- Email: [email protected]
Clinical Issues—March 2016
CONTINUING EDUCATION
Clinical Issues
1.1
www.aornjournal.org/content/cme
BYRON L. BURLINGAME, MS, RN, CNOR; KERRIE CHAMBERS, MS, RN, CNOR, CNS-CP 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.aornjournal.org/content/cme. 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.
Event: #16508 Session: #0001 Fee: For current pricing, please go to: http://www.aornjournal .org/content/cme. The CE contact hours for this article expire March 31, 2019. Pricing is subject to change.
Purpose/Goal To provide the learner with knowledge of AORN’s guidelines related to increasing ambient room temperature and clinical alarm management.
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.
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.
Conflict-of-Interest Disclosures Byron L. Burlingame, MS, RN, CNOR, and Kerrie Chambers, MS, RN, CNOR, CNS-CP, have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article. The behavioral objectives for this program were created by Helen Starbuck Pashley, MA, BSN, CNOR, clinical editor, with consultation from Susan Bakewell, MS, RN-BC, director, Perioperative Education. Ms Starbuck Pashley and Ms Bakewell have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article.
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.
http://dx.doi.org/10.1016/j.aorn.2016.01.005 ª AORN, Inc, 2016
338 j AORN Journal
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CLINICAL ISSUES
1.1
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THIS MONTH Increasing ambient room temperature Key words: OR temperature, core temperature, unplanned hypothermia, ambient room temperature, thermoregulation. Clinical alarm management Key words: alarm fatigue, clinical alarms, alert alarms.
Increasing ambient room temperature QUESTION: Is it acceptable to increase the OR temperature above the recommended range to maintain the patient’s temperature?
ANSWER: The OR temperature may be increased above the recommended temperature setting of 24 C (75.2 F) as one method of maintaining the patient’s core temperature. Heating, ventilating, and air-conditioning systems are designed to maintain OR temperature in a range of 20 C to 24 C (68 F to 75.2 F);1 however, room temperature may be intentionally increased to meet individual patient needs.2 AORN’s “Guideline for prevention of unplanned patient hypothermia”3 and other
www.aornjournal.org
evidence recommend increasing ambient room temperature as one intervention to maintain patient normothermia (ie, 36 C to 38 C [96.8 F to 100.4 F]).4-10 Neonates, infants, trauma patients, and patients with extensive burns may require ambient room temperature to be raised to prevent inadvertent hypothermia.3,4,7 Increasing ambient room temperature also may be used in combination with other means, such as prewarming and active or passive warming measures.3 Cassey et al5 evaluated the effect of increasing ambient room temperature on pediatric patients in a randomized controlled trial. Study criteria included a group (n ¼ 60) of pediatric patients ranging from six weeks to 15 years of age undergoing nonemergent surgery lasting more than 20 minutes.
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The researchers randomly divided the patients into two groups, placing the control group in an induction room where the temperature was 21 C (69.8 F) and the experimental group in an induction room where the temperature was 26 C (78.8 F). The patients remained in the induction rooms for 30 to 40 minutes before surgery, and then personnel moved them into ORs where temperatures were the same as those of the induction rooms. All patients received either inhaled induction general anesthesia or a combination of general and caudal anesthesia. Tympanic membrane temperatures were measured at multiple intervals during the study. The researchers found that regardless of age, children cooled faster in an OR with a temperature of 21 C (69.8 F). They also concluded that when children remained in a warmer room of 26 C (78.8 F) for a longer period of time before induction, their core temperature was less likely to decrease when intubated. Ozer et al6 also studied the effect of increasing the ambient OR temperature on patients. The study included male patients (n ¼ 90) between the ages of 18 and 60 years, randomly divided and placed in ORs with temperatures of 20 C to 22 C (68 F to 71.6 F) or 23 C to 25 C (73.4 F to 77 F). The researchers further subdivided the groups according to anesthesia types (ie, general anesthesia, epidural anesthesia, femoral block). All patients had temperature probes measuring tympanic membrane, peripheral, mean skin, and mean body temperature. The researchers found that when OR temperature was 20 C to 22 C (68 F to 71.6 F), mean skin temperature was significantly lower (P < 0.05) for male patients undergoing general anesthesia than for those undergoing femoral block. The researchers, when evaluating the effect of the room temperature, also found mean skin temperature and mean body temperature to be significantly lower (P < .05) for patients undergoing general anesthesia after 5, 10, 15, 20, 60, and 90 minutes in rooms 20 C to 22 C (68 F to 71.6 F) or 23 C to 25 C (73.4 F to 77 F), compared with temperatures of patients receiving epidural anesthesia or femoral block. The perioperative RN should conduct a preoperative assessment and collaborate with the interdisciplinary team to identify individual patient needs and factors that could contribute to unplanned patient hypothermia.3,4,7 Based on the preoperative assessment, the perioperative team should determine whether the ambient room temperature should be increased or whether additional measures, such as prewarming the patient and active or passive warming measures, need to be implemented.3
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Kerrie Chambers, MS, RN, CNOR, CNS-CP, was a perioperative practice specialist in the Nursing Department at AORN, Inc, Denver, CO at the time this article was written.
