- Email: [email protected]
Clinical Issues—October 2013
CONTINUING EDUCATION Clinical Issues
1.5
AMBER WOOD, MSN, RN, CNOR, CIC, CPN
www.aorn.org/CE Continuing Education Contact Hours
Approvals
indicates that continuing education (CE) contact hours are available for this activity. Earn the CE contact hours by reading this article, reviewing the purpose/goal and objectives, and completing the online Examination and Learner Evaluation at http://www.aorn.org/CE. A score of 70% correct on the examination is required for credit. Participants receive feedback on incorrect answers. Each applicant who successfully completes this program can immediately print a certificate of completion.
This program meets criteria for CNOR and CRNFA recertification, as well as other CE requirements. AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this activity for relicensure.
Event: #13528 Session: #0001 Fee: Members $9, Nonmembers $18
Conflict of Interest Disclosures
The CE contact hours for this article expire October 31, 2016. Pricing is subject to change.
Purpose/Goal To enable the learner to understand AORN recommended practices related to the use of lead aprons, terminal cleaning of sterile processing areas, and caring for patients infected with or who are colonized with CRE.
Amber Wood, MSN, RN, CNOR, CIC, CPN, has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. The behavioral objectives for this program were created by Helen Starbuck Pashley, MA, BSN, CNOR, clinical editor, with consultation from Susan Bakewell, MS, RN-BC, director, Perioperative Education. Ms Starbuck Pashley and Ms Bakewell have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article.
Objectives 1. Discuss practices that could jeopardize safety in the perioperative area. 2. Discuss common areas of concern that relate to perioperative best practices. 3. Describe implementation of evidence-based practice in relation to perioperative nursing care.
Sponsorship or Commercial Support No sponsorship or commercial support was received for this article.
Disclaimer Accreditation AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
AORN recognizes these activities as CE for RNs. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity.
http://dx.doi.org/10.1016/j.aorn.2013.07.011
Ó AORN, Inc, 2013
October 2013
Vol 98 No 4
AORN Journal j 419
CLINICAL ISSUES
1.5
www.aorn.org/CE
This Month Covering lead aprons during operative or other invasive procedures Key words: lead apron, radiological exposure, personal protective equipment, PPE, gown.
Terminal cleaning of sterile processing areas Key words: terminal cleaning, cleaning, sterile processing.
Preventing transmission of carbapenem-resistant Enterobacteriaceae (CRE) Key words: carbapenem-resistant Enterobacteriaceae, CRE, Klebsiella pneumoniae carbapenemase, KPC, carbapenem, multidrug-resistant organism, MDRO, isolation, contact precautions, cleaning.
Covering lead aprons during operative or other invasive procedures QUESTION: A licensed provider at my facility who performs invasive procedures that require radiological imaging and potential exposure to blood does not wear a fluid-resistant gown to cover the lead apron. Should perioperative team members cover lead aprons when there is potential exposure to blood during a procedure? ANSWER: Perioperative team members must wear appropriate personal protective equipment (PPE) if there is a potential for exposure to blood, according to the Occupational Safety and Health Administration’s bloodborne pathogens standard.1 A lead apron is not considered appropriate PPE because the apron does not protect the wearer’s arms, bare or clothed, from exposure to blood, body fluids, or other potentially infectious materials.
