- Email: [email protected]
Clinical Issues—July 2011
CLINICAL ISSUES
1.9 www.aorn.org/CE
This Month f f
Abdominal-perineal surgical preps Key words: surgical skin preparation, skin antisepsis, abdominal prep, perineal prep, vaginal prep, dual prep.
f f
Perineal preps and urinary catheter insertion Key words: skin prep, urinary catheter insertion.
f f
Endoscopy room requirements Key words: endoscopy room, endoscopy, environmental conditions for endoscopy.
f f
Use and decontamination of case carts Key words: case carts, sterile supplies, washing case carts, cleaning, decontamination.
f f
Storage of sterile and unsterile supplies Key words: sterile storage, storage rules, OR storage, wire racks.
f f
Abdominal-perineal surgical preps
QUESTION We are revising our surgical skin prep policy and procedure, and we have been unable to agree on a method for surgical skin prep when both the abdomen and perineal areas require prepping. What are the key elements that we should include in our policy, and is there a preferred sequence?
ANSWER The surgical skin prep policy and procedure should define the sequence of the preps, method of application, directions for prepping, and area to be prepped. Approved prep agents should also be listed in the policy and procedure. Historically, abdominal-perineal preps have been performed in several ways:
indicates that continuing education contact hours are available for this activity. Earn the contact hours by reading this article, reviewing the purpose/goal and objectives, and completing the online Learner Evaluation at http://www.aorn.org/CE. The contact hours for this article expire July 31, 2014. doi: 10.1016/j.aorn.2011.05.001
© AORN, Inc, 2011
July 2011
Vol 94
No 1 ●
AORN Journal
97
July 2011
Vol 94
by performing the perineal prep first, followed by the abdominal prep; by performing the abdominal prep, followed by the perineal prep; and by having two people perform the preps at the same time, one prepping the abdomen and one prepping the perineum.
The decision regarding the sequence in which these preps are performed must be made at the organizational level by a multidisciplinary team. The team should consider AORN’s recommended practices and the evidence or, if little evidence is available, the opinion of experts that either support or do not recommend a defined sequence. The “AORN recommended practices for preoperative patient skin antisepsis,” states “Vaginal preps for procedures that include the abdomen should be performed in a manner to prevent splashing of antiseptic agent expelled from the vagina onto the prepped abdomen.”1(p371) This indicates the outcome, but does not directly specify a sequence. The theory that the abdomen (ie, a lesscontaminated area) may become contaminated by splashback from the vaginal prep supports the perineum-to-abdomen sequence. If the abdomen is prepped first, then it could also become contaminated if the nurse uses a gloved hand to press on the abdomen (ie, the Credé maneuver) during urinary catheter insertion. Those who support the abdomen-to-perineum sequence believe that prepping the patient’s abdomen and then moving to the perineum results in moving from an area of lower bacterial count to an area of higher bacterial count, as recommended in the “AORN recommended practices for preoperative patient skin antisepsis.”1 Those who support using two prep sets and two people prepping simultaneously believe that, because each area is prepped separately from the incision outward, both will be properly prepped. In addition, the time taken to prep is markedly decreased when both areas are prepped simultaneously. 98
AORN Journal
CLINICAL ISSUES
No 1
Regardless of the sequence used, when a solution is applied with sponges and sponge sticks (eg, sponge forceps with a nonradiopaque sponge, a sponge attached to a handle by the manufacturer), two separate prep kits should be used. Each sponge or sponge stick should be dipped into the prep agent one time only. The manufacturer’s directions for application should be followed when a prep set that contains an applicator is being used. A separate applicator should be used on each site, but additional applicators may be required, depending on the amount of solution in each applicator. The prep agent for a female patient should be applied to the mons pubis, vulva, perineum, labia, vagina, cervix, inner aspects of the thighs, and anal area. For a male patient, the prep agent should be applied to the pubic area, penis, scrotum, inner aspects of the thighs, and anal area. Perineal Prep For a surgical prep involving the perineal area using a solution applied with sponges and sponge sticks, the following steps should be completed.1 Open the prep kit. Don sterile gloves. Place a moisture-proof pad under the patient’s buttocks. Apply the prep agent appropriately.
For a female patient, follow these steps: Apply the prep agent by beginning at the mons pubis downward over the vulva and perineum and end in the anal area, then discard the sponge. Apply the prep agent on the inner aspects of the thighs by using separate sponges for each thigh, starting from the outside of the labia majora and moving outward toward the knees, covering approximately the upper third of each thigh. Apply the prep agent to the labia, vagina, and cervix with sponges on sponge forceps or disposable sponge sticks. Use a generous amount of prep agent in the vagina because the vaginal
CLINICAL ISSUES mucosa has many folds and crevices that are not easily prepped. Use a dry sponge to absorb any prep solution that remains in the vagina, which prevents prep solution from entering the peritoneal cavity during the surgical procedure. Remove the moisture-proof pad. Dispose of the prep kit, remove gloves, and wash the hands. For a male patient, follow these steps: Apply the prep agent from the incision site by moving outward in a circumferential pattern toward the periphery. When applying the prep agent to the penis, if the foreskin is present, retract the foreskin and clean the glans thoroughly, by starting at the urethral meatus. Return the foreskin to its original position after the prep is complete. When a urinary catheter is being inserted, return the foreskin to the original position after inserting the catheter. Remove the moisture-proof pad. Dispose of the prep kit, remove gloves, and wash the hands.
www.aornjournal.org
Prep Agents A multidisciplinary team should select the prep agents to be used throughout the organization. Prep agents should reduce microorganisms on intact skin, be broad spectrum, be fast acting, have persistence, and meet US Food and Drug Administration requirements.2 The appropriate prep solution for an individual patient or procedure should be selected based on the compatibility of the prep agent with the tissue to be prepped, patient sensitivities, manufacturer’s recommendations, the presence of organic matter or wounds, the neonatal status, and surgeon preference.1 Summary There currently is no scientific evidence to support a specific prepping sequence, and all sequences mentioned here are based on professional opinion. Future research should explore each prepping sequence to determine
Abdominal Prep The abdominal area to be prepped will vary by procedure, and it may involve a portion of or the entire area between the nipples and the perineal area and extend to the bed on each side. The area should be large enough to allow for enlargement of the incision, if needed. The following steps should be completed for a surgical prep that involves the abdomen by using a solution applied with sponges and sponge sticks:
Open the prep kit and don sterile gloves. Cleanse the umbilicus with cotton-tipped applicators, remove detritus before applying the antiseptic prep agent. Prep the abdomen by starting at the incision site and moving outward toward the periphery. Remove the moisture-proof pad. Dispose of the prep kit, remove gloves, and wash the hands.
the amount of aerosolization that occurs during perineal prepping, the presence of infectious agents in aerosolized prep agents, whether the infectious agents are killed by the prep solution before aerosolization occurs, whether prep overlap results in the contamination of the second prep area, and whether any sequence results in an increased incidence of patient hypothermia compared with the others.