References 1. Facility Guidelines Institute, US Department of Health and Human Services, American Society for Healthcare Engineering. Guidelines for Design and Construction of Hospitals and Outpatient Facilities. Chicago, IL: American Society for Healthcare Engineering of the American Hospital Association; 2014. 2. Guideline for safe environment of care, Part 2. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2016:263-288. 3. Guideline for prevention of unplanned patient hypothermia. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2016:531-554. 4. Deren ME, Machan JT, DiGiovanni CW, Ehrlich MG, Gillerman RG. Prewarming operating rooms for prevention of intraoperative hypothermia during total knee and hip arthroplasties. J Arthroplasty. 2011;26(8):1380-1386. 5. Cassey JG, King RA, Armstrong P. Is there thermal benefit from preoperative warming in children? Paediatr Anaesth. 2010;20(1): 63-71. 6. Ozer AB, Tosun F, Demirel I, Unlu S, Bayar MK, Erhan OL. The effects of anesthetic technique and ambient temperature on thermoregulation in lower extremity surgery. J Anesth. 2013;27(4): 528-534. 7. Cheng KW, Wang CH, Chen CL, et al. Decreased fresh gas flow cannot compensate for an increased operating room temperature in maintaining body temperature during donor hepatectomy for living liver donor hepatectomy. Transplant Proc. 2010;42(3): 703-704. 8. Torossian A. Thermal management during anaesthesia and thermoregulation standards for the prevention of inadvertent perioperative hypothermia. Best Pract Res Clin Anaesthesiol. 2008; 22(4):659-668. 9. Mitchell JC, D’Angelo M. Implications of hypothermia in procedural areas. J Radiol Nurs. 2008;27(2):70-73. 10. Hooper VD, Chard R, Clifford T, et al. ASPAN’s evidence-based clinical practice guideline for the promotion of perioperative normothermia: second edition. J Perianesth Nurs. 2010;25(6): 346-365.
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March 2016, Vol. 103, No. 3
Clinical Issues
Clinical alarm management QUESTION: We have been asked to develop a policy and procedure on clinical alarms for the intraoperative area because the housewide policy and procedure does not address the unique conditions found in the OR. What are some of the considerations that should be addressed in the policy?
ANSWER: The intraoperative area should have a department-specific policy on clinical alarms because the patient in the OR is never left alone, as patients are in the intensive care unit or other areas of the facility. See the sidebar on page 343 for examples of policy statements. The OR also is unique because the responsibility for an alarm may fall to either all members of the team or a specific team member. In addition, the OR has equipment that is used only in the OR (eg, pneumatic tourniquets, electrosurgical units), and some of this equipment audibly alerts the operator and everyone else in the room when it is functioning. These are considered functional alerts and are not defined as alarms, but they contribute to the background noise and must be considered when setting alarm volumes. These functional audible alerts are not included in this discussion of alarms. The alarm policy and procedure should be authored by an interdisciplinary team that includes
perioperative RNs, clinical engineers (eg, biomedical personnel), surgeons, anesthesia professionals, risk managers, quality improvement professionals, and representatives from other disciplines as needed.
The team should define the different types of alarms that are present in the intraoperative environment as a basis for creating the policy and procedure. The OR uses equipment with both clinical and alert alarms. The clinical alarms (eg, cardiac monitor, ventilator, insufflator gas alarm) are patient specific and alert personnel to specific situations. The second type of alarm is a system-failure alert, which is often associated with medical gas systems, blood bank refrigerators, ethylene oxide monitors, or water-treatment systems. An alert alarm is connected to a system, and it alerts personnel to system failures that may affect multiple patients and to other situations that may affect the safety of personnel working nearby.1 When
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evidence is reviewed, these types of alarm are labeled as alerts instead of alarms.2 After defining the types of alarms, the team should complete an inventory of the clinical and alert alarms in the perioperative environment.1,3 This inventory should be reviewed and updated periodically (eg, annually) to facilitate incorporating new equipment. The members of the team most likely to conduct the inventory are the perioperative RN, anesthesia representative, and the clinical engineers. Completing an inventory also assists with identifying the equipment that has alarms. After completing the inventory of equipment with alarms, the multidisciplinary team can use this information to assist in determining the level of risk to the patient if the alarm signal is ignored or if it malfunctions. The assignment of the level of risk also assists with determining whether specific alarm signals have a clinical purpose or unnecessarily contribute to alarm noise and alarm fatigue. The results of the inventory and the scores, which the team assigns to the alarms indicating associated risk to the patient, may be represented in the policy and procedure as a table with a rating applied to each alarm and a key for the ratings. Such a table provides guidance to personnel and evidence for a surveyor that these steps have been accomplished. For example, using a scale of 1 to 5, with 5 as the highest risk, the ventilator alarm would have an assigned risk level of 5 because if the ventilator is not working, the risk of harm to the patient is high and the alarm source will need to be addressed instantly. An example of a level 3 risk is the patient warming unit. This source would be assigned a 3 because harm to the patient usually does not happen immediately, but it will occur over time. The policy and procedure should establish who is responsible for responding to and rectifying the causes of the various alarms. Some alarms may be the responsibility of a specific caregiver and other alarms maybe the responsibility of the team. For example, the cardiac monitor is primarily the responsibility of the anesthesia professional, but the entire perioperative team should be aware of the reason for the alarm so they can assist the anesthesia professional, if necessary, to rectify the situation. When the cardiac monitor alarms, the RN circulator should assess the situation, and he or she will need to assist the anesthesia professional to remedy the issue. Another example may be that the insufflator’s high-pressure alarm has been activated. The team at the sterile field should check for contributing factors (eg, the assistant leaning on the