Appropriate PPE does not allow blood to penetrate through to the health care worker’s work clothes, including a lead apron, under normal conditions of use for the duration that the wearer uses the PPE.1 If splash, spray, spatter, or aerosols of blood, body fluids, or other potentially infectious materials can be reasonably anticipated during a procedure, then perioperative personnel and other participating health care providers must wear fluidresistant attire, eye protection, and surgical masks.2 To reduce the patient’s risk of infection from an invasive procedure and to protect team members from exposure to bloodborne pathogens, perioperative team members should don PPE and prepare a sterile field.3 Before beginning an invasive procedure that requires radiological intervention, team members should don lead aprons before they perform surgical hand scrubs and don sterile gowns and gloves.3 The lead apron should be covered with http://dx.doi.org/10.1016/j.aorn.2013.07.011
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Ó AORN, Inc, 2013
CLINICAL ISSUES a sterile gown for the duration of the invasive procedure to provide appropriate PPE coverage and prevent blood, body fluids, or other potentially infectious material from making contact with the perioperative team members’ skin, the lead apron, or clothing; covering the lead apron with a sterile gown also prevents the potential contamination of the patient’s surgical wound.3 If a perioperative team member with the potential for exposure to blood, body fluids, or other potentially infectious materials during the invasive procedure wears a lead apron without covering it with PPE, such as a fluid-resistant gown, then the apron should be cleaned according to the manufacturer’s instructions with a US Environmental Protection Agencyeregistered disinfectant immediately after the procedure. If the lead apron is wet after the disinfection process is complete, the apron should be allowed to dry before use. Wearing a wet lead apron may cause the surgical attire to become wet, necessitating a change in attire.4 If the wet
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apron is not changed, it can create a wicking effect through a sterile gown worn over it, thus contaminating the sterile gown.4 AMBER WOOD MSN, RN, CNOR, CIC, CPN PERIOPERATIVE NURSING SPECIALIST AORN NURSING DEPARTMENT References 1. Occupational Safety and Health Standards: Toxic and Hazardous Substances: Bloodborne Pathogens, 29 CFR x1910.1030 (2012). United States Department of Labor Occupational Safety and Health Administration. http:// www.osha.gov/pls/oshaweb/owadisp.show_document? p_table¼STANDARDS&p_id¼10051. Accessed June 5, 2013. 2. Recommended practices for prevention of transmissible infections in the perioperative practice setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:331-363. 3. Recommended practices for sterile technique. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:91-120. 4. Recommended practices for surgical attire. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:51-62.
Terminal cleaning of sterile processing areas QUESTION: How should sterile processing areas be terminally cleaned? ANSWER: Sterile processing areas, including satellite locations, should be terminally cleaned every 24 hours during the regularly scheduled work week when the area is being used.1 When the areas are not occupied with scheduled personnel (eg, weekends), a multidisciplinary team, including representatives from the sterile processing department, environmental services, and infection prevention, should determine the frequency and extent of required cleaning. In deciding this, team members should consider that the presence of perioperative employees in sterile processing areas generates dust from shed skin squames, which can harbor bacteria.2 All areas that have traffic, however transient, should be considered occupied and cleaned because people shed skin squames.
For example, if the sterile processing areas are closed and no personnel are performing sterile processing activities, the team may determine that no terminal cleaning during these hours is necessary. If perioperative team members enter the sterile processing areas to retrieve instrumentation and supplies for on-call procedures and then return to the decontamination area to process soiled instrumentation, the team may determine that the decontamination areas should be terminally cleaned during nonscheduled hours while the clean areas (eg, sterile storage) may only need damp dusting of horizontal surfaces. Comparatively, if personnel are performing decontamination and sterilization procedures on a routine basis outside the regularly scheduled work week (eg, in a trauma center), the team may determine that thorough terminal cleaning of all sterile processing areas is necessary every 24 hours. The team should reevaluate terminal cleaning procedures in the sterile processing areas periodically to AORN Journal j 421
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determine whether the terminal cleaning plan needs adjustment based on departmental activity. Terminal cleaning should not commence when personnel are actively decontaminating instruments or packaging items for sterilization. When cleaning the sterile processing areas, the clean work areas (eg, the packaging area, sterile storage area) should be cleaned before moving to dirty work areas (eg, the decontamination area) to reduce the opportunity for contaminating the clean areas.1 For routine terminal cleaning, personnel who perform environmental cleaning should use a US Environmental Protection Agencyeregistered disinfectant and a clean, lint-free cloth to damp dust all horizontal surfaces, such as sterilizers, countertops, furniture, and shelving.1 Team members should clean frequently touched objects (eg, control panels, computer keyboards, magnifying glasses) and work area surfaces according to manufacturers’ instructions. The cleaning team also should remove trash from receptacles in the sterile processing areas daily or when trash receptacles are full. Environmental services cleaning personnel should mop all floors in the sterile processing areas daily, or when soiled, with a US Environmental Protection Agencyeregistered disinfectant, taking extreme caution not to generate spray, splash, or splatter near sterile supplies or instruments. The multidisciplinary team (eg, representatives from sterile processing, environmental services, infection prevention) should determine which mopping materials and tools are appropriate for use. For example, the team should decide whether to use
reusable or single-use mops made of either string or microfiber or mops that dispense cleaning solutions.2 Regardless of the type of mopping materials or tools used for cleaning, cleaning personnel should change the cleaning material after each use and not return it to the cleaning solution container to prevent contamination of the solution.2 Wetvacuuming floors in sterile processing areas is unnecessary. Perioperative team members completing the terminal cleaning procedures in sterile processing areas should document cleaning activities on a log sheet or checklist that is on display in the sterile processing department. A checklist format may be beneficial to outline specific cleaning activities to both guide cleaning personnel in performing the pre-determined terminal cleaning procedures and provide written communication that each activity was completed. Documentation of terminal cleaning on a log sheet facilitates communication of cleaning procedures among sterile processing and environmental services personnel. AMBER WOOD MSN, RN, CNOR, CIC, CPN PERIOPERATIVE NURSING SPECIALIST AORN NURSING DEPARTMENT References 1. ANSI/AAMI ST79:2010/A2:2011: Comprehensive Guide to Steam Sterilization and Sterility Assurance in Health Care Facilities. Arlington, VA: Association for the Advancement of Medical Instrumentation; 2011. 2. Recommended practices for environmental cleaning in the perioperative setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013: 243-254.