Regardless of what prepping sequence is used, each surgical site must be considered an independent site and should be prepped from the incision area outward, by moving from the area with the lowest contamination to the area with the highest contamination.1 “If a highly contaminated area is part of the procedure [eg, colostomy site], the area with a lower bacterial count is prepped first, followed by the area of higher contamination, as opposed to working from the incision site toward the periphery.”1(p370) AORN Journal
99
July 2011
Vol 94
BYRON BURLINGAME MS, BSN, RN, CNOR PERIOPERATIVE NURSING SPECIALIST AORN CENTER FOR NURSING PRACTICE References 1. Recommended practices for preoperative patient skin antisepsis. In: Perioperative Standards and Recom-
f f
CLINICAL ISSUES
No 1
mended Practices. Denver, CO: AORN, Inc; 2011:361-379. 2. US Department of Health and Human Services, Food and Drug Administration. Tentative final monograph for health-care antiseptic drug products; proposed rule. Fed Regist. 1994;59(116):31402-31452. Codified at 21 CFR Parts 333 and 369. http://www.fda.gov/OHRMS/ DOCKETS/98fr/94-14503.pdf. Accessed May 2, 2011.
Perineal preps and urinary catheter insertion
QUESTION Should a urinary catheter be inserted before or after the nurse performs a surgical prep for a procedure that involves the genital area? ANSWER When the patient requires a urinary catheter and the surgical area involves the genitals and perineum, the nurse should insert the catheter after performing the surgical skin prep. Insertion of the catheter after the surgical prep helps prevent trauma to the urethra caused by catheter manipulation during the prepping procedure. To perform the catheter insertion, use sterile supplies and aseptic technique as recommended in the “AORN recommended practices for preoperative patient skin antisepsis”1 and perform the following steps: Complete the surgical prep. Remove and dispose of the prep gloves. Open the necessary catheter supplies. Don sterile gloves.
Insert the catheter. If the patient is a male with an intact foreskin, return the foreskin over the glans. Secure the catheter appropriately.
An additional prep of the genitalia is not required. A complete catheter kit is not required if all of the necessary supplies can be opened individually and presented to the circulating nurse aseptically. In addition, opening fewer supplies may decrease the amount of waste and reduce costs.2 BYRON BURLINGAME MS, BSN, RN, CNOR PERIOPERATIVE NURSING SPECIALIST AORN CENTER FOR NURSING PRACTICE References 1.
f f
Endoscopy room requirements
QUESTION We are considering creating an endoscopy room. What types of procedures can be performed in this room? Can we put a sink in this room? What requirements should we consider when determining its location? ANSWER The requirements for an endoscopy room depend on several variables, including the defini100
2.
Recommended practices for preoperative patient skin antisepsis. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2011:361379. Recommended practices for product selection in perioperative practice settings. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2011:191-200.
AORN Journal
tion of the term endoscopy, the location of the proposed room, and the type of procedures that will be performed in the room. In the context of this question, an endoscopy room is defined as a room in which flexible endoscopes are used for the exploration of the gastrointestinal or respiratory tracts. An endoscopy room may be located within the semirestricted area of the surgical suite or within the unrestricted portion of the health care facility. The AORN
CLINICAL ISSUES “Recommended practices for traffic patterns in the perioperative practice setting” defines each of these areas of the surgical suite.1 The unrestricted area includes a central control point that is established to monitor the entrance of patients, personnel, and materials. Street clothes are permitted in this area, and traffic is not limited. The entrance to the surgical suite should be restricted to authorized personnel based on organizational policies. The semirestricted area includes the peripheral support areas of the surgical suite. It has storage areas for clean and sterile supplies, work areas for storage and processing of instruments, scrub sink areas, and corridors leading to the restricted areas of the surgical suite. Traffic in this area is limited to authorized personnel and patients. Personnel are required to wear surgical attire and cover all head and facial hair. The restricted area includes ORs, procedure rooms, and the clean core area. Surgical attire and hair coverings are required. Masks are required where open sterile supplies or scrubbed persons are located. All persons entering the restricted area should follow the AORN “Recommended practices for surgical attire.”1(p95) If the endoscopy room is located within the semirestricted area of the surgical suite, then the recommendations above for proper attire must be followed. If the endoscopy room is located in the nonrestricted area, then special scrub attire is not required unless the procedure being performed requires surgical scrub attire. Personnel, including the physicians, in the endoscopy room are required to wear proper personal protective equipment, as determined by the risk of exposure.2,3 An endoscopy may be performed in any OR (ie, restricted area). When performing an endoscopy procedure in the OR, personnel should adhere to the AORN “Recommended practices for surgical attire.”3 After an endoscopy has been
www.aornjournal.org
performed in an OR, a turnover cleaning and disinfection process as described in the AORN “Recommended practices for environmental cleaning in the perioperative setting” is needed to reestablish a safe, clean environment before the next surgical procedure.4 In addition, the Facility Guidelines Institute provides air flow, pressure, temperature, and humidity recommendations for each of these areas.5 When deciding what procedures, other than flexible gastrointestinal endoscopies, can be performed in the endoscopy room, the first factor to consider is the room’s location. If the room is in the unrestricted area of the facility, then procedures such as pain injections or examinations under anesthesia can be performed in this location; however, invasive surgical procedures cannot. In accordance with the Facility Guidelines Institute, a hand wash sink is required in an endoscopy room, independent of the room being in a semirestricted or unrestricted area.5 The presence of a sink prohibits the performance of surgical procedures traditionally performed in a room within the restricted area of a surgical suite. The Facility Guidelines Institute requires that an endoscopy room have two outdoor air exchanges and 15 total air changes per hour, whereas an OR must have four outdoor air exchanges and 20 minimum total air exchanges per hour.5 The temperature, humidity, and positive-pressure recommendations are the same for both an endoscopy room and an OR. If bronchoscopies are to be performed in this room, then negative pressure should be used to help prevent the spread of airborne contaminants.5 When a procedure performed in this room requires administration of nitrous oxide or other anesthetic gases, then a waste anesthesia gas evacuation system must be present.5 Sterile supplies needed for an endoscopic or other procedure may be opened in this room. Signage should be present on the door to the endoscopy room that states the attire requirements and limits entrance to authorized personnel only.5 AORN Journal
101
July 2011
Vol 94
BYRON BURLINGAME MS, BSN, RN, CNOR PERIOPERATIVE NURSING SPECIALIST AORN CENTER FOR NURSING PRACTICE References 1.