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patient’s abdomen), and the RN circulator should check to be certain the tubing from the insufflator to the sterile field is not kinked. When designating the personnel responsible for responding to a specific alarm, the policy and procedure should use terms such as “the person monitoring the patient” instead of “the anesthesia care provider” or “the perioperative RN” because, for example, the person doing the monitoring may be an RN (eg, during moderate sedation/analgesia and local procedures), and if the responsibility was assigned to the anesthesia care provider, the RN monitoring the patient might not think it is his or her responsibility.3 There is no benchmark information to use when determining the person or persons responsible for responding to an alarm. An example of an alarm that is usually the responsibility of the anesthesia professional in the room is the cardiac monitor, but this alarm may be the responsibility of the circulator if an anesthesia professional is not in the room. Another example of an alarm that is under the control of different people in different facilities is a tourniquet. In some facilities the anesthesia professional is responsible for investigating a tourniquet alarm, but in other facilities it is the responsibility of the RN circulator. For alarms with default settings, the team should establish policy and procedure criteria for when the default setting may be changed and who may make the change. A default setting is a setting that is automatically reset every time the device is turned off (eg, alarm volume, upper or lower rate limits). The alarm volume should be set at a level that enables the alarm to be heard over competing noises. For example, the alarms in an orthopedic room are set at a higher volume than in a general surgery room because of the noise generated by power equipment used during these procedures.4 The criteria to change the alarm volume may differ when a caregiver is near the patient, but the alarm must still be able to be heard above competing room noises. The other default settings include high or low rate limits. An example of a device with an upper or lower rate limit is the cardiac monitor. The policy and procedure should include criteria for adjusting the limits of this monitor if the alarm is continuously being activated at the default settings. For example, when the default setting for the high rate alarm of the cardiac monitor is set at 100 beats per minute, but the patient has a consistent heart rate of 110 beats per minute causing continuous activation of the high rate alarm, the anesthesia professional may set the high rate alarm to 120 because the criteria for continuous activation
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has been met. This change is clinically indicated and should be instituted to avoid false alarms. The altered setting should be reevaluated every time the parameter (eg, heart rate) is assessed. A method to document the alarm criteria is to add a column titled Criteria for changing defaults to the previously mentioned table. The criteria for who may change the default setting on the alarm should be very restrictive to help eliminate the possibility of one person changing the settings and the person who is caring for the patient not being aware of the change. For example, only the anesthesia professional should make changes to the alarm parameters on the ventilator. Another criteria that should be established in the policy and procedure is when an alarm can be inactivated and by whom. Inactivation can be achieved by disabling the alarm; disabling the alarm refers to inactivating the alarm, usually by using the on/off switch and/or setting the volume control switch to zero. Another example of disabling an alarm is inactivating it by disconnecting or cutting the wires that lead from the indicator to the alarm component of the device. When an alarm is disabled, it will not be reset if the device is turned off. As a result, only the clinical engineers should be able to disable an alarm and, if this occurs, the engineer should place a label on the equipment stating the alarm has been disabled. The policy should establish a procedure for communication to be used when the default setting has been changed or the alarm has been inactivated. This communication may include posting a notice on the device, stating that the default setting has been altered or the alarm has been inactivated.1 Posting this visible communication may help remind the primary caregiver that the default setting has changed and he or she should reevaluate the change after the next assessment of the physiological parameter being measured by the alarm. To use a prior example: the anesthesia professional should evaluate the upper limit of the cardiac monitor the next time he or she assesses the patient’s heart rate. The appropriate frequency for checking individual alarm signals for accurate settings, operation, and detectability should also be included in the policy and procedure.1 The majority of items in the perioperative setting should undergo alarm checks before every procedure. This is especially important for highrisk alarms, such as those on the anesthesia machine. During this check, it can also be determined whether the default range settings, such as the high or low values, have been changed or if the alarm volume has been increased or
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Examples of Perioperative Alarm Policy Statements