Preventing transmission of carbapenem-resistant Enterobacteriaceae (CRE) QUESTION: A patient who previously experienced a carbapenem-resistant Enterobacteriaceae (CRE) infection is coming to our facility for surgery. How should we manage this patient to prevent transmission of CRE? 422 j AORN Journal
ANSWER: Perioperative team members should collaborate with an infection preventionist to develop a plan for managing a patient diagnosed with an infection or colonized with any multidrug-resistant organism, including CRE.1 Colonization means that a person
CLINICAL ISSUES has microorganisms on or within his or her body without the body producing a detectable immune response, experiencing cellular damage, or displaying clinical symptoms of infection.2 When a microorganism overcomes the immune system of its host, the organism proliferates and invades host tissue, resulting in an infection.2 Evidence regarding when a patient with a previous CRE infection stops transmitting CRE is insufficient to determine when this occurs; therefore, perioperative nurses should manage a patient with a previous CRE infection or colonization the same as they would a currently infected or colonized patient.3 Enterobacteriaceae species often colonize the gastrointestinal tract.4 The most common carbapenemase-producing Enterobacteriaceae is Klebsiella pneumoniae carbapenemase (KPC), although several metallo-b-lactamaseeproducing strains also have emerged within the past four years, including New Delphi metallo-b-lactamase (NDM), n Verona integron-encoded metallo-b-lactamase (IVM), and 3 n imipenemase (IMP) metallo-b-lactamase. n
All of these forms of CRE should be managed in collaboration with an infection preventionist as a multidrug-resistant organism. The US Centers for Disease Control and Prevention recommend an aggressive approach to controlling CRE when it is identified, such as during a preoperative workup.3 Infection or colonization with CRE is associated with high mortality rates (ie, up to 40% to 50%) and the organism has the ability to become widespread, so CRE is a serious threat to public health in the United States.3 When facilities that have few cases of patients with CRE infection or colonization agree to accept patients from facilities with a higher population of these patients, all patients accepted from those facilities should be considered potentially colonized with CRE. These patients should be actively screened via stool, rectal, or perirectal cultures and
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placed in contact precautions until the results of the screening reveal otherwise.4 Identifying and managing patients with CRE is crucial to preventing transmission. Managing Patients With CRE Perioperative nurses should follow five core measures when managing a patient who is infected or colonized with CRE: hand hygiene, contact precautions, education, assigning designated care personnel, and environmental cleaning. These five measures are described in the Centers for Disease Control and Prevention CRE Toolkit.3 Hand hygiene. Perioperative leaders and infection preventionists should promote hand hygiene and ensure that personnel have access to hand hygiene stations.1,3 Perioperative leaders and infection preventionists also should monitor adherence to hand hygiene procedures and provide feedback to personnel.1,4 Contact precautions. Perioperative nurses should implement contact precautions for patients who are currently or were previously infected or colonized with CRE.1,3 After arrival in the perioperative area, the perioperative nurse should immediately transfer the patient to a private room with doors that close or a private area with curtains that can be closed, which helps avoid potentially exposing other people in the waiting room to CRE. If this is not possible, the perioperative nurse should collaborate with other health care providers to segregate the patient in a private area away from other patients in the waiting room to reduce the risk of CRE exposure and educate the patient on the importance of maintaining separation to reduce the risk of exposing other patients to CRE.2 Placing potentially infectious patients in a private area limits the number of exposed individuals in common areas, such as the waiting room.2 Perioperative personnel should follow standard precautions (eg, performing hand hygiene, wearing appropriate personal protective equipment) when potential exposure to blood, body fluids, or other AORN Journal j 423
