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Clinical Issues—February 2014
CONTINUING EDUCATION Clinical Issues
2.8
SHARON A. VAN WICKLIN, MSN, RN, CNOR, CRNFA, CPSN, PLNC
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indicates that continuing education (CE) contact hours are available for this activity. Earn the CE contact hours by reading this article, reviewing the purpose/goal and objectives, and completing the online Learner Evaluation at http://www.aorn.org/CE. Each applicant who successfully completes this program can immediately print a certificate of completion.
This program meets criteria for CNOR and CRNFA recertification, as well as other CE requirements. AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this activity for relicensure.
Event: #14505 Session: #0001 Fee: Members $22.40, Nonmembers $44.80 The contact hours for this article expire February 28, 2017. Pricing is subject to change.
Purpose/Goal To provide the learner with knowledge of AORN’s recommended practices related to adhesive tape rolls as a source of infection, hand hygiene before donning unsterile gloves, preparing for a procedure on a patient who is allergic to di(2-ethylhexyl)phthalate (DEHP), and surgical wound classification.
Conflict of Interest Disclosures Sharon A. Van Wicklin, MSN, RN, CNOR, CRNFA, CPSN, PLNC, has no declared affiliation that could be perceived as posing a potential conflict 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.
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 CE for RNs. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity.
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This Month Adhesive tape rolls as a source of infection Key words: adhesive tape, adhesive products, surgical tape, infection prevention.
Removing and discarding the outer layer of adhesive tape Key words: adhesive tape, surgical tape, infection prevention.
Hand hygiene before donning unsterile gloves Key words: hand hygiene, unsterile gloves, infection prevention.
Preparing for a procedure on a patient who is allergic to Di(2-ethylhexyl)phthalate (DEHP) Key words: di(2-ethylhexyl)phthalate, DEHP, polyvinyl chloride, PVC, allergy, nursing process, nursing care plan.
Surgical wound classification Key words: wound classification, documentation, surgical site infection.
Adhesive tape rolls as a source of infection QUESTION: I’ve noticed that some of my colleagues keep rolls of adhesive tape in the pockets of their cover jackets and then use those rolls of tape to secure surgical dressings and other items. Could this be a potential source of surgical site infection? ANSWER: Studies have demonstrated surgical adhesive tape to be a potential reservoir for pathogenic microorganisms.1,2 There also have been reports in the literature implicating medical adhesive products in fungal infections3-6 and in a prolonged outbreak of Staphylococcus aureus in a neonatal unit.7
Adhesive tape is used to secure IVs, artificial airways, surgical drains, surgical wound dressings, and other items that may provide a portal for microbial entry into the body and subsequent development of infection. Both the adhesive and nonadhesive surface of a tape roll may become contaminated when stored in pockets, hung on stethoscopes, or left lying on countertops or other surfaces. A single roll of tape may be handled by multiple individuals and, after contaminated, the tape may contaminate the hands of personnel who contact or handle it or become a source of contamination for the patients on whom the tape is used. The reuse of contaminated tape
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rolls is especially concerning because there is no way to disinfect a roll of surgical adhesive tape. In a study conducted by Harris et al,1 researchers performed hand hygiene using an alcohol-based hand rub and then collected 21 samples of partially used rolls of surgical tape from various areas in three different hospitals and cultured the tape samples. Results showed multidrug-resistant organisms (MDROs) in 11 of the 21 samples. Methicillinresistant S aureus (MRSA) was present in four of the samples, vancomycin-resistant enterococcus (VRE) was present in 10 of the samples, and three of the samples were positive for both MRSA and VRE. Two of the samples that were positive for VRE also were positive for methicillin-susceptible S aureus (MSSA). Additionally, the researchers reported evidence of other bacteria, including Bacillus cereus, coagulase-negative staphylococci, nonemultidrug-resistant Enterobacteriaceae, Pseudomonas species, Acinetobacter species, and other enterococci, in all of the samples. This study was limited by the small sample size and the number of clinical areas sampled; however, the results indicate that surgical adhesive tapes are commonly contaminated with MDROs.1 To determine whether surgical adhesive tape could be a source of infection, Berkowitz et al2 conducted a study in a 16-bed intensive care unit (ICU) at a 560-bed teaching hospital. The researchers cultured 24 rolls of new, unused tape on both flat surfaces and circumferentially using sterile gloves to handle the tape. The new, unused tape was shown to be free of microorganisms. Then the researchers removed all adhesive tape currently in use in the ICU and replaced it with the microorganism-free study tape. They stored one roll of tape as a control that was not used and recovered no organisms from this roll of tape during the seven-day study period. They numbered the remaining 23 rolls; cultured each of them at intervals of one, five, and seven days; and recorded the tape rolls’ locations in the unit. Notably, they found roll 23 was contaminated with more than 300 colonies of Klebsiella even though it had been in 322 j AORN Journal
CLINICAL ISSUES use for just one hour. The remaining rolls of adhesive tape, stored at the bedsides of patients, were contaminated with opportunistic bacteria, including Pseudomonas, Escherichia coli, Klebsiella, Enterobacter, and coagulase-negative staphylococci. Although most rolls of tape remained at a single location, team members had moved some rolls to different areas of the ICU; moved rolls were likely to have been used on more than one patient. For example, researchers found roll 11 at a different location each time they cultured it. In addition to the study’s small sample size, the mechanism of culturing may be a limitation of this study because the nutrients and moisture from the agar used may have adhered to the tape and provided a source of nutrients that contributed to the growth of the contaminating microorganisms. The culturing procedure also did not include testing for anaerobic bacteria. The researchers were not able to document an infection directly related to the use of the contaminated adhesive tape; however, the results of this study clearly demonstrate that rolls of tape may become rapidly contaminated with bacteria known to produce health careeassociated infections from a variety of sources, including environmental surfaces and the hands of personnel.2 When using surgical adhesive tape, the potential for infection exists because medical adhesive products are used to secure items that may come in contact with blood, mucous membranes, or normally sterile tissue. For this reason, practitioners should implement hand hygiene before and after using medical adhesive products. Additionally, single-patient-use adhesive products should be used whenever possible.8 Many adhesive products and surgical dressings are available in sealed packages for individual use. Adhesive tape in singlepatient rolls also is available.9 Traditional rolls of tape are generally 10 yards in length. The singlepatient-use rolls of tape are 1.5 yards in length, which should be sufficient for most patient uses.9 Using shorter rolls of tape also may help to reduce the amount of unused, discarded tape as well as supply costs.
CLINICAL ISSUES Adhesive-containing products not packaged for single-patient use should be stored and used in a manner that prevents infection.8 Boxes containing multiple rolls of tape should be kept closed, and individual rolls of tape should be brought to the patient care area as needed.8 Strips of adhesive tape should not be placed on potentially contaminated surfaces (eg, bedrails, IV poles) before application on the patient.8 Adhesive tape rolls should not be hung on stethoscopes, left on contaminated surfaces, or stored in pockets.8 SHARON A. VAN WICKLIN MSN, RN, CNOR, CRNFA, CPSN, PLNC PERIOPERATIVE NURSING SPECIALIST AORN NURSING DEPARTMENT
References 1. Harris PN, Ashhurst-Smith C, Berenger SJ, Shoobert A, Ferguson JK. Adhesive tape in the health care setting: another high-risk fomite? Med J Aust. 2012;196(1):34.
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2. Berkowitz DM, Lee WS, Pazin GJ, Yee RB, Ho M. Adhesive tape: potential source of nosocomial bacteria. Appl Microbiol. 1974;28(4):651-654. 3. Everett ED, Pearson S, Rogers W. Rhizopus surgical wound infection with elasticized adhesive tape dressings. Arch Surg. 1979;114(6):738-739. 4. Mead JH, Lupton GP, Dillavou CL, Odom RB. Cutaneous rhizopus infection. Occurrence as a postoperative complication associated with an elasticized adhesive dressing. JAMA. 1979;242(3):272-274. 5. Garg J, Sujatha S, Garg A, Parija SC. Nosocomial cutaneous zygomycosis in a patient with diabetic ketoacidosis. Int J Infect Dis. 2009;13(6):e508-e510. 6. Lalayanni C, Baliakas P, Xochelli A, et al. Outbreak of cutaneous zygomycosis associated with the use of adhesive tape in haematology patients. J Hosp Infect. 2012; 81(3):213-215. 7. Wilcox MH, Fitzgerald P, Freeman J, et al. A five year outbreak of methicillin-susceptible staphylococcus aureus phage type 53, 85 in a regional neonatal unit. Epidemiol Infect. 2000;124(1):37-45. 8. McNichol L, Lund C, Rosen T, Gray M. Medical adhesives and patient safety: state of the science. J Wound Ostomy Cont Nurs. 2013;40(4):365-380. 9. Love KL. Single-patient rolls of medical tapes reduce crosscontamination risk. Infect Control Today. 2013;17(1):48-50. http://www.infectioncontroltoday.com/articles/2013/01/ singlepatient-rolls-of-medical-tapes-reduce-crossconta mination-risk.aspx. Accessed September 25, 2013.
Removing and discarding the outer layer of adhesive tape QUESTION: A preceptor taught me to remove and discard the outer layer of surgical adhesive tape before applying the tape to a patient because this provides a clean adhesive surface that is free of microorganisms. Is this true? ANSWER: There is conflicting evidence regarding whether removing the outer layer of surgical adhesive tape provides a surface that is free of microorganisms.1,2 To determine whether removing and discarding the outer layer of tape on the roll before use reduced the risk of microbial transmission to patients, Redelmeier and Livesley1 examined four categories of adhesive tape: n
a negative control group that used new tape specimens from unopened boxes (n ¼ 24),
n
a positive control group that used tape specimens from dressings removed from patients with IV catheters (n ¼ 24), n an active group of tape specimens obtained from partially used rolls from various locations in the hospital (n ¼ 80), and n a modified group of tape specimens obtained by discarding the outermost layer of tape from partially used rolls and culturing the inner layer (n ¼ 42). The negative control group showed no growth in any specimens. The positive control group showed bacterial growth in 22 of 24 specimens. The active group showed significant growth, with colonies too numerous to count in 59 of 80 specimens. Notably, contamination rates were similar in rolls obtained from various locations throughout the hospital. The highest level of contamination was found in the
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tape specimens obtained from the emergency, nephrology, and hematology/oncology wards. The modified group showed microbial growth in only two of the 42 specimens. In both cases, only a single colony was present on the side surfaces of the tape rolls (ie, the outer edges). Coagulasenegative staphylococcus was the most common organism present; however, coagulase-positive staphylococcus, gram-negative bacilli, alphahemolytic streptococcus, and bacillus species also were present. Some rolls showed polymicrobial growth. This study was limited by its small sample size and the fact that there was no culturing for anaerobic bacteria or fungi. The researchers also pointed out that using a different brand of tape may have produced different results. The outcome of this study suggests that discarding the outer layer from a partially used roll of surgical adhesive tape may reduce the risk of microbial transmission to patients.1 In a study conducted by Harris et al2 to determine whether surgical adhesive tape has the potential to act as a fomite in health care settings, researchers found that the side surfaces of the tape rolls (ie, the outer edges) were contaminated with greater numbers of bacteria than the circumferential surface (ie, the area from which the tape is pulled off the roll and applied to the patient). The researchers theorized there were several reasons for this finding:
n
Side surfaces of the tape provide a greater surface area for bacterial growth.
n
Tape rolls often are placed on their side surfaces when not in use, exposing those areas of the tape to various environmental surfaces.
n
Side surfaces are coated with a sticky residue from the adhesive substance of the tape, which may cause greater numbers of bacteria and other particulates to adhere to the side surfaces.2
This study was limited by its small sample size and the clinical areas sampled as well as the difficulty of proving a relationship to clinical infection; however, the researchers discussed the use of adhesive tape to affix items such as IV catheters, surgical drains, and wound dressings and the potential for colonization and subsequent infection.2 The results of this study seem to indicate that removing a portion of the circumferential surface of the adhesive tape would make no difference because the majority of microorganisms were found on the side surfaces of the tape. Practitioners should refrain from using a previously used roll of adhesive tape to secure a surgical dressing or other item that may have come in contact with blood, mucous membranes, or sterile tissue because, as shown in Figure 1, even if the outer layer of tape is removed from the circumferential surface immediately before application, the sides of the roll of tape still may be contaminated
Figure 1. Removing the outer layer of tape does not guarantee there is no risk of infection transmission because the side surfaces also can become contaminated.
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CLINICAL ISSUES (ie, visibly or nonvisibly) with microbes or other particulates and could provide a portal for infection. Single-patient-use adhesive products should be used whenever possible.3 SHARON A. VAN WICKLIN MSN, RN, CNOR, CRNFA, CPSN, PLNC PERIOPERATIVE NURSING SPECIALIST AORN NURSING DEPARTMENT
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References 1. Redelmeier DA, Livesley NJ. Adhesive tape and intravascular-catheter-associated infections. J Gen Intern Med. 1999;14(6):373-375. 2. Harris PN, Ashhurst-Smith C, Berenger SJ, Shoobert A, Ferguson JK. Adhesive tape in the health care setting: another high-risk fomite? Med J Aust. 2012; 196(1):34. 3. McNichol L, Lund C, Rosen T, Gray M. Medical adhesives and patient safety: state of the science. J Wound Ostomy Cont Nurs. 2013;40(4):365-380.
Hand hygiene before donning unsterile gloves QUESTION: I was told by a colleague that hand hygiene was no longer required before donning unsterile gloves. Is this true? ANSWER: According to the World Health Organization (WHO), “When an indication for hand hygiene [eg, patient contact] precedes a contact that also requires glove usage [eg, surgical dressing change], hand rubbing or hand washing should be performed before donning gloves.”1(p1) Wearing unsterile gloves serves as personal protective equipment (PPE) designed to protect the clinician from contact with blood, body fluids, or other potentially infectious materials from the patient; in addition, unsterile gloves worn during activities not requiring the use of sterile gloves helps to protect patients by reducing transmission of microorganisms from the clinician’s hands and from subsequent transmission of microorganisms to other patients. Consequently, the use of unsterile gloves is an important adjunct to, but not a replacement for, proper hand hygiene practices.2 Your colleague may be referring to a prospective, randomized, controlled trial conducted by Rock et al3 to determine the need for hand hygiene before donning unsterile gloves and performing patient care. Researchers took baseline impressions of finger and palm prints from the dominant hands of 237 clinicians, including RNs,
physicians, technicians, and other personnel entering the room to perform care for patients requiring contact precautions in seven intensive care units at a single medical center. The clinicians were randomized to perform care by either directly donning unsterile gloves or performing hand hygiene and then donning unsterile gloves. The results of the study showed that the total bacterial colony counts did not differ between the two groups. Researchers identified Staphylococcus aureus on the gloves of one member of the group who performed hand hygiene before donning gloves and two members of the group who directly donned gloves. They identified all other organisms as commensal bacteria. The researchers concluded that hand hygiene performed before donning unsterile gloves did not decrease the already low bacterial counts on the unsterile gloves and, therefore, that performing hand hygiene before donning unsterile gloves may be unnecessary. The researchers described an unexpected finding of the study; it took an additional 31.5 seconds to perform hand hygiene before donning the unsterile gloves. This additional time amounted to approximately 19 minutes over a 12hour shift. The researchers theorized that this time could be spent more productively in providing direct patient care. There are limitations to this study that should be considered by clinicians before a decision is made to change current practice and eliminate hand hygiene before donning unsterile gloves. First, the
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researchers conducted the study within a single institution; because of this, the results may not be generalizable to other settings. Second, the researchers considered the method of fingerprint and palm impression prints to be a limitation. The impression method was selected because it was less cumbersome and time-consuming for the clinicians; however, this method of sampling does not sample the entire hand, and researchers sampled only the dominant hand. Cultures taken from both hands before and after patient care may have provided a more realistic sample. Likewise, sampling areas in the patient’s room that were touched by the clinicians’ gloved hands would have provided important data relative to the potential for transmission of microorganisms from the clinician’s hand to environmental surfaces and patients, as well as the need for hand hygiene before donning unsterile gloves. Finally, as clinicians review this study and what the researchers assert and consider a change in practice, it is important for them to ask the following questions: n
Is hand hygiene ever unnecessary? n Is the time spent performing hand hygiene considered nonproductive time?
Most importantly, clinicians should ask the following: Until there is scientific evidence to show otherwise, do the potential benefits of 31.5 seconds of hand hygiene performed by the clinician before donning unsterile gloves outweigh the potential harm associated with not performing hand hygiene and increasing the risk of transferring microorganisms from the clinician’s hands to the patient? Until more conclusive evidence is available, performing hand hygiene before donning unsterile gloves is still considered best practice. SHARON A. VAN WICKLIN MSN, RN, CNOR, CRNFA, CPSN, PLNC PERIOPERATIVE NURSING SPECIALIST AORN NURSING DEPARTMENT References 1. Glove use information leaflet. World Health Organization. http://www.who.int/gpsc/5may/Glove_Use_Information_ Leaflet.pdf. Accessed September 25, 2013. 2. How-to Guide: Improving Hand Hygiene. A Guide for Improving Practices among Health Care Workers. Institute for Healthcare Improvement. http://www.shea-online.org/ Assets/files/IHI_Hand_Hygiene.pdf. Accessed September 25, 2013. 3. Rock C, Harris AD, Reich NG, Johnson JK, Thom KA. Is hand hygiene before putting on nonsterile gloves in the intensive care unit a waste of health care worker time? A randomized controlled trial. Am J Infect Control. 2013;41(11):994-996.
Preparing for a procedure on a patient who is allergic to Di(2-ethylhexyl)phthalate (DEHP) QUESTION: One of our surgeons has advised us that within the next few weeks he will be operating on a patient who is allergic to DEHP. This patient has undergone previous surgeries at different facilities; however, during the most recent surgery, the patient had a severe reaction to the DEHP in the endotracheal tube. What can we do to prepare for this procedure so that we can provide the best care possible for this patient and be equipped to handle any emergencies that might arise?
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ANSWER: Whether the patient has an unusual allergy or some other type of unique medical condition that may require specific interventions, perioperative RNs can use the nursing process as an organizing framework for systematic planning and care delivery for all perioperative patients. The process begins with assessment (ie, gathering information). The perioperative RN reviews the information that has been gathered during the assessment, identifies the problem, and formulates a nursing diagnosis. He or she then develops an individualized plan of care,
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TABLE 1. Medical Devices Known to Release DEHP IV storage bags IV infusion sets IV infusion catheters Blood storage bags Blood administration sets Polyvinyl chloride exam gloves Chest tubes Hemodialysis tubing Extracorporeal membrane oxygenation tubing
1
Ventilator tubing Endotracheal tubes Nasogastric tubes Enteral and parenteral nutrition storage bags Urinary catheters Suction catheters Nasal cannula tubing Syringes Cardiopulmonary bypass tubing
DEHP ¼ Di(2-ethylhexyl)phthalate. 1. Safety assessment of di(2-ethylhexyl)phthalate (DEHP) released from medical devices. US Food and Drug Administration. http://www.fda.gov/downloads /MedicalDevices/DeviceRegulationandGuidance/GuidanceDocuments/UCM080457.pdf. Accessed September 10, 2013.
devises interventions and strategies to accomplish the plan, and implements the plan. Finally, the RN evaluates the outcome and modifies the plan of care if necessary. In this case, the surgeon has provided advance notification, so the team is at an advantage and can gather information about DEHP allergies to develop a specific plan of care. The substance DEHP is known as a plasticizer. Plasticizers are used to soften the polyvinyl chloride plastic polymer in medical devices and make them flexible.1 According to the US Food and Drug Administration (FDA), Although the toxic and carcinogenic effects of DEHP have been well established in experimental animals, the ability of this compound to produce adverse effects in humans is controversial. As a result, the ability of DEHP and other phthalate esters [ie, plasticizers] to produce adverse effects in humans has been a topic of active discussion and debate in the scientific and regulatory communities.1(p3) Di(2-ethylhexyl)phthalate is found in items such as IV bags and tubing and endotracheal tubes1 (Table 1) and is the only plasticizer approved for medical use by the FDA.2 Table 2 describes the actions to be taken by the perioperative team to accomplish the steps of the nursing process when planning care delivery for a
patient with a DEHP allergy. The table is helpful in planning care for a patient who is allergic to DEHP; however, these actions can be modified easily when planning care delivery for perioperative patients who present unique challenges, such as a patient who has a latex sensitivity, a patient scheduled for a perineal procedure who has an allergy to povidone iodine, or a patient with another unique allergy or medical condition that requires additional assessment and planning. Perioperative RNs and other members of the perioperative team can provide the best care possible when there is open communication to alert the team about an unusual situation and a multidisciplinary team can be gathered to assess and plan for the situation ahead of time. After the procedure, it is important to review strategies that were successful, as well as those that could be improved, and to share the information both internally and externally so that others in the perioperative community can learn from these experiences. Acknowledgment: The author thanks Gregg L. Puluka, BSN, RN, CNOR, staff nurse-CN4, at the Bristol-Myers Squibb Children’s Hospital at Robert Wood Johnson University Hospital, New Brunswick, NJ, for his assistance writing this question. SHARON A. VAN WICKLIN MSN, RN, CNOR, CRNFA, CPSN, PLNC PERIOPERATIVE NURSING SPECIALIST AORN NURSING DEPARTMENT
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TABLE 2. Nursing Care Plan for a Patient Who Is Allergic to DEHP Nursing process Assess
Actions n
n
n n n n n n n n
Select primary personnel and alternate personnel for case assignment from admission to discharge (eg, preoperative RN, RN circulator, scrub person, first assistant, postanesthesia care unit RN, any additional personnel required). Gather a multidisciplinary team (eg, infection preventionist, anesthesia professional, surgeon, risk management personnel) and the selected perioperative personnel to assess the situation and explore strategies for reducing risk and safely completing the procedure. Conduct a literature search and review websites such as http://www.noharm.org to identify scientific information, case reports, and best practices relevant to DEHP allergy. Question colleagues with expert knowledge or previous experience caring for patients with the DEHP allergy regarding best practices and strategies to be implemented for safe care. Access the patient’s medical records, including those from other facilities if necessary, to review the patient’s medical history and past surgical experiences and treatments. Question the patient and designated support person regarding the patient’s previous surgical experiences and treatments. Consult with materials management personnel to search for alternative products that are DEHP-free or have the lowest DEHP content possible. Consult with manufacturers of products currently in use to determine the availability of alternative products that are DEHP-free or have the lowest DEHP content possible. Document the search results and all multidisciplinary actions taken to gather information related to the DEHP allergy in a file that can be easily retrieved, reviewed, and consulted at a later date. Document the preoperative assessment in the patient’s record.
Diagnose
n
Formulate relevant nursing diagnoses (eg, risk of allergic response) and document them in the patient’s record.
Plan
n
Meet with the multidisciplinary team and assigned perioperative personnel to review the results of the literature search and to devise strategies to be implemented preoperatively, intraoperatively, and postoperatively. Determine the DEHP content of all products to be used during care of the patient. Review the necessity of using products with DEHP content for which there are no DEHP-free alternatives. Devise and communicate the plan for providing perioperative care, completing the procedure, and addressing emergency situations that may arise. Collaborate with the anesthesia professionals about the use of preoperative steroids or other medications that may reduce the potential for inflammation or allergic reaction. Review strategies for rapid treatment of anaphylaxis or other emergency situations (eg, laryngospasm) that may arise. Plan to have emergency medications and equipment and additional personnel immediately available. Provide full disclosure and description of the plan to both the patient and his or her designated support person. Document the multidisciplinary plan related to the DEHP allergy in a file that can be easily retrieved, reviewed, and consulted at a later date. Document the perioperative plan of care in the patient’s record. Remove all DEHP-containing products from the procedure room the evening before the procedure and complete terminal cleaning. Initiate the preoperative briefing with surgical team members to review the plan before the procedure. Verify the plan with surgical team members during the time out and include this verification in the time-out documentation.
n n n n n n n n n n n n
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TABLE 2. (continued ) Nursing Care Plan for a Patient Who Is Allergic to DEHP Nursing process Implement
Actions n n n
Evaluate
n n n
n n n
Implement the plan with the assigned or alternate perioperative personnel and applicable multidisciplinary team members. Document the multidisciplinary implementation strategies for the DEHP allergy in a file that can be easily retrieved, reviewed, and consulted at a later date. Document the applied interventions in the patient’s record. Initiate the postdischarge debrief with all involved perioperative personnel and multidisciplinary team members. Review and evaluate the implemented strategies (ie, both successful and nonsuccessful) and other elements of the implemented plan during the debrief session. Document the multidisciplinary team’s evaluation of the plan and implementations related to the DEHP allergy and suggestions for future implementations in a file that can be easily retrieved, reviewed, and consulted at a later date. Create a policy and procedure for perioperative care of patients with DEHP allergy and disseminate it to perioperative personnel. Provide education regarding DEHP allergy and procedural best practices for patients with DEHP allergy, including a discussion of the relative case for all perioperative personnel. Consider broader dissemination of the information relative to care of patients with DEHP allergy by submitting a manuscript for publication.
DEHP ¼ Di(2-ethylhexyl)phthalate.
References 1. Safety assessment of di(2-ethylhexyl)phthalate (DEHP) released from medical devices. US Food and Drug Administration. http://www.fda.gov/downloads/Med icalDevices/DeviceRegulationandGuidance/Guidance
Documents/UCM080457.pdf. Accessed September 25, 2013. 2. Vetrano AM, Laskin DL, Archer F, et al. Inflammatory effects of phthalates in neonatal neutrophils. Pediatr Res. 2010;68(2):134-139.
Surgical wound classification QUESTION: We are having disagreements at our facility about how certain procedures should be classified when using the Centers for Disease Control and Prevention (CDC) surgical wound classification system. Which wound classifications should be assigned to the following procedures?
n
n
n
Excision of lipoma in a room where the humidity is greater than 60% n Carpal tunnel release on a patient with a colostomy n Burn debridement n Laparoscopic cholecystectomy on a patient with chronic cholecystitis
n n n n
Cesarean delivery on a patient who experienced a long labor or ruptured membranes Breast biopsy with needle localization Return of a patient to surgery for evacuation of a hematoma or delayed wound closure Removal of implants or hardware Closed reduction of a nasal fracture Hemorrhoidectomy with sigmoidoscopy
ANSWER: Perioperative RNs should assign the surgical wound classification based on a careful assessment of the specific factors associated with each surgical procedure.1 According to the CDC, wounds should AORN Journal j 329
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be classified based on the likelihood and degree of wound contamination at the time of surgery.1 Following are definitions of the four CDC surgical wound classifications: [Class I] 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 [eg, bulb drain]. Operative incisional wounds that follow nonpenetrating (blunt) trauma should be included in this category if they meet the criteria. [Class II] 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 [eg, spillage from gastrointestinal tract]. [Class III] Contaminated wounds: These include open, fresh, accidental wounds, operations with major breaks in sterile technique [eg, procedure performed with unsterile instruments] or gross spillage from the gastrointestinal tract, and incisions in which acute, nonpurulent inflammation is encountered. [Class IV] 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(p109) AORN developed the Surgical Wound Classification Decision Tree (Figure 2) as a tool to assist perioperative RNs in accurately classifying surgical
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CLINICAL ISSUES wounds using the CDC surgical wound classification system. This tool is included in the 2013 “Recommended practices for prevention of transmissible infections in the perioperative practice setting”2 and also can be found on the AORN web site at http://www.aorn.org by searching for “Surgical Wound Classification Decision Tree.” The decision tree is an algorithm that presents organized, directed wound classification questions designed to lead the perioperative RN to the correct wound classification. Applying the Surgical Wound Classification Decision Tree to the list of procedures provided in the question results in the classifications to follow. Excision of Lipoma in a Room Where the Humidity Is Greater Than 60%: [Class I] Clean Although the humidity level may be greater than the desired parameter of 60%,3 humidity levels that exceed 60% do not constitute a major break in sterile technique; therefore, the wound classification would remain as Class I. In its surgical wound classification, the CDC uses the example of open cardiac massage as a definition of a major break in sterile technique.1 Essentially, a major break in sterile technique is a catastrophic event, more in the nature of discovering that the instruments used during the procedure had not been sterilized or having an unsterile item (eg, the surgeon’s eyeglass loupes) fall into the sterile wound, as opposed to humidity levels in the room exceeding desired parameters. Another point of confusion that sometimes arises when there is a break in sterile technique is that the perioperative RN changes the wound classification from a Class I procedure to a Class II procedure. Class II procedures are specific to the respiratory, alimentary, or genitourinary tracts.1 If those tracts are not entered during the surgery, the procedure would never qualify as Class II. In the event of a true major break in sterile technique during a Class I procedure, the wound classification would change from Class I to Class III.
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Figure 2. The AORN Surgical Wound Classification Decision Tree is intended to guide perioperative nurses in assigning the correct wound class. Figure reprinted, with permission, from Perioperative Standards and Recommended Practices. Copyright ª AORN, Inc, 2014. AORN Journal j 331
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Carpal Tunnel Release on a Patient With a Colostomy: [Class I] Clean The mere presence of an ostomy in an area that is not proximal to the surgical incision does not affect the wound class. Therefore, the wound classification would remain as Class I. Burn Debridement: [Class III] Contaminated A burn is an accidental injury; therefore, debridement of the burn would be considered a Class III procedure. If, however, there is purulence or necrotic tissue present, the burn debridement would be a Class IV procedure. Laparoscopic Cholecystectomy on a Patient With Chronic Cholecystitis: [Class II] CleanContaminated The assigned wound classification for a cholecystectomy should be based on the specific factors associated with the procedure. The classification is not based on whether the diagnosis is acute or chronic cholecystitis; instead, the wound classification depends on evidence of infection or contamination; spillage from the gastrointestinal tract; nonpurulent inflammation, which could be chronic; or the presence of purulence or devitalized tissue found or occurring during the procedure. A cholecystectomy procedure with no evidence of infection and no break in surgical technique (eg, spillage from the gastrointestinal tract) would be classified as Class II. If there was visible gross spillage of bile during the procedure, it would be classified as Class III. If the drainage from the gallbladder was purulent or if the gallbladder was necrotic, then the procedure would be classified as Class IV. Cesarean Delivery on a Patient Who Experienced a Long Labor or Ruptured Membranes: [Class II] Clean-Contaminated Cesarean deliveries with or without ruptured membranes or long labors are Class II procedures. The exceptions are when there is a specific reason to assign a Class III (eg, presence of meconium representing spillage from the fetal gastrointestinal tract) or a Class IV (eg, presence of purulence). 332 j AORN Journal
CLINICAL ISSUES Breast Biopsy With Needle Localization: [Class I] Clean A needle localization procedure performed before the breast biopsy procedure does not constitute either a major break in sterile technique or an old wound because there is no purulence or necrotic tissue present. Therefore, this would be a Class I procedure. Return of a Patient to Surgery for Evacuation of a Hematoma or Delayed Wound Closure: [Class I] Clean A return to surgery for bleeding or evacuation of a hematoma does not necessarily meet the conditions for a Class III or Class IV assignment; therefore, it would remain as a Class I unless there are mitigating factors present, such as inflammation or purulence. Likewise, a delayed wound closure does not meet the requirements for a Class III or Class IV assignment unless there is devitalized tissue or purulence present in the wound being closed. Removal of Implants or Hardware: [Class I] Clean Unless the procedure meets the specifications for a Class III or Class IV assignment (eg, inflammation, purulence, necrotic tissue), removal of implants or hardware should be classified as Class I. If the respiratory, alimentary, or genitourinary tract is entered to retrieve the implant (eg, vaginal mesh), then the procedure would be a Class II. Closed Reduction of a Nasal Fracture: No Wound Classification Closed reduction of a nasal fracture does not produce a surgical wound. Therefore, there is no surgical wound classification assignment. Hemorrhoidectomy With Sigmoidoscopy: [Class II] Clean-Contaminated for the Hemorrhoidectomy; No Wound Classification for the Sigmoidoscopy When hemorrhoids are excised, the gastrointestinal tract is entered; therefore, the hemorrhoidectomy is a Class II procedure. There is no classification for a sigmoidoscopy because there is no surgical wound.
CLINICAL ISSUES SHARON A. VAN WICKLIN MSN, RN, CNOR, CRNFA, CPSN, PLNC PERIOPERATIVE NURSING SPECIALIST AORN NURSING DEPARTMENT References 1. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR; Hospital Infection Control Practices Advisory Committee. Guidelines for prevention of surgical
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site infection, 1999. Am J Infect Control. 1999;27(2): 99-134. 2. Recommended practices for prevention of transmissible infections in the perioperative practice setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:331-364. 3. ANSI/ASHRAE/ASHE Addendum D to ANSI/ASHRAE/ ASHE Standard 170-2008. Atlanta, GA: American Society of Heating, Refrigerating and Air-Conditioning Engineers; 2010.
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LEARNER EVALUATION CONTINUING EDUCATION PROGRAM
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his evaluation is used to determine the extent to which this continuing education program met your learning needs. The evaluation is printed here for your convenience. To receive continuing education credit, you must complete the online Learner Evaluation at http://www.aorn.org/CE. Rate the items as described below. PURPOSE/GOAL To provide the learner with knowledge of AORN’s recommended practices related to adhesive tape rolls as a source of infection, hand hygiene before donning unsterile gloves, preparing for a procedure on a patient who is allergic to di(2-ethylhexyl)phthalate (DEHP), and surgical wound classification. OBJECTIVES To what extent were the following objectives of this continuing education program achieved? 1. Discuss practices that could jeopardize safety in the perioperative area. Low 1. 2. 3. 4. 5. High 2. Discuss common areas of concern that relate to perioperative best practices. Low 1. 2. 3. 4. 5. High 3. Describe implementation of evidence-based practice in relation to perioperative nursing care. Low 1. 2. 3. 4. 5. High CONTENT 4. To what extent did this article increase your knowledge of the subject matter? Low 1. 2. 3. 4. 5. High
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5. To what extent were your individual objectives met? Low 1. 2. 3. 4. 5. High 6. Will you be able to use the information from this article in your work setting? 1. Yes 2. No 7. Will you change your practice as a result of reading this article? (If yes, answer question #7A. If no, answer question #7B.) 7A. How will you change your practice? (Select all that apply) 1. I will provide education to my team regarding why change is needed. 2. I will work with management to change/ implement a policy and procedure. 3. I will plan an informational meeting with physicians to seek their input and acceptance of the need for change. 4. I will implement change and evaluate the effect of the change at regular intervals until the change is incorporated as best practice. 5. Other: ________________________________ 7B. If you will not change your practice as a result of reading this article, why? (Select all that apply) 1. The content of the article is not relevant to my practice. 2. I do not have enough time to teach others about the purpose of the needed change. 3. I do not have management support to make a change. 4. Other: ________________________________ 8. Our accrediting body requires that we verify the time you needed to complete the 2.8 continuing education contact hour (168-minute) program: _________________________________
AORN, Inc, 2014
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SHARON A. VAN WICKLIN, MSN, RN, CNOR, CRNFA, CPSN, PLNC
www.aorn.org/CE Continuing Education Contact Hours
Approvals
indicates that continuing education (CE) contact hours are available for this activity. Earn the CE contact hours by reading this article, reviewing the purpose/goal and objectives, and completing the online Learner Evaluation at http://www.aorn.org/CE. Each applicant who successfully completes this program can immediately print a certificate of completion.
This program meets criteria for CNOR and CRNFA recertification, as well as other CE requirements. AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this activity for relicensure.
Event: #14505 Session: #0001 Fee: Members $22.40, Nonmembers $44.80 The contact hours for this article expire February 28, 2017. Pricing is subject to change.
Purpose/Goal To provide the learner with knowledge of AORN’s recommended practices related to adhesive tape rolls as a source of infection, hand hygiene before donning unsterile gloves, preparing for a procedure on a patient who is allergic to di(2-ethylhexyl)phthalate (DEHP), and surgical wound classification.
Conflict of Interest Disclosures Sharon A. Van Wicklin, MSN, RN, CNOR, CRNFA, CPSN, PLNC, has no declared affiliation that could be perceived as posing a potential conflict 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.
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 CE for RNs. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity.
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CLINICAL ISSUES
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This Month Adhesive tape rolls as a source of infection Key words: adhesive tape, adhesive products, surgical tape, infection prevention.
Removing and discarding the outer layer of adhesive tape Key words: adhesive tape, surgical tape, infection prevention.
Hand hygiene before donning unsterile gloves Key words: hand hygiene, unsterile gloves, infection prevention.
Preparing for a procedure on a patient who is allergic to Di(2-ethylhexyl)phthalate (DEHP) Key words: di(2-ethylhexyl)phthalate, DEHP, polyvinyl chloride, PVC, allergy, nursing process, nursing care plan.
Surgical wound classification Key words: wound classification, documentation, surgical site infection.
Adhesive tape rolls as a source of infection QUESTION: I’ve noticed that some of my colleagues keep rolls of adhesive tape in the pockets of their cover jackets and then use those rolls of tape to secure surgical dressings and other items. Could this be a potential source of surgical site infection? ANSWER: Studies have demonstrated surgical adhesive tape to be a potential reservoir for pathogenic microorganisms.1,2 There also have been reports in the literature implicating medical adhesive products in fungal infections3-6 and in a prolonged outbreak of Staphylococcus aureus in a neonatal unit.7
Adhesive tape is used to secure IVs, artificial airways, surgical drains, surgical wound dressings, and other items that may provide a portal for microbial entry into the body and subsequent development of infection. Both the adhesive and nonadhesive surface of a tape roll may become contaminated when stored in pockets, hung on stethoscopes, or left lying on countertops or other surfaces. A single roll of tape may be handled by multiple individuals and, after contaminated, the tape may contaminate the hands of personnel who contact or handle it or become a source of contamination for the patients on whom the tape is used. The reuse of contaminated tape
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rolls is especially concerning because there is no way to disinfect a roll of surgical adhesive tape. In a study conducted by Harris et al,1 researchers performed hand hygiene using an alcohol-based hand rub and then collected 21 samples of partially used rolls of surgical tape from various areas in three different hospitals and cultured the tape samples. Results showed multidrug-resistant organisms (MDROs) in 11 of the 21 samples. Methicillinresistant S aureus (MRSA) was present in four of the samples, vancomycin-resistant enterococcus (VRE) was present in 10 of the samples, and three of the samples were positive for both MRSA and VRE. Two of the samples that were positive for VRE also were positive for methicillin-susceptible S aureus (MSSA). Additionally, the researchers reported evidence of other bacteria, including Bacillus cereus, coagulase-negative staphylococci, nonemultidrug-resistant Enterobacteriaceae, Pseudomonas species, Acinetobacter species, and other enterococci, in all of the samples. This study was limited by the small sample size and the number of clinical areas sampled; however, the results indicate that surgical adhesive tapes are commonly contaminated with MDROs.1 To determine whether surgical adhesive tape could be a source of infection, Berkowitz et al2 conducted a study in a 16-bed intensive care unit (ICU) at a 560-bed teaching hospital. The researchers cultured 24 rolls of new, unused tape on both flat surfaces and circumferentially using sterile gloves to handle the tape. The new, unused tape was shown to be free of microorganisms. Then the researchers removed all adhesive tape currently in use in the ICU and replaced it with the microorganism-free study tape. They stored one roll of tape as a control that was not used and recovered no organisms from this roll of tape during the seven-day study period. They numbered the remaining 23 rolls; cultured each of them at intervals of one, five, and seven days; and recorded the tape rolls’ locations in the unit. Notably, they found roll 23 was contaminated with more than 300 colonies of Klebsiella even though it had been in 322 j AORN Journal
CLINICAL ISSUES use for just one hour. The remaining rolls of adhesive tape, stored at the bedsides of patients, were contaminated with opportunistic bacteria, including Pseudomonas, Escherichia coli, Klebsiella, Enterobacter, and coagulase-negative staphylococci. Although most rolls of tape remained at a single location, team members had moved some rolls to different areas of the ICU; moved rolls were likely to have been used on more than one patient. For example, researchers found roll 11 at a different location each time they cultured it. In addition to the study’s small sample size, the mechanism of culturing may be a limitation of this study because the nutrients and moisture from the agar used may have adhered to the tape and provided a source of nutrients that contributed to the growth of the contaminating microorganisms. The culturing procedure also did not include testing for anaerobic bacteria. The researchers were not able to document an infection directly related to the use of the contaminated adhesive tape; however, the results of this study clearly demonstrate that rolls of tape may become rapidly contaminated with bacteria known to produce health careeassociated infections from a variety of sources, including environmental surfaces and the hands of personnel.2 When using surgical adhesive tape, the potential for infection exists because medical adhesive products are used to secure items that may come in contact with blood, mucous membranes, or normally sterile tissue. For this reason, practitioners should implement hand hygiene before and after using medical adhesive products. Additionally, single-patient-use adhesive products should be used whenever possible.8 Many adhesive products and surgical dressings are available in sealed packages for individual use. Adhesive tape in singlepatient rolls also is available.9 Traditional rolls of tape are generally 10 yards in length. The singlepatient-use rolls of tape are 1.5 yards in length, which should be sufficient for most patient uses.9 Using shorter rolls of tape also may help to reduce the amount of unused, discarded tape as well as supply costs.
CLINICAL ISSUES Adhesive-containing products not packaged for single-patient use should be stored and used in a manner that prevents infection.8 Boxes containing multiple rolls of tape should be kept closed, and individual rolls of tape should be brought to the patient care area as needed.8 Strips of adhesive tape should not be placed on potentially contaminated surfaces (eg, bedrails, IV poles) before application on the patient.8 Adhesive tape rolls should not be hung on stethoscopes, left on contaminated surfaces, or stored in pockets.8 SHARON A. VAN WICKLIN MSN, RN, CNOR, CRNFA, CPSN, PLNC PERIOPERATIVE NURSING SPECIALIST AORN NURSING DEPARTMENT
References 1. Harris PN, Ashhurst-Smith C, Berenger SJ, Shoobert A, Ferguson JK. Adhesive tape in the health care setting: another high-risk fomite? Med J Aust. 2012;196(1):34.
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2. Berkowitz DM, Lee WS, Pazin GJ, Yee RB, Ho M. Adhesive tape: potential source of nosocomial bacteria. Appl Microbiol. 1974;28(4):651-654. 3. Everett ED, Pearson S, Rogers W. Rhizopus surgical wound infection with elasticized adhesive tape dressings. Arch Surg. 1979;114(6):738-739. 4. Mead JH, Lupton GP, Dillavou CL, Odom RB. Cutaneous rhizopus infection. Occurrence as a postoperative complication associated with an elasticized adhesive dressing. JAMA. 1979;242(3):272-274. 5. Garg J, Sujatha S, Garg A, Parija SC. Nosocomial cutaneous zygomycosis in a patient with diabetic ketoacidosis. Int J Infect Dis. 2009;13(6):e508-e510. 6. Lalayanni C, Baliakas P, Xochelli A, et al. Outbreak of cutaneous zygomycosis associated with the use of adhesive tape in haematology patients. J Hosp Infect. 2012; 81(3):213-215. 7. Wilcox MH, Fitzgerald P, Freeman J, et al. A five year outbreak of methicillin-susceptible staphylococcus aureus phage type 53, 85 in a regional neonatal unit. Epidemiol Infect. 2000;124(1):37-45. 8. McNichol L, Lund C, Rosen T, Gray M. Medical adhesives and patient safety: state of the science. J Wound Ostomy Cont Nurs. 2013;40(4):365-380. 9. Love KL. Single-patient rolls of medical tapes reduce crosscontamination risk. Infect Control Today. 2013;17(1):48-50. http://www.infectioncontroltoday.com/articles/2013/01/ singlepatient-rolls-of-medical-tapes-reduce-crossconta mination-risk.aspx. Accessed September 25, 2013.
Removing and discarding the outer layer of adhesive tape QUESTION: A preceptor taught me to remove and discard the outer layer of surgical adhesive tape before applying the tape to a patient because this provides a clean adhesive surface that is free of microorganisms. Is this true? ANSWER: There is conflicting evidence regarding whether removing the outer layer of surgical adhesive tape provides a surface that is free of microorganisms.1,2 To determine whether removing and discarding the outer layer of tape on the roll before use reduced the risk of microbial transmission to patients, Redelmeier and Livesley1 examined four categories of adhesive tape: n
a negative control group that used new tape specimens from unopened boxes (n ¼ 24),
n
a positive control group that used tape specimens from dressings removed from patients with IV catheters (n ¼ 24), n an active group of tape specimens obtained from partially used rolls from various locations in the hospital (n ¼ 80), and n a modified group of tape specimens obtained by discarding the outermost layer of tape from partially used rolls and culturing the inner layer (n ¼ 42). The negative control group showed no growth in any specimens. The positive control group showed bacterial growth in 22 of 24 specimens. The active group showed significant growth, with colonies too numerous to count in 59 of 80 specimens. Notably, contamination rates were similar in rolls obtained from various locations throughout the hospital. The highest level of contamination was found in the
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tape specimens obtained from the emergency, nephrology, and hematology/oncology wards. The modified group showed microbial growth in only two of the 42 specimens. In both cases, only a single colony was present on the side surfaces of the tape rolls (ie, the outer edges). Coagulasenegative staphylococcus was the most common organism present; however, coagulase-positive staphylococcus, gram-negative bacilli, alphahemolytic streptococcus, and bacillus species also were present. Some rolls showed polymicrobial growth. This study was limited by its small sample size and the fact that there was no culturing for anaerobic bacteria or fungi. The researchers also pointed out that using a different brand of tape may have produced different results. The outcome of this study suggests that discarding the outer layer from a partially used roll of surgical adhesive tape may reduce the risk of microbial transmission to patients.1 In a study conducted by Harris et al2 to determine whether surgical adhesive tape has the potential to act as a fomite in health care settings, researchers found that the side surfaces of the tape rolls (ie, the outer edges) were contaminated with greater numbers of bacteria than the circumferential surface (ie, the area from which the tape is pulled off the roll and applied to the patient). The researchers theorized there were several reasons for this finding:
n
Side surfaces of the tape provide a greater surface area for bacterial growth.
n
Tape rolls often are placed on their side surfaces when not in use, exposing those areas of the tape to various environmental surfaces.
n
Side surfaces are coated with a sticky residue from the adhesive substance of the tape, which may cause greater numbers of bacteria and other particulates to adhere to the side surfaces.2
This study was limited by its small sample size and the clinical areas sampled as well as the difficulty of proving a relationship to clinical infection; however, the researchers discussed the use of adhesive tape to affix items such as IV catheters, surgical drains, and wound dressings and the potential for colonization and subsequent infection.2 The results of this study seem to indicate that removing a portion of the circumferential surface of the adhesive tape would make no difference because the majority of microorganisms were found on the side surfaces of the tape. Practitioners should refrain from using a previously used roll of adhesive tape to secure a surgical dressing or other item that may have come in contact with blood, mucous membranes, or sterile tissue because, as shown in Figure 1, even if the outer layer of tape is removed from the circumferential surface immediately before application, the sides of the roll of tape still may be contaminated
Figure 1. Removing the outer layer of tape does not guarantee there is no risk of infection transmission because the side surfaces also can become contaminated.
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CLINICAL ISSUES (ie, visibly or nonvisibly) with microbes or other particulates and could provide a portal for infection. Single-patient-use adhesive products should be used whenever possible.3 SHARON A. VAN WICKLIN MSN, RN, CNOR, CRNFA, CPSN, PLNC PERIOPERATIVE NURSING SPECIALIST AORN NURSING DEPARTMENT
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References 1. Redelmeier DA, Livesley NJ. Adhesive tape and intravascular-catheter-associated infections. J Gen Intern Med. 1999;14(6):373-375. 2. Harris PN, Ashhurst-Smith C, Berenger SJ, Shoobert A, Ferguson JK. Adhesive tape in the health care setting: another high-risk fomite? Med J Aust. 2012; 196(1):34. 3. McNichol L, Lund C, Rosen T, Gray M. Medical adhesives and patient safety: state of the science. J Wound Ostomy Cont Nurs. 2013;40(4):365-380.
Hand hygiene before donning unsterile gloves QUESTION: I was told by a colleague that hand hygiene was no longer required before donning unsterile gloves. Is this true? ANSWER: According to the World Health Organization (WHO), “When an indication for hand hygiene [eg, patient contact] precedes a contact that also requires glove usage [eg, surgical dressing change], hand rubbing or hand washing should be performed before donning gloves.”1(p1) Wearing unsterile gloves serves as personal protective equipment (PPE) designed to protect the clinician from contact with blood, body fluids, or other potentially infectious materials from the patient; in addition, unsterile gloves worn during activities not requiring the use of sterile gloves helps to protect patients by reducing transmission of microorganisms from the clinician’s hands and from subsequent transmission of microorganisms to other patients. Consequently, the use of unsterile gloves is an important adjunct to, but not a replacement for, proper hand hygiene practices.2 Your colleague may be referring to a prospective, randomized, controlled trial conducted by Rock et al3 to determine the need for hand hygiene before donning unsterile gloves and performing patient care. Researchers took baseline impressions of finger and palm prints from the dominant hands of 237 clinicians, including RNs,
physicians, technicians, and other personnel entering the room to perform care for patients requiring contact precautions in seven intensive care units at a single medical center. The clinicians were randomized to perform care by either directly donning unsterile gloves or performing hand hygiene and then donning unsterile gloves. The results of the study showed that the total bacterial colony counts did not differ between the two groups. Researchers identified Staphylococcus aureus on the gloves of one member of the group who performed hand hygiene before donning gloves and two members of the group who directly donned gloves. They identified all other organisms as commensal bacteria. The researchers concluded that hand hygiene performed before donning unsterile gloves did not decrease the already low bacterial counts on the unsterile gloves and, therefore, that performing hand hygiene before donning unsterile gloves may be unnecessary. The researchers described an unexpected finding of the study; it took an additional 31.5 seconds to perform hand hygiene before donning the unsterile gloves. This additional time amounted to approximately 19 minutes over a 12hour shift. The researchers theorized that this time could be spent more productively in providing direct patient care. There are limitations to this study that should be considered by clinicians before a decision is made to change current practice and eliminate hand hygiene before donning unsterile gloves. First, the
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researchers conducted the study within a single institution; because of this, the results may not be generalizable to other settings. Second, the researchers considered the method of fingerprint and palm impression prints to be a limitation. The impression method was selected because it was less cumbersome and time-consuming for the clinicians; however, this method of sampling does not sample the entire hand, and researchers sampled only the dominant hand. Cultures taken from both hands before and after patient care may have provided a more realistic sample. Likewise, sampling areas in the patient’s room that were touched by the clinicians’ gloved hands would have provided important data relative to the potential for transmission of microorganisms from the clinician’s hand to environmental surfaces and patients, as well as the need for hand hygiene before donning unsterile gloves. Finally, as clinicians review this study and what the researchers assert and consider a change in practice, it is important for them to ask the following questions: n
Is hand hygiene ever unnecessary? n Is the time spent performing hand hygiene considered nonproductive time?
Most importantly, clinicians should ask the following: Until there is scientific evidence to show otherwise, do the potential benefits of 31.5 seconds of hand hygiene performed by the clinician before donning unsterile gloves outweigh the potential harm associated with not performing hand hygiene and increasing the risk of transferring microorganisms from the clinician’s hands to the patient? Until more conclusive evidence is available, performing hand hygiene before donning unsterile gloves is still considered best practice. SHARON A. VAN WICKLIN MSN, RN, CNOR, CRNFA, CPSN, PLNC PERIOPERATIVE NURSING SPECIALIST AORN NURSING DEPARTMENT References 1. Glove use information leaflet. World Health Organization. http://www.who.int/gpsc/5may/Glove_Use_Information_ Leaflet.pdf. Accessed September 25, 2013. 2. How-to Guide: Improving Hand Hygiene. A Guide for Improving Practices among Health Care Workers. Institute for Healthcare Improvement. http://www.shea-online.org/ Assets/files/IHI_Hand_Hygiene.pdf. Accessed September 25, 2013. 3. Rock C, Harris AD, Reich NG, Johnson JK, Thom KA. Is hand hygiene before putting on nonsterile gloves in the intensive care unit a waste of health care worker time? A randomized controlled trial. Am J Infect Control. 2013;41(11):994-996.
Preparing for a procedure on a patient who is allergic to Di(2-ethylhexyl)phthalate (DEHP) QUESTION: One of our surgeons has advised us that within the next few weeks he will be operating on a patient who is allergic to DEHP. This patient has undergone previous surgeries at different facilities; however, during the most recent surgery, the patient had a severe reaction to the DEHP in the endotracheal tube. What can we do to prepare for this procedure so that we can provide the best care possible for this patient and be equipped to handle any emergencies that might arise?
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ANSWER: Whether the patient has an unusual allergy or some other type of unique medical condition that may require specific interventions, perioperative RNs can use the nursing process as an organizing framework for systematic planning and care delivery for all perioperative patients. The process begins with assessment (ie, gathering information). The perioperative RN reviews the information that has been gathered during the assessment, identifies the problem, and formulates a nursing diagnosis. He or she then develops an individualized plan of care,
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TABLE 1. Medical Devices Known to Release DEHP IV storage bags IV infusion sets IV infusion catheters Blood storage bags Blood administration sets Polyvinyl chloride exam gloves Chest tubes Hemodialysis tubing Extracorporeal membrane oxygenation tubing
1
Ventilator tubing Endotracheal tubes Nasogastric tubes Enteral and parenteral nutrition storage bags Urinary catheters Suction catheters Nasal cannula tubing Syringes Cardiopulmonary bypass tubing
DEHP ¼ Di(2-ethylhexyl)phthalate. 1. Safety assessment of di(2-ethylhexyl)phthalate (DEHP) released from medical devices. US Food and Drug Administration. http://www.fda.gov/downloads /MedicalDevices/DeviceRegulationandGuidance/GuidanceDocuments/UCM080457.pdf. Accessed September 10, 2013.
devises interventions and strategies to accomplish the plan, and implements the plan. Finally, the RN evaluates the outcome and modifies the plan of care if necessary. In this case, the surgeon has provided advance notification, so the team is at an advantage and can gather information about DEHP allergies to develop a specific plan of care. The substance DEHP is known as a plasticizer. Plasticizers are used to soften the polyvinyl chloride plastic polymer in medical devices and make them flexible.1 According to the US Food and Drug Administration (FDA), Although the toxic and carcinogenic effects of DEHP have been well established in experimental animals, the ability of this compound to produce adverse effects in humans is controversial. As a result, the ability of DEHP and other phthalate esters [ie, plasticizers] to produce adverse effects in humans has been a topic of active discussion and debate in the scientific and regulatory communities.1(p3) Di(2-ethylhexyl)phthalate is found in items such as IV bags and tubing and endotracheal tubes1 (Table 1) and is the only plasticizer approved for medical use by the FDA.2 Table 2 describes the actions to be taken by the perioperative team to accomplish the steps of the nursing process when planning care delivery for a
patient with a DEHP allergy. The table is helpful in planning care for a patient who is allergic to DEHP; however, these actions can be modified easily when planning care delivery for perioperative patients who present unique challenges, such as a patient who has a latex sensitivity, a patient scheduled for a perineal procedure who has an allergy to povidone iodine, or a patient with another unique allergy or medical condition that requires additional assessment and planning. Perioperative RNs and other members of the perioperative team can provide the best care possible when there is open communication to alert the team about an unusual situation and a multidisciplinary team can be gathered to assess and plan for the situation ahead of time. After the procedure, it is important to review strategies that were successful, as well as those that could be improved, and to share the information both internally and externally so that others in the perioperative community can learn from these experiences. Acknowledgment: The author thanks Gregg L. Puluka, BSN, RN, CNOR, staff nurse-CN4, at the Bristol-Myers Squibb Children’s Hospital at Robert Wood Johnson University Hospital, New Brunswick, NJ, for his assistance writing this question. SHARON A. VAN WICKLIN MSN, RN, CNOR, CRNFA, CPSN, PLNC PERIOPERATIVE NURSING SPECIALIST AORN NURSING DEPARTMENT
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TABLE 2. Nursing Care Plan for a Patient Who Is Allergic to DEHP Nursing process Assess
Actions n
n
n n n n n n n n
Select primary personnel and alternate personnel for case assignment from admission to discharge (eg, preoperative RN, RN circulator, scrub person, first assistant, postanesthesia care unit RN, any additional personnel required). Gather a multidisciplinary team (eg, infection preventionist, anesthesia professional, surgeon, risk management personnel) and the selected perioperative personnel to assess the situation and explore strategies for reducing risk and safely completing the procedure. Conduct a literature search and review websites such as http://www.noharm.org to identify scientific information, case reports, and best practices relevant to DEHP allergy. Question colleagues with expert knowledge or previous experience caring for patients with the DEHP allergy regarding best practices and strategies to be implemented for safe care. Access the patient’s medical records, including those from other facilities if necessary, to review the patient’s medical history and past surgical experiences and treatments. Question the patient and designated support person regarding the patient’s previous surgical experiences and treatments. Consult with materials management personnel to search for alternative products that are DEHP-free or have the lowest DEHP content possible. Consult with manufacturers of products currently in use to determine the availability of alternative products that are DEHP-free or have the lowest DEHP content possible. Document the search results and all multidisciplinary actions taken to gather information related to the DEHP allergy in a file that can be easily retrieved, reviewed, and consulted at a later date. Document the preoperative assessment in the patient’s record.
Diagnose
n
Formulate relevant nursing diagnoses (eg, risk of allergic response) and document them in the patient’s record.
Plan
n
Meet with the multidisciplinary team and assigned perioperative personnel to review the results of the literature search and to devise strategies to be implemented preoperatively, intraoperatively, and postoperatively. Determine the DEHP content of all products to be used during care of the patient. Review the necessity of using products with DEHP content for which there are no DEHP-free alternatives. Devise and communicate the plan for providing perioperative care, completing the procedure, and addressing emergency situations that may arise. Collaborate with the anesthesia professionals about the use of preoperative steroids or other medications that may reduce the potential for inflammation or allergic reaction. Review strategies for rapid treatment of anaphylaxis or other emergency situations (eg, laryngospasm) that may arise. Plan to have emergency medications and equipment and additional personnel immediately available. Provide full disclosure and description of the plan to both the patient and his or her designated support person. Document the multidisciplinary plan related to the DEHP allergy in a file that can be easily retrieved, reviewed, and consulted at a later date. Document the perioperative plan of care in the patient’s record. Remove all DEHP-containing products from the procedure room the evening before the procedure and complete terminal cleaning. Initiate the preoperative briefing with surgical team members to review the plan before the procedure. Verify the plan with surgical team members during the time out and include this verification in the time-out documentation.
n n n n n n n n n n n n
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TABLE 2. (continued ) Nursing Care Plan for a Patient Who Is Allergic to DEHP Nursing process Implement
Actions n n n
Evaluate
n n n
n n n
Implement the plan with the assigned or alternate perioperative personnel and applicable multidisciplinary team members. Document the multidisciplinary implementation strategies for the DEHP allergy in a file that can be easily retrieved, reviewed, and consulted at a later date. Document the applied interventions in the patient’s record. Initiate the postdischarge debrief with all involved perioperative personnel and multidisciplinary team members. Review and evaluate the implemented strategies (ie, both successful and nonsuccessful) and other elements of the implemented plan during the debrief session. Document the multidisciplinary team’s evaluation of the plan and implementations related to the DEHP allergy and suggestions for future implementations in a file that can be easily retrieved, reviewed, and consulted at a later date. Create a policy and procedure for perioperative care of patients with DEHP allergy and disseminate it to perioperative personnel. Provide education regarding DEHP allergy and procedural best practices for patients with DEHP allergy, including a discussion of the relative case for all perioperative personnel. Consider broader dissemination of the information relative to care of patients with DEHP allergy by submitting a manuscript for publication.
DEHP ¼ Di(2-ethylhexyl)phthalate.
References 1. Safety assessment of di(2-ethylhexyl)phthalate (DEHP) released from medical devices. US Food and Drug Administration. http://www.fda.gov/downloads/Med icalDevices/DeviceRegulationandGuidance/Guidance
Documents/UCM080457.pdf. Accessed September 25, 2013. 2. Vetrano AM, Laskin DL, Archer F, et al. Inflammatory effects of phthalates in neonatal neutrophils. Pediatr Res. 2010;68(2):134-139.
Surgical wound classification QUESTION: We are having disagreements at our facility about how certain procedures should be classified when using the Centers for Disease Control and Prevention (CDC) surgical wound classification system. Which wound classifications should be assigned to the following procedures?
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Excision of lipoma in a room where the humidity is greater than 60% n Carpal tunnel release on a patient with a colostomy n Burn debridement n Laparoscopic cholecystectomy on a patient with chronic cholecystitis
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Cesarean delivery on a patient who experienced a long labor or ruptured membranes Breast biopsy with needle localization Return of a patient to surgery for evacuation of a hematoma or delayed wound closure Removal of implants or hardware Closed reduction of a nasal fracture Hemorrhoidectomy with sigmoidoscopy
ANSWER: Perioperative RNs should assign the surgical wound classification based on a careful assessment of the specific factors associated with each surgical procedure.1 According to the CDC, wounds should AORN Journal j 329
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be classified based on the likelihood and degree of wound contamination at the time of surgery.1 Following are definitions of the four CDC surgical wound classifications: [Class I] 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 [eg, bulb drain]. Operative incisional wounds that follow nonpenetrating (blunt) trauma should be included in this category if they meet the criteria. [Class II] 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 [eg, spillage from gastrointestinal tract]. [Class III] Contaminated wounds: These include open, fresh, accidental wounds, operations with major breaks in sterile technique [eg, procedure performed with unsterile instruments] or gross spillage from the gastrointestinal tract, and incisions in which acute, nonpurulent inflammation is encountered. [Class IV] 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(p109) AORN developed the Surgical Wound Classification Decision Tree (Figure 2) as a tool to assist perioperative RNs in accurately classifying surgical
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CLINICAL ISSUES wounds using the CDC surgical wound classification system. This tool is included in the 2013 “Recommended practices for prevention of transmissible infections in the perioperative practice setting”2 and also can be found on the AORN web site at http://www.aorn.org by searching for “Surgical Wound Classification Decision Tree.” The decision tree is an algorithm that presents organized, directed wound classification questions designed to lead the perioperative RN to the correct wound classification. Applying the Surgical Wound Classification Decision Tree to the list of procedures provided in the question results in the classifications to follow. Excision of Lipoma in a Room Where the Humidity Is Greater Than 60%: [Class I] Clean Although the humidity level may be greater than the desired parameter of 60%,3 humidity levels that exceed 60% do not constitute a major break in sterile technique; therefore, the wound classification would remain as Class I. In its surgical wound classification, the CDC uses the example of open cardiac massage as a definition of a major break in sterile technique.1 Essentially, a major break in sterile technique is a catastrophic event, more in the nature of discovering that the instruments used during the procedure had not been sterilized or having an unsterile item (eg, the surgeon’s eyeglass loupes) fall into the sterile wound, as opposed to humidity levels in the room exceeding desired parameters. Another point of confusion that sometimes arises when there is a break in sterile technique is that the perioperative RN changes the wound classification from a Class I procedure to a Class II procedure. Class II procedures are specific to the respiratory, alimentary, or genitourinary tracts.1 If those tracts are not entered during the surgery, the procedure would never qualify as Class II. In the event of a true major break in sterile technique during a Class I procedure, the wound classification would change from Class I to Class III.
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Figure 2. The AORN Surgical Wound Classification Decision Tree is intended to guide perioperative nurses in assigning the correct wound class. Figure reprinted, with permission, from Perioperative Standards and Recommended Practices. Copyright ª AORN, Inc, 2014. AORN Journal j 331
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Carpal Tunnel Release on a Patient With a Colostomy: [Class I] Clean The mere presence of an ostomy in an area that is not proximal to the surgical incision does not affect the wound class. Therefore, the wound classification would remain as Class I. Burn Debridement: [Class III] Contaminated A burn is an accidental injury; therefore, debridement of the burn would be considered a Class III procedure. If, however, there is purulence or necrotic tissue present, the burn debridement would be a Class IV procedure. Laparoscopic Cholecystectomy on a Patient With Chronic Cholecystitis: [Class II] CleanContaminated The assigned wound classification for a cholecystectomy should be based on the specific factors associated with the procedure. The classification is not based on whether the diagnosis is acute or chronic cholecystitis; instead, the wound classification depends on evidence of infection or contamination; spillage from the gastrointestinal tract; nonpurulent inflammation, which could be chronic; or the presence of purulence or devitalized tissue found or occurring during the procedure. A cholecystectomy procedure with no evidence of infection and no break in surgical technique (eg, spillage from the gastrointestinal tract) would be classified as Class II. If there was visible gross spillage of bile during the procedure, it would be classified as Class III. If the drainage from the gallbladder was purulent or if the gallbladder was necrotic, then the procedure would be classified as Class IV. Cesarean Delivery on a Patient Who Experienced a Long Labor or Ruptured Membranes: [Class II] Clean-Contaminated Cesarean deliveries with or without ruptured membranes or long labors are Class II procedures. The exceptions are when there is a specific reason to assign a Class III (eg, presence of meconium representing spillage from the fetal gastrointestinal tract) or a Class IV (eg, presence of purulence). 332 j AORN Journal
CLINICAL ISSUES Breast Biopsy With Needle Localization: [Class I] Clean A needle localization procedure performed before the breast biopsy procedure does not constitute either a major break in sterile technique or an old wound because there is no purulence or necrotic tissue present. Therefore, this would be a Class I procedure. Return of a Patient to Surgery for Evacuation of a Hematoma or Delayed Wound Closure: [Class I] Clean A return to surgery for bleeding or evacuation of a hematoma does not necessarily meet the conditions for a Class III or Class IV assignment; therefore, it would remain as a Class I unless there are mitigating factors present, such as inflammation or purulence. Likewise, a delayed wound closure does not meet the requirements for a Class III or Class IV assignment unless there is devitalized tissue or purulence present in the wound being closed. Removal of Implants or Hardware: [Class I] Clean Unless the procedure meets the specifications for a Class III or Class IV assignment (eg, inflammation, purulence, necrotic tissue), removal of implants or hardware should be classified as Class I. If the respiratory, alimentary, or genitourinary tract is entered to retrieve the implant (eg, vaginal mesh), then the procedure would be a Class II. Closed Reduction of a Nasal Fracture: No Wound Classification Closed reduction of a nasal fracture does not produce a surgical wound. Therefore, there is no surgical wound classification assignment. Hemorrhoidectomy With Sigmoidoscopy: [Class II] Clean-Contaminated for the Hemorrhoidectomy; No Wound Classification for the Sigmoidoscopy When hemorrhoids are excised, the gastrointestinal tract is entered; therefore, the hemorrhoidectomy is a Class II procedure. There is no classification for a sigmoidoscopy because there is no surgical wound.
CLINICAL ISSUES SHARON A. VAN WICKLIN MSN, RN, CNOR, CRNFA, CPSN, PLNC PERIOPERATIVE NURSING SPECIALIST AORN NURSING DEPARTMENT References 1. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR; Hospital Infection Control Practices Advisory Committee. Guidelines for prevention of surgical
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site infection, 1999. Am J Infect Control. 1999;27(2): 99-134. 2. Recommended practices for prevention of transmissible infections in the perioperative practice setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:331-364. 3. ANSI/ASHRAE/ASHE Addendum D to ANSI/ASHRAE/ ASHE Standard 170-2008. Atlanta, GA: American Society of Heating, Refrigerating and Air-Conditioning Engineers; 2010.
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LEARNER EVALUATION CONTINUING EDUCATION PROGRAM
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his evaluation is used to determine the extent to which this continuing education program met your learning needs. The evaluation is printed here for your convenience. To receive continuing education credit, you must complete the online Learner Evaluation at http://www.aorn.org/CE. Rate the items as described below. PURPOSE/GOAL To provide the learner with knowledge of AORN’s recommended practices related to adhesive tape rolls as a source of infection, hand hygiene before donning unsterile gloves, preparing for a procedure on a patient who is allergic to di(2-ethylhexyl)phthalate (DEHP), and surgical wound classification. OBJECTIVES To what extent were the following objectives of this continuing education program achieved? 1. Discuss practices that could jeopardize safety in the perioperative area. Low 1. 2. 3. 4. 5. High 2. Discuss common areas of concern that relate to perioperative best practices. Low 1. 2. 3. 4. 5. High 3. Describe implementation of evidence-based practice in relation to perioperative nursing care. Low 1. 2. 3. 4. 5. High CONTENT 4. To what extent did this article increase your knowledge of the subject matter? Low 1. 2. 3. 4. 5. High
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5. To what extent were your individual objectives met? Low 1. 2. 3. 4. 5. High 6. Will you be able to use the information from this article in your work setting? 1. Yes 2. No 7. Will you change your practice as a result of reading this article? (If yes, answer question #7A. If no, answer question #7B.) 7A. How will you change your practice? (Select all that apply) 1. I will provide education to my team regarding why change is needed. 2. I will work with management to change/ implement a policy and procedure. 3. I will plan an informational meeting with physicians to seek their input and acceptance of the need for change. 4. I will implement change and evaluate the effect of the change at regular intervals until the change is incorporated as best practice. 5. Other: ________________________________ 7B. If you will not change your practice as a result of reading this article, why? (Select all that apply) 1. The content of the article is not relevant to my practice. 2. I do not have enough time to teach others about the purpose of the needed change. 3. I do not have management support to make a change. 4. Other: ________________________________ 8. Our accrediting body requires that we verify the time you needed to complete the 2.8 continuing education contact hour (168-minute) program: _________________________________
AORN, Inc, 2014