans, newspaper, and possibly glass containers. Have your hospital contact your local sanitation company for information. MARYO’NEALE,RN, MN, CNOR PERIOPERATIVE NURSING SPECIALIST
CENTER FOR NURSING PRACTICE Notes 1. “Recommended practices for surgical attire,” in AORN Standards and Recommended Practices (Denver: Association of Operating Room Nurses, Inc, 1993) 105. 2. S Goings, “Surgeon a clue in puzzle of unusual outbreak,” Hospital Infection Control 6 (May 1979) 57-59. 3. “Recommended practices for skin preparation of patients,” in AORN Standards and Recommended Practices (Denver: Association of Operating Room Nurses, Inc, 1993) 195. 4.Ibid, 196. 5. “Recommended practices for surgical hand scrubs,” in AORN Standards and Recommended Practices (Denver: Association of Operating Room Nurses, Inc, 1993) 130, 6. Ibid. 7. J S Garner, M S Favero, “Guideline for handwashing and hospital environmental control,” in Guidelines for Prevention and Control of Nosocomial Infection (Atlanta: Centers for Disease Control and Prevention, 1985) 12. 8. American National Standards Institute/ Association for the Advancement of Medical Instrumentation, Good Hospital Practice: Flash Sterilization-Stearn Sterilization of Patient Care Items f o r Immediate Use ST37 (Arlington,Va: American National Standards Institute/Association for the Advancement of Medical Instrumentation, 1992) 7. 9. Ibid. 10. “Proposed recommended practices: Environmental responsibility in the practice setting,” AORN Journal 57 (April 1993) 970-977. 11. Ibid, 972.