An inventory of all alarms will be conducted annually by the multidisciplinary alarm-management team. Equipment that is purchased and is not included on the alarm inventory will be added when it is initially tested by the clinical engineering department. No clinical alarm may be disabled without meeting the criteria determined by the alarm-management team. The default settings on the alarm may be altered only after an assessment is performed and it is determined that the patient’s current [insert the parameter being monitored] is outside the default setting. The altered setting should be reevaluated every time the parameter is assessed. The person responsible for responding to the alarm is the only person who can change the alarm default settings. The direct caregiver or the person responsible for responding to the alarm may turn the alarm off only if the person is near the patient at all times. When an alarm default parameter has been changed or an alarm has been disabled, an alarm default setting change form will be completed and will be attached to the monitor in a location that is clearly visible to the caregiver caring for the patient. Changes in the default settings will be communicated during changes of personnel. The alarms on the anesthesia machine, vital signs monitor, and [add in all other equipment that the multidisciplinary team determines should be included] will be checked before every procedure. All alarms will be returned to the default settings between procedures. All audible alarms will be set at mid-point volume between procedures. The alarms on all patient-related equipment will be tested when purchased and at least daily, unless the device is on the list of life-saving equipment (eg, anesthesia ventilator), which requires testing before each use. The person discovering a malfunctioning alarm will remove the piece of equipment from service as soon as it is safe to do so. The person discovering a malfunctioning alarm will complete a “Do not use tag” and attach it to the item. The device with the malfunctioning alarm will then be sent to the [insert the title of the correct location in facility] for repair. Alarm-management policy and procedure will be included in educational offerings on all new equipment and annually on all rarely used equipment and during the equipment safety review. The risk manager or designee will complete monthly rounds to review compliance with the alarm policy and procedure and measure response times if an alarm is activated during these rounds.
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Clinical Issues
decreased. The frequency of testing should be based on the manufacturer’s instructions for use and the level of risk assigned by the multidisciplinary team when the inventory is completed. The policy also should contain a section dedicated to the educational requirements for the perioperative team. The entire team should be educated on all of the various clinical and alert alarms, including what they mean and how to appropriately respond to them.1 The education may be presented in a question-and-answer format (eg, who, when, what, why, how) regarding alarm management. Education should include informing the perioperative team who is responsible for responding to the alarm, who can change the default settings, and who can inactivate each type of alarm (eg, the anesthesia care provider is responsible for the cardiac monitor alarms, the circulator is responsible for the alarm on the tourniquet); when to respond to an alarm and, if two alarms are occurring simultaneously, which alarm to respond to first; that the decision about which alarm to respond to first should be based on the priority ratings that have been assigned by the multidisciplinary team; that any team member may be called on to assist the designated person responsible, so each team member needs to know what to do during that situation; what occurrence is causing activation of the alarm (eg, the team should know that if the tourniquet alarms at the end of the set time limit, there needs to be a collaborative discussion between the members of the perioperative team to determine actions that should be taken); why the alarm is present, including the physiological implications of not responding to the alarm; and what the alarm indicates and how to correct the situation. In the case of an insufflator alarm, if the high-pressure alarm is activated, the person responding to the alarm needs to determine the cause (eg, the team members at the sterile field are leaning on the patient’s abdomen, there is a kink in the tubing system) and then correct the situation. After the perioperative team has received training, educators should conduct a follow-up evaluation of actual performance and competency verification to validate that personnel have put the education into action and the actions taken in response to alarms are consistent for every member of the team. One way to accomplish this is to conduct rounds and ask team members, “What would you do if the insufflator alarm sounded and you were in the middle of a procedure?” Any person who answers incorrectly should receive more education as soon as possible.
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References Byron L. Burlingame, MS, RN, CNOR, is a senior perioperative practice specialist in the Nursing Department at AORN, Inc, Denver, CO.
1. Guideline for safe environment of care, Part 1. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2016: 237-262. 2. Lukasewicz CL, Mattox EA. Understanding clinical alarm safety. Crit Care Nurse. 2015;35(4):45-57. 3. The Alarm Safety Handbook: Strategies, Tools, and Guidance. Plymouth Meeting, PA: ECRI Institute; 2014. 4. Position statements. AORN, Inc. https://www.aorn.org/guidelines/ clinical-resources/position-statements. Accessed January 12, 2016.
TM
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LEARNER EVALUATION
Continuing Education: Clinical Issues 1.1
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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 online Learner Evaluation at http://www .aornjournal.org/content/cme. Rate the items as described below.
PURPOSE/GOAL
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 1.1 continuing education contact hour (66-minute) program: _______________
To provide the learner with knowledge of AORN’s guidelines related to increasing ambient room temperature and clinical alarm management.
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.
3.
Discuss common areas of concern that relate to perioperative best practices. Low 1. 2. 3. 4. 5. High Describe implementation of evidence-based practice in relation to perioperative nursing care. Low 1. 2. 3. 4. 5. High
CONTENT 4.
5.
To what extent did this article increase your knowledge of the subject matter? Low 1. 2. 3. 4. 5. High To what extent were your individual objectives met? Low 1. 2. 3. 4. 5. High
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AORN Journal j 345
Clinical Issues
1.1
www.aornjournal.org/content/cme
BYRON L. BURLINGAME, MS, RN, CNOR; KERRIE CHAMBERS, MS, RN, CNOR, CNS-CP 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.aornjournal.org/content/cme. 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.