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potentially infectious materials can be reasonably anticipated.1 Perioperative personnel should don an isolation gown and gloves on room entry and discard the gown and gloves immediately before exiting the room of a patient who requires contact precautions.1 The discarded isolation gown and gloves should be placed in a receptacle within the patient’s room or holding area so that common areas and corridors are not contaminated. Scrubbed personnel in the OR or procedure room should wear a surgical gown in accordance with sterile technique, rather than an isolation gown. Perioperative team members should handle reusable noncritical equipment (eg, computers, personal electronic devices, commodes, IV pumps) in a manner that prevents personal or environmental contamination and that allows the equipment to be disinfected between patient uses.1 When feasible, the perioperative nurse should dedicate noncritical equipment (eg, stethoscopes, blood pressure cuffs, thermometers, electrocardiogram leads) to singlepatient use.1 Perioperative personnel should take measures to limit the transmission of CRE during transport, including preventing the contamination of environmental surfaces.1 When transport is necessary, the perioperative nurse should notify the receiving team members before transport that the patient requires contact precautions so that receiving personnel are prepared to care for the patient on arrival. Perioperative team members who transport the patient should n
cover any infectious skin lesions or draining wounds before transport and place clean linen over the patient, n clean any part of the transport vehicle that will be touched by personnel, n remove their contaminated gown and gloves and perform hand hygiene before touching the clean parts of the transport vehicle, and n transport the patient to his or her destination (eg, OR or procedure room, postanesthesia care unit, intensive care unit).
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CLINICAL ISSUES If patient contact during transport is expected (eg, uncooperative patient, intubated patient), the team members transporting the patient should continue wearing a gown and gloves during transport and ensure that contact points in the environment (eg, door push plates, elevator buttons) are not contaminated. To prevent environmental contamination, perioperative team members should take advantage of no-touch or automated door openings; if these are not available, they may require an escort who can press push plates and elevator buttons. Perioperative nurses should educate the patient about contact precautions and have frequent communication with the patient.1 In addition, perioperative nurses should evaluate the patient who requires contact precautions for negative feelings (eg, anxiety, depression, decreased satisfaction) and improve social contact with the patient.1 Education. Perioperative leaders and infection preventionists should educate perioperative team members about CRE, proper hand hygiene, and contact precautions.1,3 As part of this education, perioperative leaders and infection preventionists should monitor personnel adherence to hand hygiene and contact precaution procedures and provide feedback to personnel.1,3 Designated patient care personnel. Perioperative managers may want to assign designated personnel to provide direct care to patients who are infected or colonized with CRE.3 If there are multiple patients with CRE infection or colonization, perioperative nurses may allow these patients and personnel to share the same area.1,3 Environmental cleaning. Personnel performing environmental cleaning and disinfection should wear an isolation gown and gloves when cleaning areas in which patients infected or colonized with CRE have been cared for.1,5 After the patient leaves the room or area (eg, bay), personnel should perform enhanced environmental cleaning that extends beyond routine cleaning for patients who are not in
CLINICAL ISSUES isolation precautions.1,5 In contrast to routine environmental cleaning (ie, cleaning of contaminated objects, some high-touch objects), enhanced environmental cleaning involves cleaning all touched objects regardless of visible contamination. For example, routine cleaning does not typically include light switches and door handles, but these surfaces would be cleaned as part of enhanced cleaning. Team members should use a US Environmental Protection Agencyeregistered disinfectant to clean and disinfect all high-touch surfaces (eg, control panels, switches, knobs, work areas, handles, door push plates, telephones, computers, chairs, receptacle lids) and specific items or surfaces that have been touched by the patient with CRE or personnel in the course of patient care.1,5 High-touch surfaces in the OR also include the anesthesia cart and equipment, the anesthesia machine, patient monitors, and the OR bed and safety strap. High-touch surfaces in the perioperative patient care areas include curtains, patient monitors, the patient bed, the over-bed table, the television remote control, and the call light. Members of the cleaning team also should remove trash and used linen from receptacles in the room. As part of routine cleaning procedures, perioperative team members should clean any items that are used, soiled, or potentially soiled (eg, splash, splatter, spray) during the procedure. These items may include n n n n n n
OR bed attachments (eg, arm boards, stirrups, headrests), positioning devices (eg, gel roll, donuts, bean bag), patient transfer devices (eg, roll boards), overhead procedure lights, tables and Mayo stands, and equipment that may be either mobile or mounted (eg, suction regulator, medical gas regulator, imaging viewer, viewing monitors, radiology equipment, electrosurgical unit, microscope, robot, laser).
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Team members should mop the floor with a US Environmental Protection Agencyeregistered disinfectant after the patient leaves the room or bay if the floor is soiled or might have been soiled with splash, spray, or splatter during the procedure or patient care activities. If any item or article of linen that was previously in contact with the patient touches the floor, the floor should be cleaned. Theoretically, items that come into contact with a patient who is infected or colonized with CRE become contaminated. Team members should mop any soiled, potentially soiled, or contaminated areas of the floor, including the adjacent surrounding areas, taking care to mop the cleanest areas first to avoid cross-contamination from dirty areas. Cleaning personnel should inspect all areas of the floor for cleanliness, including under the OR bed and areas that were exposed to contamination during the procedure or patient care activities. If the area of potential soil or contamination is unknown, team members should mop the entire floor from the cleanest area to the dirtiest area, which may be determined by visible soil or proximity to the area of patient care. A multidisciplinary team (eg, representatives from perioperative services, environmental services, infection prevention) should determine which mopping materials and tools are appropriate for use in the OR or procedure room (eg, reusable or single-use mops made of either string or microfiber, mops that dispense cleaning solutions).5 Regardless of the type of mopping materials or tools used for cleaning in any perioperative area, cleaning team members should change the cleaning material after each use and not return it to the cleaning solution container to prevent contamination of the solution.5 Perioperative personnel involved in patient care activities should notify team members who perform environmental cleaning about potential areas of contamination, including the location of patient care activities if the care took place in an atypical location. For example, if the OR bed is turned to conduct the procedure and then returned to its original location, personnel performing environmental AORN Journal j 425
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cleaning may not be aware of areas of the room that were exposed to potential contamination because of the bed being moved. If perioperative team members adhere to these core measures, it is not necessary to perform extraordinary cleaning procedures (eg, cleaning walls and all surfaces of equipment or furniture, including wheels and casters; cleaning procedures for prion contamination such as Creutzfeldt-Jakob disease), to close the room, or to schedule the patient who is infected or colonized with CRE at the end of the day.5
AMBER WOOD MSN, RN, CNOR, CIC, CPN PERIOPERATIVE NURSING SPECIALIST AORN NURSING DEPARTMENT
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References 1. Recommended practices for prevention of transmissible infections in the perioperative practice setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:331-364. 2. Siegel JD, Rhinehart E, Jackson M, Chiarello L; the Healthcare Infection Control Practices Advisory Committee. 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Health Care Settings. Am J Infect Control. 2007;35(10 Suppl 2): S65-S164. 3. 2012 CRE toolkitdguidance for control of carbapenemresistant Enterobacteriaceae (CRE). Centers for Disease Control and Prevention. http://www.cdc.gov/hai/organ isms/cre/cre-toolkit/rCREprevention-AppendixC.html. Accessed July 8, 2013. 4. Recommended practices for environmental cleaning in the perioperative setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013: 243-254. 5. Carbapenem-resistant Enterobacteriaceae: Clinician’s FAQs. Centers for Disease Control and Prevention. http:// www.cdc.gov/hai/organisms/cre/cre-clinicianFAQ.html. Accessed June 11, 2013.
LEARNER EVALUATION
1.5
CONTINUING EDUCATION PROGRAM
Clinical Issues
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.
www.aorn.org/CE
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.)
PURPOSE/GOAL
To enable the learner to understand AORN recommended practices related to the use of lead aprons, terminal cleaning of sterile processing areas, and caring for patients infected with or who are colonized with CRE. 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.
2.
Low 1. 2. 3. 4. 5. High 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
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/ 3.
implement a policy and procedure. 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: ________________________________ CONTENT
4. To what extent did this article increase your knowledge of the subject matter? Low 1. 2. 3. 4. 5. High
Ó AORN, Inc, 2013
8. Our accrediting body requires that we verify the time you needed to complete the 1.5 continuing education contact hour (90-minute) program: _________________________________
October 2013
Vol 98 No 4
AORN Journal j 427
1.5
AMBER WOOD, MSN, RN, CNOR, CIC, CPN
www.aorn.org/CE Continuing Education Contact Hours
Approvals
indicates that continuing education (CE) contact hours are available for this activity. Earn the CE contact hours by reading this article, reviewing the purpose/goal and objectives, and completing the online Examination and Learner Evaluation at http://www.aorn.org/CE. A score of 70% correct on the examination is required for credit. Participants receive feedback on incorrect answers. Each applicant who successfully completes this program can immediately print a certificate of completion.
This program meets criteria for CNOR and CRNFA recertification, as well as other CE requirements. AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this activity for relicensure.
Event: #13528 Session: #0001 Fee: Members $9, Nonmembers $18
Conflict of Interest Disclosures
The CE contact hours for this article expire October 31, 2016. Pricing is subject to change.
Purpose/Goal To enable the learner to understand AORN recommended practices related to the use of lead aprons, terminal cleaning of sterile processing areas, and caring for patients infected with or who are colonized with CRE.
Amber Wood, MSN, RN, CNOR, CIC, CPN, has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. The behavioral objectives for this program were created by Helen Starbuck Pashley, MA, BSN, CNOR, clinical editor, with consultation from Susan Bakewell, MS, RN-BC, director, Perioperative Education. Ms Starbuck Pashley and Ms Bakewell have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article.
Objectives 1. Discuss practices that could jeopardize safety in the perioperative area. 2. Discuss common areas of concern that relate to perioperative best practices. 3. Describe implementation of evidence-based practice in relation to perioperative nursing care.
Sponsorship or Commercial Support No sponsorship or commercial support was received for this article.
Disclaimer Accreditation AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
AORN recognizes these activities as CE for RNs. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity.
http://dx.doi.org/10.1016/j.aorn.2013.07.011
Ó AORN, Inc, 2013
October 2013
Vol 98 No 4
AORN Journal j 419
CLINICAL ISSUES
1.5
www.aorn.org/CE
This Month Covering lead aprons during operative or other invasive procedures Key words: lead apron, radiological exposure, personal protective equipment, PPE, gown.
Terminal cleaning of sterile processing areas Key words: terminal cleaning, cleaning, sterile processing.
Preventing transmission of carbapenem-resistant Enterobacteriaceae (CRE) Key words: carbapenem-resistant Enterobacteriaceae, CRE, Klebsiella pneumoniae carbapenemase, KPC, carbapenem, multidrug-resistant organism, MDRO, isolation, contact precautions, cleaning.
Covering lead aprons during operative or other invasive procedures QUESTION: A licensed provider at my facility who performs invasive procedures that require radiological imaging and potential exposure to blood does not wear a fluid-resistant gown to cover the lead apron. Should perioperative team members cover lead aprons when there is potential exposure to blood during a procedure? ANSWER: Perioperative team members must wear appropriate personal protective equipment (PPE) if there is a potential for exposure to blood, according to the Occupational Safety and Health Administration’s bloodborne pathogens standard.1 A lead apron is not considered appropriate PPE because the apron does not protect the wearer’s arms, bare or clothed, from exposure to blood, body fluids, or other potentially infectious materials.
Appropriate PPE does not allow blood to penetrate through to the health care worker’s work clothes, including a lead apron, under normal conditions of use for the duration that the wearer uses the PPE.1 If splash, spray, spatter, or aerosols of blood, body fluids, or other potentially infectious materials can be reasonably anticipated during a procedure, then perioperative personnel and other participating health care providers must wear fluidresistant attire, eye protection, and surgical masks.2 To reduce the patient’s risk of infection from an invasive procedure and to protect team members from exposure to bloodborne pathogens, perioperative team members should don PPE and prepare a sterile field.3 Before beginning an invasive procedure that requires radiological intervention, team members should don lead aprons before they perform surgical hand scrubs and don sterile gowns and gloves.3 The lead apron should be covered with http://dx.doi.org/10.1016/j.aorn.2013.07.011
420 j AORN Journal
October 2013 Vol 98 No 4
Ó AORN, Inc, 2013
CLINICAL ISSUES a sterile gown for the duration of the invasive procedure to provide appropriate PPE coverage and prevent blood, body fluids, or other potentially infectious material from making contact with the perioperative team members’ skin, the lead apron, or clothing; covering the lead apron with a sterile gown also prevents the potential contamination of the patient’s surgical wound.3 If a perioperative team member with the potential for exposure to blood, body fluids, or other potentially infectious materials during the invasive procedure wears a lead apron without covering it with PPE, such as a fluid-resistant gown, then the apron should be cleaned according to the manufacturer’s instructions with a US Environmental Protection Agencyeregistered disinfectant immediately after the procedure. If the lead apron is wet after the disinfection process is complete, the apron should be allowed to dry before use. