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Clinical Issues—February 2010
CLINICAL ISSUES
0.7 This Month f f
Continuously monitoring an open but unused sterile field Key words: procedural delay, continuous monitoring, sterile field.
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Documentation of skin status after pneumatic tourniquet use Key words: pneumatic tourniquet, skin assessment, perfusion status.
f f
Blanket warmer settings Key words: blanket warming cabinets, fluid warming cabinets, temperature settings.
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Continuously monitoring an open but unused sterile field
QUESTION: At our AORN chapter meeting, we discussed various situations that had occurred after a procedure setup was opened and remained open for a period of time before it was used. One person described a procedure that was delayed for four hours; everything in the setup had to be discarded because the policy at that facility sets a time limit of two hours after which a setup is considered contaminated and must be discarded. Another person described a situation in which a housekeeper entered the room because she needed to clean cabinets in the OR. The housekeeper knew that the sterile field should not be contaminated so she covered it with a sheet; the circulating nurse found the housekeeper in the act of removing the sheet. In another facility, a maintenance man walked up a back stairway and was seen
working in his street clothes in a room that contained a sterile field. He had entered the room even though the door had been taped shut. What is the correct way to handle a room in which the sterile field has been established, when a long period of time lapses before the procedure starts? ANSWER: AORN’s “Recommended practices for maintaining a sterile field” states that “sterile fields should be prepared as close as possible to the time of use,”1(p320) and, if a sterile field is established in advance, then it should be monitored continuously.1 Continuous monitoring requires that a person be present to observe any events that occur that may result in contamination. The purpose of monitoring is to observe for or prevent an event that could contaminate the sterile field. Contamination may be caused by
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.aornjournal.org/ce. The contact hours for this article expire February 28, 2013.
© AORN, Inc, 2010
February 2010
Vol 91
No 2 ● AORN Journal
287
February 2010 Vol 91
personnel entering the room who are unfamiliar with maintaining a sterile field, falling objects, or other means, such as insects.
The field should be monitored by a person who is familiar with the principles of maintaining a sterile field; however, an RN is not required to perform this task. Some health care organizations establish a definitive time frame for allowing a sterile instrument tray or sterile field to remain open before use. Although results of research showed a correlation between the length of time a tray has been open and the potential for contamination, no definitive time frame has been established.2 Even if the health care organization specifies a time frame in the facility’s policies and procedures, the sterile field must be monitored continuously during that entire time frame. The practice of taping a door shut is unacceptable because it does not prevent an event from occurring that could contaminate the sterile field. For example, an object (eg, ceiling tile) could inadvertently fall on the sterile field or an insect could land on the sterile field. The tape on the door also is not a dependable means of keeping f f
people out of the room (eg, staff members who enter the room for legitimate reasons, such as to obtain a piece of equipment). A staff member may temporarily remove the tape for legitimate reasons but not replace the tape; thus, the barrier intended to keep people out of the room, especially those who are unfamiliar with the principles of aseptic technique, no longer exists. Another person may then enter the room because he or she does not know about the missing barrier and may contaminate the field unbeknownst to the people who are planning to use the sterile supplies for a procedure. Taping the door shut or setting a time frame for unused sterile setups does not negate the need for continuous monitoring.1 BYRON BURLINGAME RN, BSN, MS, CNOR PERIOPERATIVE NURSING SPECIALIST AORN CENTER FOR NURSING PRACTICE References 1.
2.
Recommended practices for maintaining a sterile field. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2009:317-325. Dalstrom DJ, Venkatarayappa I, Manternach AL, Palcic MS, Heyse BA, Prayson MJ. Time-dependent contamination of opened sterile operating-room trays. J Bone Joint Surg Am. 2008;90(5):1022-1025.
Documentation of skin status after pneumatic tourniquet use
QUESTION: We are reviewing our intraoperative record and have a question regarding the documentation of the evaluation of an extremity after tourniquet use. We are using AORN’s 2010 Perioperative Standards and Recommended Practices as a guide. Currently, we only document the patient’s skin condition. We are interpreting the recommended practices to indicate the need to document the perfusion status on the intraoperative record. Our preoperative and postoperative documentation addresses perfusion (eg, pulses, capillary refill). Should we be documenting perfusion intraoperatively after the tourniquet is removed? 288
CLINICAL ISSUES
No 2
AORN Journal
ANSWER: Evaluation of perfusion status should be included in the perioperative record.1 The perioperative record should reflect continuous evaluation through all phases of the perioperative process. The patient’s record should reflect the perioperative plan of care that includes assessment, diagnosis, outcome identification, planning, implementing, and evaluation.2 Posttourniquet-use evaluation requires nursing judgment that includes, but is not limited to, consideration of the patient’s condition, the patient’s comorbidities,
CLINICAL ISSUES the length of time that the tourniquet was inflated, the length of the procedure, and 1 the condition of the affected limb.
While in the OR, immediately after tourniquet use, the perioperative RN’s evaluation should include the condition of the patient’s skin and tissue under the tourniquet cuff (eg, color, temperature, integrity), pulses distal to the tourniquet cuff, vital signs, oxygen saturation, and temperature.1 Although the anesthesia care provider may document the patient’s vital signs and oxygen saturation, the perioperative nurse should document at least the patient’s skin condition and pulses distal to the tourniquet. The perioperative nurse should evaluate the outcome of patient care at the end of the procedure and document the results of that evaluation on the intraoperative record. Evalua-
f f
www.aornjournal.org
tion of sensation and the patient’s ability to move the limb may not be possible immediately after surgery if the patient received a regional block, but continuous monitoring and documentation should occur after surgery as part of the continuum of care. CAROL PETERSEN RN, BSN, MAOM, CNOR MANAGER, PERIOPERATIVE INFORMATICS AORN CENTER FOR NURSING PRACTICE References 1.
2.
Recommended practices for the use of the pneumatic tourniquet in the perioperative practice setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2010:175-187. Recommended practices for documentation of perioperative nursing care. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2010: 289-291.
Blanket warmer settings
QUESTION: We have heard conflicting reports about the temperatures for blanket warming cabinets. What is the appropriate temperature setting for a blanket warming cabinet?
ANSWER: Temperature settings on cabinets designed to warm blankets should not exceed 130° F (54° C) according to revised recommendations from the ECRI Institute.1 Each cabinet should be labeled to define the maximum temperature setting, and the temperature settings should be monitored. Perioperative personnel should follow manufacturers’ recommendations for storing blankets to achieve effective heating. Filling cabinets beyond the designated capacity can cause uneven and ineffective heating.1 Blankets should be warmed in a cabinet or compartment separate from where fluids are warmed. The temperature settings for cabinets
designed to warm fluids should not exceed 110° F (43° C).2 Solutions should be warmed in separate cabinets or separate compartments in cabinets that have separate heating elements and controllers. Periodically, AORN receives updates that affect information in its recommended practices. The official AORN documents are updated as soon as possible. This update from ECRI came at a time in our publication cycle such that AORN’s “Recommended practices for a safe environment of care”3 could be updated to reflect the changes in the 2010 Perioperative Standards and Recommended Practices. Throughout the year, perioperative nurses can check updates in ClinicalInfoLink for the most current information at http://www .aorn.org/PracticeResources/NurseConsultation/ New. BONNIE DENHOLM RN, BSN, MS, CNOR PERIOPERATIVE NURSING SPECIALIST AORN CENTER FOR NURSING PRACTICE AORN Journal
289
February 2010 Vol 91
CLINICAL ISSUES
No 2
References 1.
2.
Hazard report: ECRI Institute revises its recommendation for temperature limits on blanket warmers. Health Devices. 2009;38(7):230-231. ECRI Institute upholds recommendations on warming
3.
cabinet temperatures. Risk Manage Reporter. 2007;26(2): 9-10. https://www.ecri.org/Documents/HRC_Newsletter_ 0407.pdf. Accessed October 27, 2009. Recommended practices for a safe environment of care. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2010:217-239.
The authors of this column have no declared affiliations that could be perceived as potential conflicts of interest in publishing this article.
290
AORN Journal
LEARNER EVALUATION CONTINUING EDUCATION PROGRAM
0.7
Clinical Issues
T
his evaluation is used to determine the extent to which this continuing education program met your learning needs. The Learner 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 regarding 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 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 the change is needed. 2. I will work with management to change and/or implement a policy and procedure. 3. I will plan an informational meeting with physicians to seek their input and acceptance of the need for the change. 4. I will implement the 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 0.7 continuing education contact hour (42-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: #10008; Session: #4001; Fee: Members $3.50, Nonmembers $7 The deadline for this program is February 28, 2013. Each applicant who successfully completes this program will be able to print a certificate of completion.
© AORN, Inc, 2010
February 2010
Vol 91
No 2 ● AORN Journal
291
0.7 This Month f f
Continuously monitoring an open but unused sterile field Key words: procedural delay, continuous monitoring, sterile field.
f f
Documentation of skin status after pneumatic tourniquet use Key words: pneumatic tourniquet, skin assessment, perfusion status.
f f
Blanket warmer settings Key words: blanket warming cabinets, fluid warming cabinets, temperature settings.
f f
Continuously monitoring an open but unused sterile field
QUESTION: At our AORN chapter meeting, we discussed various situations that had occurred after a procedure setup was opened and remained open for a period of time before it was used. One person described a procedure that was delayed for four hours; everything in the setup had to be discarded because the policy at that facility sets a time limit of two hours after which a setup is considered contaminated and must be discarded. Another person described a situation in which a housekeeper entered the room because she needed to clean cabinets in the OR. The housekeeper knew that the sterile field should not be contaminated so she covered it with a sheet; the circulating nurse found the housekeeper in the act of removing the sheet. In another facility, a maintenance man walked up a back stairway and was seen
working in his street clothes in a room that contained a sterile field. He had entered the room even though the door had been taped shut. What is the correct way to handle a room in which the sterile field has been established, when a long period of time lapses before the procedure starts? ANSWER: AORN’s “Recommended practices for maintaining a sterile field” states that “sterile fields should be prepared as close as possible to the time of use,”1(p320) and, if a sterile field is established in advance, then it should be monitored continuously.1 Continuous monitoring requires that a person be present to observe any events that occur that may result in contamination. The purpose of monitoring is to observe for or prevent an event that could contaminate the sterile field. Contamination may be caused by
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.aornjournal.org/ce. The contact hours for this article expire February 28, 2013.
© AORN, Inc, 2010
February 2010
Vol 91
No 2 ● AORN Journal
287
February 2010 Vol 91
personnel entering the room who are unfamiliar with maintaining a sterile field, falling objects, or other means, such as insects.
The field should be monitored by a person who is familiar with the principles of maintaining a sterile field; however, an RN is not required to perform this task. Some health care organizations establish a definitive time frame for allowing a sterile instrument tray or sterile field to remain open before use. Although results of research showed a correlation between the length of time a tray has been open and the potential for contamination, no definitive time frame has been established.2 Even if the health care organization specifies a time frame in the facility’s policies and procedures, the sterile field must be monitored continuously during that entire time frame. The practice of taping a door shut is unacceptable because it does not prevent an event from occurring that could contaminate the sterile field. For example, an object (eg, ceiling tile) could inadvertently fall on the sterile field or an insect could land on the sterile field. The tape on the door also is not a dependable means of keeping f f
people out of the room (eg, staff members who enter the room for legitimate reasons, such as to obtain a piece of equipment). A staff member may temporarily remove the tape for legitimate reasons but not replace the tape; thus, the barrier intended to keep people out of the room, especially those who are unfamiliar with the principles of aseptic technique, no longer exists. Another person may then enter the room because he or she does not know about the missing barrier and may contaminate the field unbeknownst to the people who are planning to use the sterile supplies for a procedure. Taping the door shut or setting a time frame for unused sterile setups does not negate the need for continuous monitoring.1 BYRON BURLINGAME RN, BSN, MS, CNOR PERIOPERATIVE NURSING SPECIALIST AORN CENTER FOR NURSING PRACTICE References 1.
2.
Recommended practices for maintaining a sterile field. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2009:317-325. Dalstrom DJ, Venkatarayappa I, Manternach AL, Palcic MS, Heyse BA, Prayson MJ. Time-dependent contamination of opened sterile operating-room trays. J Bone Joint Surg Am. 2008;90(5):1022-1025.
Documentation of skin status after pneumatic tourniquet use
QUESTION: We are reviewing our intraoperative record and have a question regarding the documentation of the evaluation of an extremity after tourniquet use. We are using AORN’s 2010 Perioperative Standards and Recommended Practices as a guide. Currently, we only document the patient’s skin condition. We are interpreting the recommended practices to indicate the need to document the perfusion status on the intraoperative record. Our preoperative and postoperative documentation addresses perfusion (eg, pulses, capillary refill). Should we be documenting perfusion intraoperatively after the tourniquet is removed? 288
CLINICAL ISSUES
No 2
AORN Journal
ANSWER: Evaluation of perfusion status should be included in the perioperative record.1 The perioperative record should reflect continuous evaluation through all phases of the perioperative process. The patient’s record should reflect the perioperative plan of care that includes assessment, diagnosis, outcome identification, planning, implementing, and evaluation.2 Posttourniquet-use evaluation requires nursing judgment that includes, but is not limited to, consideration of the patient’s condition, the patient’s comorbidities,
CLINICAL ISSUES the length of time that the tourniquet was inflated, the length of the procedure, and 1 the condition of the affected limb.
While in the OR, immediately after tourniquet use, the perioperative RN’s evaluation should include the condition of the patient’s skin and tissue under the tourniquet cuff (eg, color, temperature, integrity), pulses distal to the tourniquet cuff, vital signs, oxygen saturation, and temperature.1 Although the anesthesia care provider may document the patient’s vital signs and oxygen saturation, the perioperative nurse should document at least the patient’s skin condition and pulses distal to the tourniquet. The perioperative nurse should evaluate the outcome of patient care at the end of the procedure and document the results of that evaluation on the intraoperative record. Evalua-
f f
www.aornjournal.org
tion of sensation and the patient’s ability to move the limb may not be possible immediately after surgery if the patient received a regional block, but continuous monitoring and documentation should occur after surgery as part of the continuum of care. CAROL PETERSEN RN, BSN, MAOM, CNOR MANAGER, PERIOPERATIVE INFORMATICS AORN CENTER FOR NURSING PRACTICE References 1.
2.
Recommended practices for the use of the pneumatic tourniquet in the perioperative practice setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2010:175-187. Recommended practices for documentation of perioperative nursing care. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2010: 289-291.
Blanket warmer settings
QUESTION: We have heard conflicting reports about the temperatures for blanket warming cabinets. What is the appropriate temperature setting for a blanket warming cabinet?
ANSWER: Temperature settings on cabinets designed to warm blankets should not exceed 130° F (54° C) according to revised recommendations from the ECRI Institute.1 Each cabinet should be labeled to define the maximum temperature setting, and the temperature settings should be monitored. Perioperative personnel should follow manufacturers’ recommendations for storing blankets to achieve effective heating. Filling cabinets beyond the designated capacity can cause uneven and ineffective heating.1 Blankets should be warmed in a cabinet or compartment separate from where fluids are warmed. The temperature settings for cabinets
designed to warm fluids should not exceed 110° F (43° C).2 Solutions should be warmed in separate cabinets or separate compartments in cabinets that have separate heating elements and controllers. Periodically, AORN receives updates that affect information in its recommended practices. The official AORN documents are updated as soon as possible. This update from ECRI came at a time in our publication cycle such that AORN’s “Recommended practices for a safe environment of care”3 could be updated to reflect the changes in the 2010 Perioperative Standards and Recommended Practices. Throughout the year, perioperative nurses can check updates in ClinicalInfoLink for the most current information at http://www .aorn.org/PracticeResources/NurseConsultation/ New. BONNIE DENHOLM RN, BSN, MS, CNOR PERIOPERATIVE NURSING SPECIALIST AORN CENTER FOR NURSING PRACTICE AORN Journal
289
February 2010 Vol 91
CLINICAL ISSUES
No 2
References 1.
2.
Hazard report: ECRI Institute revises its recommendation for temperature limits on blanket warmers. Health Devices. 2009;38(7):230-231. ECRI Institute upholds recommendations on warming
3.
cabinet temperatures. Risk Manage Reporter. 2007;26(2): 9-10. https://www.ecri.org/Documents/HRC_Newsletter_ 0407.pdf. Accessed October 27, 2009. Recommended practices for a safe environment of care. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2010:217-239.
The authors of this column have no declared affiliations that could be perceived as potential conflicts of interest in publishing this article.
290
AORN Journal
LEARNER EVALUATION CONTINUING EDUCATION PROGRAM
0.7
Clinical Issues
T
his evaluation is used to determine the extent to which this continuing education program met your learning needs. The Learner 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 regarding 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 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 the change is needed. 2. I will work with management to change and/or implement a policy and procedure. 3. I will plan an informational meeting with physicians to seek their input and acceptance of the need for the change. 4. I will implement the 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 0.7 continuing education contact hour (42-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: #10008; Session: #4001; Fee: Members $3.50, Nonmembers $7 The deadline for this program is February 28, 2013. Each applicant who successfully completes this program will be able to print a certificate of completion.
© AORN, Inc, 2010
February 2010
Vol 91
No 2 ● AORN Journal
291