Event: #16508 Session: #0001 Fee: For current pricing, please go to: http://www.aornjournal .org/content/cme. The CE contact hours for this article expire March 31, 2019. Pricing is subject to change.
Purpose/Goal To provide the learner with knowledge of AORN’s guidelines related to increasing ambient room temperature and clinical alarm management.
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.
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.
Conflict-of-Interest Disclosures Byron L. Burlingame, MS, RN, CNOR, and Kerrie Chambers, MS, RN, CNOR, CNS-CP, have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article. The behavioral objectives for this program were created by Helen Starbuck Pashley, MA, BSN, CNOR, clinical editor, with consultation from Susan Bakewell, MS, RN-BC, director, Perioperative Education. Ms Starbuck Pashley and Ms Bakewell have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article.
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.
http://dx.doi.org/10.1016/j.aorn.2016.01.005 ª AORN, Inc, 2016
338 j AORN Journal
www.aornjournal.org
CLINICAL ISSUES
1.1
www.aornjournal.org/content/cme
THIS MONTH Increasing ambient room temperature Key words: OR temperature, core temperature, unplanned hypothermia, ambient room temperature, thermoregulation. Clinical alarm management Key words: alarm fatigue, clinical alarms, alert alarms.
Increasing ambient room temperature QUESTION: Is it acceptable to increase the OR temperature above the recommended range to maintain the patient’s temperature?
ANSWER: The OR temperature may be increased above the recommended temperature setting of 24 C (75.2 F) as one method of maintaining the patient’s core temperature. Heating, ventilating, and air-conditioning systems are designed to maintain OR temperature in a range of 20 C to 24 C (68 F to 75.2 F);1 however, room temperature may be intentionally increased to meet individual patient needs.2 AORN’s “Guideline for prevention of unplanned patient hypothermia”3 and other
www.aornjournal.org
evidence recommend increasing ambient room temperature as one intervention to maintain patient normothermia (ie, 36 C to 38 C [96.8 F to 100.4 F]).4-10 Neonates, infants, trauma patients, and patients with extensive burns may require ambient room temperature to be raised to prevent inadvertent hypothermia.3,4,7 Increasing ambient room temperature also may be used in combination with other means, such as prewarming and active or passive warming measures.3 Cassey et al5 evaluated the effect of increasing ambient room temperature on pediatric patients in a randomized controlled trial. Study criteria included a group (n ¼ 60) of pediatric patients ranging from six weeks to 15 years of age undergoing nonemergent surgery lasting more than 20 minutes.
AORN Journal j 339
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The researchers randomly divided the patients into two groups, placing the control group in an induction room where the temperature was 21 C (69.8 F) and the experimental group in an induction room where the temperature was 26 C (78.8 F). The patients remained in the induction rooms for 30 to 40 minutes before surgery, and then personnel moved them into ORs where temperatures were the same as those of the induction rooms. All patients received either inhaled induction general anesthesia or a combination of general and caudal anesthesia. Tympanic membrane temperatures were measured at multiple intervals during the study. The researchers found that regardless of age, children cooled faster in an OR with a temperature of 21 C (69.8 F). They also concluded that when children remained in a warmer room of 26 C (78.8 F) for a longer period of time before induction, their core temperature was less likely to decrease when intubated. Ozer et al6 also studied the effect of increasing the ambient OR temperature on patients. The study included male patients (n ¼ 90) between the ages of 18 and 60 years, randomly divided and placed in ORs with temperatures of 20 C to 22 C (68 F to 71.6 F) or 23 C to 25 C (73.4 F to 77 F). The researchers further subdivided the groups according to anesthesia types (ie, general anesthesia, epidural anesthesia, femoral block). All patients had temperature probes measuring tympanic membrane, peripheral, mean skin, and mean body temperature. The researchers found that when OR temperature was 20 C to 22 C (68 F to 71.6 F), mean skin temperature was significantly lower (P < 0.05) for male patients undergoing general anesthesia than for those undergoing femoral block. The researchers, when evaluating the effect of the room temperature, also found mean skin temperature and mean body temperature to be significantly lower (P < .05) for patients undergoing general anesthesia after 5, 10, 15, 20, 60, and 90 minutes in rooms 20 C to 22 C (68 F to 71.6 F) or 23 C to 25 C (73.4 F to 77 F), compared with temperatures of patients receiving epidural anesthesia or femoral block. The perioperative RN should conduct a preoperative assessment and collaborate with the interdisciplinary team to identify individual patient needs and factors that could contribute to unplanned patient hypothermia.3,4,7 Based on the preoperative assessment, the perioperative team should determine whether the ambient room temperature should be increased or whether additional measures, such as prewarming the patient and active or passive warming measures, need to be implemented.3
340 j AORN Journal
March 2016, Vol. 103, No. 3
Kerrie Chambers, MS, RN, CNOR, CNS-CP, was a perioperative practice specialist in the Nursing Department at AORN, Inc, Denver, CO at the time this article was written.
References 1. Facility Guidelines Institute, US Department of Health and Human Services, American Society for Healthcare Engineering. Guidelines for Design and Construction of Hospitals and Outpatient Facilities. Chicago, IL: American Society for Healthcare Engineering of the American Hospital Association; 2014. 2. Guideline for safe environment of care, Part 2. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2016:263-288. 3. Guideline for prevention of unplanned patient hypothermia. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2016:531-554. 4. Deren ME, Machan JT, DiGiovanni CW, Ehrlich MG, Gillerman RG. Prewarming operating rooms for prevention of intraoperative hypothermia during total knee and hip arthroplasties. J Arthroplasty. 2011;26(8):1380-1386. 5. Cassey JG, King RA, Armstrong P. Is there thermal benefit from preoperative warming in children? Paediatr Anaesth. 2010;20(1): 63-71. 6. Ozer AB, Tosun F, Demirel I, Unlu S, Bayar MK, Erhan OL. The effects of anesthetic technique and ambient temperature on thermoregulation in lower extremity surgery. J Anesth. 2013;27(4): 528-534. 7. Cheng KW, Wang CH, Chen CL, et al. Decreased fresh gas flow cannot compensate for an increased operating room temperature in maintaining body temperature during donor hepatectomy for living liver donor hepatectomy. Transplant Proc. 2010;42(3): 703-704. 8. Torossian A. Thermal management during anaesthesia and thermoregulation standards for the prevention of inadvertent perioperative hypothermia. Best Pract Res Clin Anaesthesiol. 2008; 22(4):659-668. 9. Mitchell JC, D’Angelo M. Implications of hypothermia in procedural areas. J Radiol Nurs. 2008;27(2):70-73. 10. Hooper VD, Chard R, Clifford T, et al. ASPAN’s evidence-based clinical practice guideline for the promotion of perioperative normothermia: second edition. J Perianesth Nurs. 2010;25(6): 346-365.
www.aornjournal.org
March 2016, Vol. 103, No. 3
Clinical Issues
Clinical alarm management QUESTION: We have been asked to develop a policy and procedure on clinical alarms for the intraoperative area because the housewide policy and procedure does not address the unique conditions found in the OR. What are some of the considerations that should be addressed in the policy?
ANSWER: The intraoperative area should have a department-specific policy on clinical alarms because the patient in the OR is never left alone, as patients are in the intensive care unit or other areas of the facility. See the sidebar on page 343 for examples of policy statements. The OR also is unique because the responsibility for an alarm may fall to either all members of the team or a specific team member. In addition, the OR has equipment that is used only in the OR (eg, pneumatic tourniquets, electrosurgical units), and some of this equipment audibly alerts the operator and everyone else in the room when it is functioning. These are considered functional alerts and are not defined as alarms, but they contribute to the background noise and must be considered when setting alarm volumes. These functional audible alerts are not included in this discussion of alarms. The alarm policy and procedure should be authored by an interdisciplinary team that includes
perioperative RNs, clinical engineers (eg, biomedical personnel), surgeons, anesthesia professionals, risk managers, quality improvement professionals, and representatives from other disciplines as needed.
The team should define the different types of alarms that are present in the intraoperative environment as a basis for creating the policy and procedure. The OR uses equipment with both clinical and alert alarms. The clinical alarms (eg, cardiac monitor, ventilator, insufflator gas alarm) are patient specific and alert personnel to specific situations. The second type of alarm is a system-failure alert, which is often associated with medical gas systems, blood bank refrigerators, ethylene oxide monitors, or water-treatment systems. An alert alarm is connected to a system, and it alerts personnel to system failures that may affect multiple patients and to other situations that may affect the safety of personnel working nearby.1 When
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evidence is reviewed, these types of alarm are labeled as alerts instead of alarms.2 After defining the types of alarms, the team should complete an inventory of the clinical and alert alarms in the perioperative environment.1,3 This inventory should be reviewed and updated periodically (eg, annually) to facilitate incorporating new equipment. The members of the team most likely to conduct the inventory are the perioperative RN, anesthesia representative, and the clinical engineers. Completing an inventory also assists with identifying the equipment that has alarms. After completing the inventory of equipment with alarms, the multidisciplinary team can use this information to assist in determining the level of risk to the patient if the alarm signal is ignored or if it malfunctions. The assignment of the level of risk also assists with determining whether specific alarm signals have a clinical purpose or unnecessarily contribute to alarm noise and alarm fatigue. The results of the inventory and the scores, which the team assigns to the alarms indicating associated risk to the patient, may be represented in the policy and procedure as a table with a rating applied to each alarm and a key for the ratings. Such a table provides guidance to personnel and evidence for a surveyor that these steps have been accomplished. For example, using a scale of 1 to 5, with 5 as the highest risk, the ventilator alarm would have an assigned risk level of 5 because if the ventilator is not working, the risk of harm to the patient is high and the alarm source will need to be addressed instantly. An example of a level 3 risk is the patient warming unit. This source would be assigned a 3 because harm to the patient usually does not happen immediately, but it will occur over time. The policy and procedure should establish who is responsible for responding to and rectifying the causes of the various alarms. Some alarms may be the responsibility of a specific caregiver and other alarms maybe the responsibility of the team. For example, the cardiac monitor is primarily the responsibility of the anesthesia professional, but the entire perioperative team should be aware of the reason for the alarm so they can assist the anesthesia professional, if necessary, to rectify the situation. When the cardiac monitor alarms, the RN circulator should assess the situation, and he or she will need to assist the anesthesia professional to remedy the issue. Another example may be that the insufflator’s high-pressure alarm has been activated. The team at the sterile field should check for contributing factors (eg, the assistant leaning on the
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patient’s abdomen), and the RN circulator should check to be certain the tubing from the insufflator to the sterile field is not kinked. When designating the personnel responsible for responding to a specific alarm, the policy and procedure should use terms such as “the person monitoring the patient” instead of “the anesthesia care provider” or “the perioperative RN” because, for example, the person doing the monitoring may be an RN (eg, during moderate sedation/analgesia and local procedures), and if the responsibility was assigned to the anesthesia care provider, the RN monitoring the patient might not think it is his or her responsibility.3 There is no benchmark information to use when determining the person or persons responsible for responding to an alarm. An example of an alarm that is usually the responsibility of the anesthesia professional in the room is the cardiac monitor, but this alarm may be the responsibility of the circulator if an anesthesia professional is not in the room. Another example of an alarm that is under the control of different people in different facilities is a tourniquet. In some facilities the anesthesia professional is responsible for investigating a tourniquet alarm, but in other facilities it is the responsibility of the RN circulator. For alarms with default settings, the team should establish policy and procedure criteria for when the default setting may be changed and who may make the change. A default setting is a setting that is automatically reset every time the device is turned off (eg, alarm volume, upper or lower rate limits). The alarm volume should be set at a level that enables the alarm to be heard over competing noises. For example, the alarms in an orthopedic room are set at a higher volume than in a general surgery room because of the noise generated by power equipment used during these procedures.4 The criteria to change the alarm volume may differ when a caregiver is near the patient, but the alarm must still be able to be heard above competing room noises. The other default settings include high or low rate limits. An example of a device with an upper or lower rate limit is the cardiac monitor. The policy and procedure should include criteria for adjusting the limits of this monitor if the alarm is continuously being activated at the default settings. For example, when the default setting for the high rate alarm of the cardiac monitor is set at 100 beats per minute, but the patient has a consistent heart rate of 110 beats per minute causing continuous activation of the high rate alarm, the anesthesia professional may set the high rate alarm to 120 because the criteria for continuous activation
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has been met. This change is clinically indicated and should be instituted to avoid false alarms. The altered setting should be reevaluated every time the parameter (eg, heart rate) is assessed. A method to document the alarm criteria is to add a column titled Criteria for changing defaults to the previously mentioned table. The criteria for who may change the default setting on the alarm should be very restrictive to help eliminate the possibility of one person changing the settings and the person who is caring for the patient not being aware of the change. For example, only the anesthesia professional should make changes to the alarm parameters on the ventilator. Another criteria that should be established in the policy and procedure is when an alarm can be inactivated and by whom. Inactivation can be achieved by disabling the alarm; disabling the alarm refers to inactivating the alarm, usually by using the on/off switch and/or setting the volume control switch to zero. Another example of disabling an alarm is inactivating it by disconnecting or cutting the wires that lead from the indicator to the alarm component of the device. When an alarm is disabled, it will not be reset if the device is turned off. As a result, only the clinical engineers should be able to disable an alarm and, if this occurs, the engineer should place a label on the equipment stating the alarm has been disabled. The policy should establish a procedure for communication to be used when the default setting has been changed or the alarm has been inactivated. This communication may include posting a notice on the device, stating that the default setting has been altered or the alarm has been inactivated.1 Posting this visible communication may help remind the primary caregiver that the default setting has changed and he or she should reevaluate the change after the next assessment of the physiological parameter being measured by the alarm. To use a prior example: the anesthesia professional should evaluate the upper limit of the cardiac monitor the next time he or she assesses the patient’s heart rate. The appropriate frequency for checking individual alarm signals for accurate settings, operation, and detectability should also be included in the policy and procedure.1 The majority of items in the perioperative setting should undergo alarm checks before every procedure. This is especially important for highrisk alarms, such as those on the anesthesia machine. During this check, it can also be determined whether the default range settings, such as the high or low values, have been changed or if the alarm volume has been increased or
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March 2016, Vol. 103, No. 3
Examples of Perioperative Alarm Policy Statements
An inventory of all alarms will be conducted annually by the multidisciplinary alarm-management team. Equipment that is purchased and is not included on the alarm inventory will be added when it is initially tested by the clinical engineering department. No clinical alarm may be disabled without meeting the criteria determined by the alarm-management team. The default settings on the alarm may be altered only after an assessment is performed and it is determined that the patient’s current [insert the parameter being monitored] is outside the default setting. The altered setting should be reevaluated every time the parameter is assessed. The person responsible for responding to the alarm is the only person who can change the alarm default settings. The direct caregiver or the person responsible for responding to the alarm may turn the alarm off only if the person is near the patient at all times. When an alarm default parameter has been changed or an alarm has been disabled, an alarm default setting change form will be completed and will be attached to the monitor in a location that is clearly visible to the caregiver caring for the patient. Changes in the default settings will be communicated during changes of personnel. The alarms on the anesthesia machine, vital signs monitor, and [add in all other equipment that the multidisciplinary team determines should be included] will be checked before every procedure. All alarms will be returned to the default settings between procedures. All audible alarms will be set at mid-point volume between procedures. The alarms on all patient-related equipment will be tested when purchased and at least daily, unless the device is on the list of life-saving equipment (eg, anesthesia ventilator), which requires testing before each use. The person discovering a malfunctioning alarm will remove the piece of equipment from service as soon as it is safe to do so. The person discovering a malfunctioning alarm will complete a “Do not use tag” and attach it to the item. The device with the malfunctioning alarm will then be sent to the [insert the title of the correct location in facility] for repair. Alarm-management policy and procedure will be included in educational offerings on all new equipment and annually on all rarely used equipment and during the equipment safety review. The risk manager or designee will complete monthly rounds to review compliance with the alarm policy and procedure and measure response times if an alarm is activated during these rounds.
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Clinical Issues
decreased. The frequency of testing should be based on the manufacturer’s instructions for use and the level of risk assigned by the multidisciplinary team when the inventory is completed. The policy also should contain a section dedicated to the educational requirements for the perioperative team. The entire team should be educated on all of the various clinical and alert alarms, including what they mean and how to appropriately respond to them.1 The education may be presented in a question-and-answer format (eg, who, when, what, why, how) regarding alarm management. Education should include informing the perioperative team who is responsible for responding to the alarm, who can change the default settings, and who can inactivate each type of alarm (eg, the anesthesia care provider is responsible for the cardiac monitor alarms, the circulator is responsible for the alarm on the tourniquet); when to respond to an alarm and, if two alarms are occurring simultaneously, which alarm to respond to first; that the decision about which alarm to respond to first should be based on the priority ratings that have been assigned by the multidisciplinary team; that any team member may be called on to assist the designated person responsible, so each team member needs to know what to do during that situation; what occurrence is causing activation of the alarm (eg, the team should know that if the tourniquet alarms at the end of the set time limit, there needs to be a collaborative discussion between the members of the perioperative team to determine actions that should be taken); why the alarm is present, including the physiological implications of not responding to the alarm; and what the alarm indicates and how to correct the situation. In the case of an insufflator alarm, if the high-pressure alarm is activated, the person responding to the alarm needs to determine the cause (eg, the team members at the sterile field are leaning on the patient’s abdomen, there is a kink in the tubing system) and then correct the situation. After the perioperative team has received training, educators should conduct a follow-up evaluation of actual performance and competency verification to validate that personnel have put the education into action and the actions taken in response to alarms are consistent for every member of the team. One way to accomplish this is to conduct rounds and ask team members, “What would you do if the insufflator alarm sounded and you were in the middle of a procedure?” Any person who answers incorrectly should receive more education as soon as possible.
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References Byron L. Burlingame, MS, RN, CNOR, is a senior perioperative practice specialist in the Nursing Department at AORN, Inc, Denver, CO.
1. Guideline for safe environment of care, Part 1. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2016: 237-262. 2. Lukasewicz CL, Mattox EA. Understanding clinical alarm safety. Crit Care Nurse. 2015;35(4):45-57. 3. The Alarm Safety Handbook: Strategies, Tools, and Guidance. Plymouth Meeting, PA: ECRI Institute; 2014. 4. Position statements. AORN, Inc. https://www.aorn.org/guidelines/ clinical-resources/position-statements. Accessed January 12, 2016.
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LEARNER EVALUATION
Continuing Education: Clinical Issues 1.1
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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 .aornjournal.org/content/cme. Rate the items as described below.
PURPOSE/GOAL
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 1.1 continuing education contact hour (66-minute) program: _______________
To provide the learner with knowledge of AORN’s guidelines related to increasing ambient room temperature and clinical alarm management.
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.
3.
Discuss common areas of concern that relate to perioperative best practices. Low 1. 2. 3. 4. 5. High Describe implementation of evidence-based practice in relation to perioperative nursing care. Low 1. 2. 3. 4. 5. High
CONTENT 4.
5.
To what extent did this article increase your knowledge of the subject matter? Low 1. 2. 3. 4. 5. High To what extent were your individual objectives met? Low 1. 2. 3. 4. 5. High
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