2.
f f
Recommended practices for traffic patterns in the perioperative practice setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2011:95-98. Facility Guidelines Institute. 3.9 Specific requirements for gastrointestinal endoscopy facilities. In: Guidelines for Design and Construction of Health Care Facilities. Washington, DC: American Society for Healthcare Engi-
neering (ASHE) of the American Hospital Association; 2010:275-282. 3. Personal protective equipment. In: Occupational safety and health standards: Bloodborne pathogens. Fed Regist. 1991;56(235):64004-64182. Codified at 29 CFR §1910.1030. http://www.osha.gov/pls/oshaweb/ owadisp.show_document?p_table⫽STANDARDS&p_ id⫽10051#1910.1030(d)(3). Accessed April 24, 2011. 4. Recommended practices for surgical attire. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2011:57-71. 5. Recommended practices for environmental cleaning in the perioperative setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2011:237-250.
Use and decontamination of case carts
QUESTION Can case carts be taken into an OR and left there during the procedure? If this is allowed, how should the cart be washed after each procedure, and can the extra supplies on the cart be returned to the supply storage area? ANSWER Case carts may be left in the OR during surgical procedures. If the cart is left in the OR during the procedure and it contains sterile supplies, a barrier should be present between the supplies and the patient. The barrier can be created by keeping the doors on the cart closed or keeping an impervious covering over the supplies. After the procedure, if the integrity of the sterile supply package is intact and the external packaging has not been contaminated, then the sterile supplies should be removed from the cart and returned to the sterile storage area.1-3 Contamination can occur when a person in the room touches the product with contaminated gloves or if blood, body fluids, or moisture is present on it. After removal of the sterile supplies, contaminated items used during the procedure should be placed on or in the cart. The cart and its contents should then be transported to the decontamination area. All the surfaces of the cart, including the wheels, should be decontaminated because the cart was in the OR during a surgical procedure.1,3 102
CLINICAL ISSUES
No 1
AORN Journal
Decontamination can be accomplished by using an Environmental Protection Agency-approved germicide and by placing the cart in a cart washer. If a cart washer is not available, then the cart should be washed manually. Impervious cart covers should be cleaned when contaminated and on a regularly scheduled basis by using a health care organization-approved disinfectant that is registered with the Environmental Protection Agency.4 When case carts are used as a back table, all of the sterile supplies should be removed from the cart before the initial drape is opened. If the supplies are not removed, the back table drape may become contaminated during the procedure as people reach in and out of the cart or the supplies in the cart may become contaminated by the back table drape particularly during the removal process. BYRON BURLINGAME MS, BSN, RN, CNOR PERIOPERATIVE NURSING SPECIALIST AORN CENTER FOR NURSING PRACTICE References 1.
2.
Recommended practices for sterilization in the perioperative practice setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2011:463-485. Recommended practices for selection and use of packaging systems for sterilization. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2011:453-462.
CLINICAL ISSUES
www.aornjournal.org
3.
ANSI/AAMI ST79:2006. In: Comprehensive Guide to Steam Sterilization and Sterility Assurance in Health Care Facilities. Arlington, VA: Association for the Advancement of Medical Instrumentation; 2010.
f f
Storage of sterile and unsterile supplies
QUESTION Should sterile items be stored separately from unsterile items? If this is not required, what are the requirements for storage of sterile and unsterile supplies? ANSWER Sterile and unsterile items may be stored in the same location if they are separated and if the proper storage conditions exist.1 Designing and maintaining adequate storage space and creating the proper conditions is often a challenge in health care organizations. When designing or determining methods and locations for storage, size requirements should be determined first, based on the items to be stored and building codes; then environmental, fire safety, and infection control recommendations must be considered. The Facility Guidelines Institute2 recommends that sufficient storage areas be designed and maintained to keep the exit corridors at the minimum width described in the fire codes (eg, 6 ft of clear and unobstructed surface).3 The corridors should be as free as possible of equipment and supplies. The storage area for the entire surgical suite should be not less than 300 sq ft (27.87 m2) or 50 sq ft (4.65 m2) per OR, whichever is larger. An OR designated for special services (eg, cardiac, orthopedic, neurosurgery) may require adjacent storage for larger pieces of equipment.2 The method of storage depends on the items to be stored and whether they are located within the semirestricted or restricted areas of the OR. Sterile storage in the semirestricted and restricted areas can be accomplished by several methods, including
wire racks, portable shelving systems,
4.
Recommended practices for environmental cleaning in the perioperative setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2011:237-250.
attached shelves, or cupboards.
If supplies are stored within the OR, then they must be covered at all times with an impervious barrier (eg, doors closed on cabinets, plastic sleeves/covers over wire racks). A wire rack with attached shelves increases visibility and accommodates the storage of larger items. Items may be stored on wire rack hooks or shelves or in bins through which the items can be seen. To hang items, use clips as hooks to attach the items and maintain package integrity. This method allows for a diverse configuration to accommodate items of different sizes. Automatic storage and inventory systems that may increase efficiencies in storage and inventory control also are available. These systems may require keypad entry and active removal or return of items. The automatic storage and inventory systems have front-locking, transparent thermoplastic doors for visibility of items. Shelves within the system can be configured to store nonsterile items separately from sterile items and allow for easy, clear access.2 When clean and sterile supplies must be stored together, it is best to separate them by storing the sterile items on the upper shelves and the clean items on the lower shelves. If nonsterile items are stored above sterile items, lint, dust, and other debris may fall onto the sterile items. Whatever storage method is used, attention should be given to how sterile items are handled and positioned to decrease the potential of breaching the packaging.1 Contamination may result when the packages are breached (eg, crushed, bent, compressed, punctured) because air and microorganisms are forced into the package contents. If sterile and AORN Journal
103
July 2011
Vol 94
unsterile items are packaged similarly, they should not be placed in close proximity on the shelves because this may increase the potential for inadvertently selecting the wrong item.1 AORN’s “Recommended practices for traffic patterns in the perioperative practice setting”1 and the Association for the Advancement of Medical Instrumentation Comprehensive Guide to Steam Sterilization and Sterility Assurance in Health Care Facilities4 state that access to the sterile storage area should be limited and separated from high-traffic areas. Decontamination and substerile areas are not appropriate locations for storage of sterile or clean items because of the risk of exposure to contaminants. Supplies, clean or sterile, should not be stored next to or under sinks, near exposed water or sewer pipes, or in locations where they may become wet. If sterile supplies become wet, the supplies must be considered unsterile, removed from storage, and disposed of or resterilized per facility and manufacturer policy. Items that are not intended to rest on the floor (eg, positioning devices) should be stored on appropriate shelves or racks. If an item that is not intended to rest on the floor is stored on the floor, then the item may inhibit adequate cleaning of the floor or the mopping action may contaminate the item.1 Storage of supplies on floors, windowsills, and areas other than designated shelving, counters, or carts should be avoided. Windowsill storage should be avoided because condensation caused by the differences in temperature between the inside and outside air may collect on sills. Closed or covered cabinets are recommended for the storage of seldom-used supplies to limit dust accumulation and decrease contact and handling.1 When the location of an OR suite requires storage of sterile supplies and clean supplies or equipment in the same room, the environmental recommendations for sterile supply storage should be followed. The Facility Guidelines Institute2 and the Association for the Advancement of Medical Instrumentation1 recommend storing sterile 104
CLINICAL ISSUES
No 1
AORN Journal
packages under environmentally controlled conditions that include a temperature of approximately 75° F (24° C), a maximum relative humidity of 70%, a positive air flow pressure in relation to adjacent areas, and 1,2,5 a minimum of four air exchanges per hour.
Fire Safety Many state fire code regulations require that sterile supplies be stored at least 18 inches from the ceiling. Ceiling clearance regulations that identify criteria required for proper functioning of the sprinkler system are based on standards established by the National Fire Protection Association.6 A local fire marshal should be consulted regarding storage heights and the distance from walls to ensure that local fire codes are followed. State health department and Centers for Medicare & Medicaid Services regulations may be more specific and the most stringent regulations should be followed. Infection Control When using a portable wire rack system, the cart should be placed at least 2 inches from outside walls. Adequate space is needed around sterile materials to allow for air circulation in the room and to prevent contact between sterile items and condensation that might form on the interior surfaces of outside walls. The bottom shelf of the cart should be at least 8 inches to 10 inches from the floor, and the bottom shelf of the rack should be solid or have a solid overlay placed on the wire shelf.1,2 The solid lower shelf is intended to protect items on the shelf from contamination that may occur during mopping.1 Sterile items that become wet when floors are cleaned are considered contaminated. The impervious covers, shelves, or carts used for sterile or unsterile storage should be maintained in a clean and dry condition. Cleaning should be performed on a regularly scheduled basis and should be accomplished by using a health care organization approved dis-
CLINICAL ISSUES infectant that is registered with the Environmental Protection Agency.7 BYRON BURLINGAME MS, BSN, RN, CNOR PERIOPERATIVE NURSING SPECIALIST AORN CENTER FOR NURSING PRACTICE
www.aornjournal.org
3. 4.
5.
References 1. ANSI/AAMI ST79:2006. In: Comprehensive Guide to Steam Sterilization and Sterility Assurance in Health Care Facilities. Arlington, VA: Association for the Advancement of Medical Instrumentation; 2010:24, 29. 2. Facility Guidelines Institute. Part 2 Hospitals. In: Guidelines for Design and Construction of Health Care Facilities. Washington, DC: American Society for Healthcare
6.
7.
Engineering (ASHE) of the American Hospital Association; 2010:45-214. NFPA 101: Life Safety Code. Quincy, MA: National Fire Protection Association; 2009. Recommended practices for traffic patterns in the perioperative practice setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2011:95-98. Recommended practices for a safe environment of care. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2011:215-236. Installation requirements. In: NFPA 13: Standard for the Installation of Sprinkler Systems. Quincy, MA: National Fire Protection Association; 2011:13-51. Recommended practices for environmental cleaning in the perioperative setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2011:237-250.
The author of this column has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
Bring Your Clinical Questions to AORN’s Team of Perioperative Nurse Specialists When you find yourself puzzled by a clinical issue, remember that AORN’s perioperative nursing specialists are just a telephone call away. For answers to your questions, contact the Center for Nursing Practice at (800) 755-2676. AORN’s Perioperative Standards and Recommended Practices is an excellent resource for perioperative nurses. Purchase your copy at www.aornbookstore.org.
AORN Journal
105
LEARNER EVALUATION CONTINUING EDUCATION PROGRAM
1.9
Clinical Issues
www.aorn.org/CE
T
his evaluation is used to determine the extent to which this continuing education program met your learning needs. The evaluation is printed here for your convenience. To receive continuing education credit, you must complete the Learner Evaluation online at http://www.aorn.org/CE. Rate the items as described below. PURPOSE/GOAL To educate perioperative nurses about providing safe nursing care throughout the perioperative continuum. OBJECTIVES To what extent were the following objectives of this continuing education program achieved? 1. Discuss practices that could jeopardize safety in the perioperative area. Low 1. 2. 3. 4. 5. High 2. Discuss common areas of concern that relate to perioperative best practices. Low 1. 2. 3. 4. 5. High 3. Describe implementation of evidence-based practice in relation to perioperative nursing care. Low 1. 2. 3. 4. 5. High CONTENT 4. To what extent did this article increase your knowledge of the subject matter? Low 1. 2. 3. 4. 5. High 5. To what extent were your individual objectives met? Low 1. 2. 3. 4. 5. High
6. Will you be able to use the information from this article in your work setting? 1. Yes 2. No 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 teach others about the purpose of the needed change. 3. I do not have management support to make a change. 4. Other: 8. Our accrediting body requires that we verify the time you needed to complete the 1.9 continuing education contact hour (114-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: #11512; Session: #0001 Fee: Members $9.50 Nonmembers $19 The deadline for this program is July 31, 2014. Each applicant who successfully completes this program can immediately print a certificate of completion.
106
AORN Journal ●
July 2011
Vol 94
No 1
© AORN, Inc, 2011
1.9 www.aorn.org/CE
This Month f f
Abdominal-perineal surgical preps Key words: surgical skin preparation, skin antisepsis, abdominal prep, perineal prep, vaginal prep, dual prep.
f f
Perineal preps and urinary catheter insertion Key words: skin prep, urinary catheter insertion.
f f
Endoscopy room requirements Key words: endoscopy room, endoscopy, environmental conditions for endoscopy.
f f
Use and decontamination of case carts Key words: case carts, sterile supplies, washing case carts, cleaning, decontamination.
f f
Storage of sterile and unsterile supplies Key words: sterile storage, storage rules, OR storage, wire racks.
f f
Abdominal-perineal surgical preps
QUESTION We are revising our surgical skin prep policy and procedure, and we have been unable to agree on a method for surgical skin prep when both the abdomen and perineal areas require prepping. What are the key elements that we should include in our policy, and is there a preferred sequence?
ANSWER The surgical skin prep policy and procedure should define the sequence of the preps, method of application, directions for prepping, and area to be prepped. Approved prep agents should also be listed in the policy and procedure. Historically, abdominal-perineal preps have been performed in several ways:
indicates that continuing education contact hours are available for this activity. Earn the contact hours by reading this article, reviewing the purpose/goal and objectives, and completing the online Learner Evaluation at http://www.aorn.org/CE. The contact hours for this article expire July 31, 2014. doi: 10.1016/j.aorn.2011.05.001
© AORN, Inc, 2011
July 2011
Vol 94
No 1 ●
AORN Journal
97
July 2011
Vol 94
by performing the perineal prep first, followed by the abdominal prep; by performing the abdominal prep, followed by the perineal prep; and by having two people perform the preps at the same time, one prepping the abdomen and one prepping the perineum.
The decision regarding the sequence in which these preps are performed must be made at the organizational level by a multidisciplinary team. The team should consider AORN’s recommended practices and the evidence or, if little evidence is available, the opinion of experts that either support or do not recommend a defined sequence. The “AORN recommended practices for preoperative patient skin antisepsis,” states “Vaginal preps for procedures that include the abdomen should be performed in a manner to prevent splashing of antiseptic agent expelled from the vagina onto the prepped abdomen.”1(p371) This indicates the outcome, but does not directly specify a sequence. The theory that the abdomen (ie, a lesscontaminated area) may become contaminated by splashback from the vaginal prep supports the perineum-to-abdomen sequence. If the abdomen is prepped first, then it could also become contaminated if the nurse uses a gloved hand to press on the abdomen (ie, the Credé maneuver) during urinary catheter insertion. Those who support the abdomen-to-perineum sequence believe that prepping the patient’s abdomen and then moving to the perineum results in moving from an area of lower bacterial count to an area of higher bacterial count, as recommended in the “AORN recommended practices for preoperative patient skin antisepsis.”1 Those who support using two prep sets and two people prepping simultaneously believe that, because each area is prepped separately from the incision outward, both will be properly prepped. In addition, the time taken to prep is markedly decreased when both areas are prepped simultaneously. 98
AORN Journal
CLINICAL ISSUES
No 1
Regardless of the sequence used, when a solution is applied with sponges and sponge sticks (eg, sponge forceps with a nonradiopaque sponge, a sponge attached to a handle by the manufacturer), two separate prep kits should be used. Each sponge or sponge stick should be dipped into the prep agent one time only. The manufacturer’s directions for application should be followed when a prep set that contains an applicator is being used. A separate applicator should be used on each site, but additional applicators may be required, depending on the amount of solution in each applicator. The prep agent for a female patient should be applied to the mons pubis, vulva, perineum, labia, vagina, cervix, inner aspects of the thighs, and anal area. For a male patient, the prep agent should be applied to the pubic area, penis, scrotum, inner aspects of the thighs, and anal area. Perineal Prep For a surgical prep involving the perineal area using a solution applied with sponges and sponge sticks, the following steps should be completed.1 Open the prep kit. Don sterile gloves. Place a moisture-proof pad under the patient’s buttocks. Apply the prep agent appropriately.
For a female patient, follow these steps: Apply the prep agent by beginning at the mons pubis downward over the vulva and perineum and end in the anal area, then discard the sponge. Apply the prep agent on the inner aspects of the thighs by using separate sponges for each thigh, starting from the outside of the labia majora and moving outward toward the knees, covering approximately the upper third of each thigh. Apply the prep agent to the labia, vagina, and cervix with sponges on sponge forceps or disposable sponge sticks. Use a generous amount of prep agent in the vagina because the vaginal
CLINICAL ISSUES mucosa has many folds and crevices that are not easily prepped. Use a dry sponge to absorb any prep solution that remains in the vagina, which prevents prep solution from entering the peritoneal cavity during the surgical procedure. Remove the moisture-proof pad. Dispose of the prep kit, remove gloves, and wash the hands. For a male patient, follow these steps: Apply the prep agent from the incision site by moving outward in a circumferential pattern toward the periphery. When applying the prep agent to the penis, if the foreskin is present, retract the foreskin and clean the glans thoroughly, by starting at the urethral meatus. Return the foreskin to its original position after the prep is complete. When a urinary catheter is being inserted, return the foreskin to the original position after inserting the catheter. Remove the moisture-proof pad. Dispose of the prep kit, remove gloves, and wash the hands.
www.aornjournal.org
Prep Agents A multidisciplinary team should select the prep agents to be used throughout the organization. Prep agents should reduce microorganisms on intact skin, be broad spectrum, be fast acting, have persistence, and meet US Food and Drug Administration requirements.2 The appropriate prep solution for an individual patient or procedure should be selected based on the compatibility of the prep agent with the tissue to be prepped, patient sensitivities, manufacturer’s recommendations, the presence of organic matter or wounds, the neonatal status, and surgeon preference.1 Summary There currently is no scientific evidence to support a specific prepping sequence, and all sequences mentioned here are based on professional opinion. Future research should explore each prepping sequence to determine
Abdominal Prep The abdominal area to be prepped will vary by procedure, and it may involve a portion of or the entire area between the nipples and the perineal area and extend to the bed on each side. The area should be large enough to allow for enlargement of the incision, if needed. The following steps should be completed for a surgical prep that involves the abdomen by using a solution applied with sponges and sponge sticks:
Open the prep kit and don sterile gloves. Cleanse the umbilicus with cotton-tipped applicators, remove detritus before applying the antiseptic prep agent. Prep the abdomen by starting at the incision site and moving outward toward the periphery. Remove the moisture-proof pad. Dispose of the prep kit, remove gloves, and wash the hands.
the amount of aerosolization that occurs during perineal prepping, the presence of infectious agents in aerosolized prep agents, whether the infectious agents are killed by the prep solution before aerosolization occurs, whether prep overlap results in the contamination of the second prep area, and whether any sequence results in an increased incidence of patient hypothermia compared with the others.
Regardless of what prepping sequence is used, each surgical site must be considered an independent site and should be prepped from the incision area outward, by moving from the area with the lowest contamination to the area with the highest contamination.1 “If a highly contaminated area is part of the procedure [eg, colostomy site], the area with a lower bacterial count is prepped first, followed by the area of higher contamination, as opposed to working from the incision site toward the periphery.”1(p370) AORN Journal
99
July 2011
Vol 94
BYRON BURLINGAME MS, BSN, RN, CNOR PERIOPERATIVE NURSING SPECIALIST AORN CENTER FOR NURSING PRACTICE References 1. Recommended practices for preoperative patient skin antisepsis. In: Perioperative Standards and Recom-
f f
CLINICAL ISSUES
No 1
mended Practices. Denver, CO: AORN, Inc; 2011:361-379. 2. US Department of Health and Human Services, Food and Drug Administration. Tentative final monograph for health-care antiseptic drug products; proposed rule. Fed Regist. 1994;59(116):31402-31452. Codified at 21 CFR Parts 333 and 369. http://www.fda.gov/OHRMS/ DOCKETS/98fr/94-14503.pdf. Accessed May 2, 2011.
Perineal preps and urinary catheter insertion
QUESTION Should a urinary catheter be inserted before or after the nurse performs a surgical prep for a procedure that involves the genital area? ANSWER When the patient requires a urinary catheter and the surgical area involves the genitals and perineum, the nurse should insert the catheter after performing the surgical skin prep. Insertion of the catheter after the surgical prep helps prevent trauma to the urethra caused by catheter manipulation during the prepping procedure. To perform the catheter insertion, use sterile supplies and aseptic technique as recommended in the “AORN recommended practices for preoperative patient skin antisepsis”1 and perform the following steps: Complete the surgical prep. Remove and dispose of the prep gloves. Open the necessary catheter supplies. Don sterile gloves.
Insert the catheter. If the patient is a male with an intact foreskin, return the foreskin over the glans. Secure the catheter appropriately.
An additional prep of the genitalia is not required. A complete catheter kit is not required if all of the necessary supplies can be opened individually and presented to the circulating nurse aseptically. In addition, opening fewer supplies may decrease the amount of waste and reduce costs.2 BYRON BURLINGAME MS, BSN, RN, CNOR PERIOPERATIVE NURSING SPECIALIST AORN CENTER FOR NURSING PRACTICE References 1.
f f
Endoscopy room requirements
QUESTION We are considering creating an endoscopy room. What types of procedures can be performed in this room? Can we put a sink in this room? What requirements should we consider when determining its location? ANSWER The requirements for an endoscopy room depend on several variables, including the defini100
2.
Recommended practices for preoperative patient skin antisepsis. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2011:361379. Recommended practices for product selection in perioperative practice settings. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2011:191-200.
AORN Journal
tion of the term endoscopy, the location of the proposed room, and the type of procedures that will be performed in the room. In the context of this question, an endoscopy room is defined as a room in which flexible endoscopes are used for the exploration of the gastrointestinal or respiratory tracts. An endoscopy room may be located within the semirestricted area of the surgical suite or within the unrestricted portion of the health care facility. The AORN
CLINICAL ISSUES “Recommended practices for traffic patterns in the perioperative practice setting” defines each of these areas of the surgical suite.1 The unrestricted area includes a central control point that is established to monitor the entrance of patients, personnel, and materials. Street clothes are permitted in this area, and traffic is not limited. The entrance to the surgical suite should be restricted to authorized personnel based on organizational policies. The semirestricted area includes the peripheral support areas of the surgical suite. It has storage areas for clean and sterile supplies, work areas for storage and processing of instruments, scrub sink areas, and corridors leading to the restricted areas of the surgical suite. Traffic in this area is limited to authorized personnel and patients. Personnel are required to wear surgical attire and cover all head and facial hair. The restricted area includes ORs, procedure rooms, and the clean core area. Surgical attire and hair coverings are required. Masks are required where open sterile supplies or scrubbed persons are located. All persons entering the restricted area should follow the AORN “Recommended practices for surgical attire.”1(p95) If the endoscopy room is located within the semirestricted area of the surgical suite, then the recommendations above for proper attire must be followed. If the endoscopy room is located in the nonrestricted area, then special scrub attire is not required unless the procedure being performed requires surgical scrub attire. Personnel, including the physicians, in the endoscopy room are required to wear proper personal protective equipment, as determined by the risk of exposure.2,3 An endoscopy may be performed in any OR (ie, restricted area). When performing an endoscopy procedure in the OR, personnel should adhere to the AORN “Recommended practices for surgical attire.”3 After an endoscopy has been
www.aornjournal.org
performed in an OR, a turnover cleaning and disinfection process as described in the AORN “Recommended practices for environmental cleaning in the perioperative setting” is needed to reestablish a safe, clean environment before the next surgical procedure.4 In addition, the Facility Guidelines Institute provides air flow, pressure, temperature, and humidity recommendations for each of these areas.5 When deciding what procedures, other than flexible gastrointestinal endoscopies, can be performed in the endoscopy room, the first factor to consider is the room’s location. If the room is in the unrestricted area of the facility, then procedures such as pain injections or examinations under anesthesia can be performed in this location; however, invasive surgical procedures cannot. In accordance with the Facility Guidelines Institute, a hand wash sink is required in an endoscopy room, independent of the room being in a semirestricted or unrestricted area.5 The presence of a sink prohibits the performance of surgical procedures traditionally performed in a room within the restricted area of a surgical suite. The Facility Guidelines Institute requires that an endoscopy room have two outdoor air exchanges and 15 total air changes per hour, whereas an OR must have four outdoor air exchanges and 20 minimum total air exchanges per hour.5 The temperature, humidity, and positive-pressure recommendations are the same for both an endoscopy room and an OR. If bronchoscopies are to be performed in this room, then negative pressure should be used to help prevent the spread of airborne contaminants.5 When a procedure performed in this room requires administration of nitrous oxide or other anesthetic gases, then a waste anesthesia gas evacuation system must be present.5 Sterile supplies needed for an endoscopic or other procedure may be opened in this room. Signage should be present on the door to the endoscopy room that states the attire requirements and limits entrance to authorized personnel only.5 AORN Journal
101
July 2011
Vol 94
BYRON BURLINGAME MS, BSN, RN, CNOR PERIOPERATIVE NURSING SPECIALIST AORN CENTER FOR NURSING PRACTICE References 1.
2.
f f
Recommended practices for traffic patterns in the perioperative practice setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2011:95-98. Facility Guidelines Institute. 3.9 Specific requirements for gastrointestinal endoscopy facilities. In: Guidelines for Design and Construction of Health Care Facilities. Washington, DC: American Society for Healthcare Engi-
neering (ASHE) of the American Hospital Association; 2010:275-282. 3. Personal protective equipment. In: Occupational safety and health standards: Bloodborne pathogens. Fed Regist. 1991;56(235):64004-64182. Codified at 29 CFR §1910.1030. http://www.osha.gov/pls/oshaweb/ owadisp.show_document?p_table⫽STANDARDS&p_ id⫽10051#1910.1030(d)(3). Accessed April 24, 2011. 4. Recommended practices for surgical attire. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2011:57-71. 5. Recommended practices for environmental cleaning in the perioperative setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2011:237-250.
Use and decontamination of case carts
QUESTION Can case carts be taken into an OR and left there during the procedure? If this is allowed, how should the cart be washed after each procedure, and can the extra supplies on the cart be returned to the supply storage area? ANSWER Case carts may be left in the OR during surgical procedures. If the cart is left in the OR during the procedure and it contains sterile supplies, a barrier should be present between the supplies and the patient. The barrier can be created by keeping the doors on the cart closed or keeping an impervious covering over the supplies. After the procedure, if the integrity of the sterile supply package is intact and the external packaging has not been contaminated, then the sterile supplies should be removed from the cart and returned to the sterile storage area.1-3 Contamination can occur when a person in the room touches the product with contaminated gloves or if blood, body fluids, or moisture is present on it. After removal of the sterile supplies, contaminated items used during the procedure should be placed on or in the cart. The cart and its contents should then be transported to the decontamination area. All the surfaces of the cart, including the wheels, should be decontaminated because the cart was in the OR during a surgical procedure.1,3 102
CLINICAL ISSUES
No 1
AORN Journal
Decontamination can be accomplished by using an Environmental Protection Agency-approved germicide and by placing the cart in a cart washer. If a cart washer is not available, then the cart should be washed manually. Impervious cart covers should be cleaned when contaminated and on a regularly scheduled basis by using a health care organization-approved disinfectant that is registered with the Environmental Protection Agency.4 When case carts are used as a back table, all of the sterile supplies should be removed from the cart before the initial drape is opened. If the supplies are not removed, the back table drape may become contaminated during the procedure as people reach in and out of the cart or the supplies in the cart may become contaminated by the back table drape particularly during the removal process. BYRON BURLINGAME MS, BSN, RN, CNOR PERIOPERATIVE NURSING SPECIALIST AORN CENTER FOR NURSING PRACTICE References 1.
2.
Recommended practices for sterilization in the perioperative practice setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2011:463-485. Recommended practices for selection and use of packaging systems for sterilization. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2011:453-462.
CLINICAL ISSUES
www.aornjournal.org
3.
ANSI/AAMI ST79:2006. In: Comprehensive Guide to Steam Sterilization and Sterility Assurance in Health Care Facilities. Arlington, VA: Association for the Advancement of Medical Instrumentation; 2010.
f f
Storage of sterile and unsterile supplies
QUESTION Should sterile items be stored separately from unsterile items? If this is not required, what are the requirements for storage of sterile and unsterile supplies? ANSWER Sterile and unsterile items may be stored in the same location if they are separated and if the proper storage conditions exist.1 Designing and maintaining adequate storage space and creating the proper conditions is often a challenge in health care organizations. When designing or determining methods and locations for storage, size requirements should be determined first, based on the items to be stored and building codes; then environmental, fire safety, and infection control recommendations must be considered. The Facility Guidelines Institute2 recommends that sufficient storage areas be designed and maintained to keep the exit corridors at the minimum width described in the fire codes (eg, 6 ft of clear and unobstructed surface).3 The corridors should be as free as possible of equipment and supplies. The storage area for the entire surgical suite should be not less than 300 sq ft (27.87 m2) or 50 sq ft (4.65 m2) per OR, whichever is larger. An OR designated for special services (eg, cardiac, orthopedic, neurosurgery) may require adjacent storage for larger pieces of equipment.2 The method of storage depends on the items to be stored and whether they are located within the semirestricted or restricted areas of the OR. Sterile storage in the semirestricted and restricted areas can be accomplished by several methods, including
wire racks, portable shelving systems,
4.
Recommended practices for environmental cleaning in the perioperative setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2011:237-250.
attached shelves, or cupboards.
If supplies are stored within the OR, then they must be covered at all times with an impervious barrier (eg, doors closed on cabinets, plastic sleeves/covers over wire racks). A wire rack with attached shelves increases visibility and accommodates the storage of larger items. Items may be stored on wire rack hooks or shelves or in bins through which the items can be seen. To hang items, use clips as hooks to attach the items and maintain package integrity. This method allows for a diverse configuration to accommodate items of different sizes. Automatic storage and inventory systems that may increase efficiencies in storage and inventory control also are available. These systems may require keypad entry and active removal or return of items. The automatic storage and inventory systems have front-locking, transparent thermoplastic doors for visibility of items. Shelves within the system can be configured to store nonsterile items separately from sterile items and allow for easy, clear access.2 When clean and sterile supplies must be stored together, it is best to separate them by storing the sterile items on the upper shelves and the clean items on the lower shelves. If nonsterile items are stored above sterile items, lint, dust, and other debris may fall onto the sterile items. Whatever storage method is used, attention should be given to how sterile items are handled and positioned to decrease the potential of breaching the packaging.1 Contamination may result when the packages are breached (eg, crushed, bent, compressed, punctured) because air and microorganisms are forced into the package contents. If sterile and AORN Journal
103
July 2011
Vol 94
unsterile items are packaged similarly, they should not be placed in close proximity on the shelves because this may increase the potential for inadvertently selecting the wrong item.1 AORN’s “Recommended practices for traffic patterns in the perioperative practice setting”1 and the Association for the Advancement of Medical Instrumentation Comprehensive Guide to Steam Sterilization and Sterility Assurance in Health Care Facilities4 state that access to the sterile storage area should be limited and separated from high-traffic areas. Decontamination and substerile areas are not appropriate locations for storage of sterile or clean items because of the risk of exposure to contaminants. Supplies, clean or sterile, should not be stored next to or under sinks, near exposed water or sewer pipes, or in locations where they may become wet. If sterile supplies become wet, the supplies must be considered unsterile, removed from storage, and disposed of or resterilized per facility and manufacturer policy. Items that are not intended to rest on the floor (eg, positioning devices) should be stored on appropriate shelves or racks. If an item that is not intended to rest on the floor is stored on the floor, then the item may inhibit adequate cleaning of the floor or the mopping action may contaminate the item.1 Storage of supplies on floors, windowsills, and areas other than designated shelving, counters, or carts should be avoided. Windowsill storage should be avoided because condensation caused by the differences in temperature between the inside and outside air may collect on sills. Closed or covered cabinets are recommended for the storage of seldom-used supplies to limit dust accumulation and decrease contact and handling.1 When the location of an OR suite requires storage of sterile supplies and clean supplies or equipment in the same room, the environmental recommendations for sterile supply storage should be followed. The Facility Guidelines Institute2 and the Association for the Advancement of Medical Instrumentation1 recommend storing sterile 104
CLINICAL ISSUES
No 1
AORN Journal
packages under environmentally controlled conditions that include a temperature of approximately 75° F (24° C), a maximum relative humidity of 70%, a positive air flow pressure in relation to adjacent areas, and 1,2,5 a minimum of four air exchanges per hour.
Fire Safety Many state fire code regulations require that sterile supplies be stored at least 18 inches from the ceiling. Ceiling clearance regulations that identify criteria required for proper functioning of the sprinkler system are based on standards established by the National Fire Protection Association.6 A local fire marshal should be consulted regarding storage heights and the distance from walls to ensure that local fire codes are followed. State health department and Centers for Medicare & Medicaid Services regulations may be more specific and the most stringent regulations should be followed. Infection Control When using a portable wire rack system, the cart should be placed at least 2 inches from outside walls. Adequate space is needed around sterile materials to allow for air circulation in the room and to prevent contact between sterile items and condensation that might form on the interior surfaces of outside walls. The bottom shelf of the cart should be at least 8 inches to 10 inches from the floor, and the bottom shelf of the rack should be solid or have a solid overlay placed on the wire shelf.1,2 The solid lower shelf is intended to protect items on the shelf from contamination that may occur during mopping.1 Sterile items that become wet when floors are cleaned are considered contaminated. The impervious covers, shelves, or carts used for sterile or unsterile storage should be maintained in a clean and dry condition. Cleaning should be performed on a regularly scheduled basis and should be accomplished by using a health care organization approved dis-
CLINICAL ISSUES infectant that is registered with the Environmental Protection Agency.7 BYRON BURLINGAME MS, BSN, RN, CNOR PERIOPERATIVE NURSING SPECIALIST AORN CENTER FOR NURSING PRACTICE
www.aornjournal.org
3. 4.
5.
References 1. ANSI/AAMI ST79:2006. In: Comprehensive Guide to Steam Sterilization and Sterility Assurance in Health Care Facilities. Arlington, VA: Association for the Advancement of Medical Instrumentation; 2010:24, 29. 2. Facility Guidelines Institute. Part 2 Hospitals. In: Guidelines for Design and Construction of Health Care Facilities. Washington, DC: American Society for Healthcare
6.
7.
Engineering (ASHE) of the American Hospital Association; 2010:45-214. NFPA 101: Life Safety Code. Quincy, MA: National Fire Protection Association; 2009. Recommended practices for traffic patterns in the perioperative practice setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2011:95-98. Recommended practices for a safe environment of care. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2011:215-236. Installation requirements. In: NFPA 13: Standard for the Installation of Sprinkler Systems. Quincy, MA: National Fire Protection Association; 2011:13-51. Recommended practices for environmental cleaning in the perioperative setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2011:237-250.
The author of this column has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
Bring Your Clinical Questions to AORN’s Team of Perioperative Nurse Specialists When you find yourself puzzled by a clinical issue, remember that AORN’s perioperative nursing specialists are just a telephone call away. For answers to your questions, contact the Center for Nursing Practice at (800) 755-2676. AORN’s Perioperative Standards and Recommended Practices is an excellent resource for perioperative nurses. Purchase your copy at www.aornbookstore.org.
AORN Journal
105
LEARNER EVALUATION CONTINUING EDUCATION PROGRAM
1.9
Clinical Issues
www.aorn.org/CE
T
his evaluation is used to determine the extent to which this continuing education program met your learning needs. The evaluation is printed here for your convenience. To receive continuing education credit, you must complete the Learner Evaluation online at http://www.aorn.org/CE. Rate the items as described below. PURPOSE/GOAL To educate perioperative nurses about providing safe nursing care throughout the perioperative continuum. OBJECTIVES To what extent were the following objectives of this continuing education program achieved? 1. Discuss practices that could jeopardize safety in the perioperative area. Low 1. 2. 3. 4. 5. High 2. Discuss common areas of concern that relate to perioperative best practices. Low 1. 2. 3. 4. 5. High 3. Describe implementation of evidence-based practice in relation to perioperative nursing care. Low 1. 2. 3. 4. 5. High CONTENT 4. To what extent did this article increase your knowledge of the subject matter? Low 1. 2. 3. 4. 5. High 5. To what extent were your individual objectives met? Low 1. 2. 3. 4. 5. High
6. Will you be able to use the information from this article in your work setting? 1. Yes 2. No 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 teach others about the purpose of the needed change. 3. I do not have management support to make a change. 4. Other: 8. Our accrediting body requires that we verify the time you needed to complete the 1.9 continuing education contact hour (114-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: #11512; Session: #0001 Fee: Members $9.50 Nonmembers $19 The deadline for this program is July 31, 2014. Each applicant who successfully completes this program can immediately print a certificate of completion.
106
AORN Journal ●
July 2011
Vol 94
No 1
© AORN, Inc, 2011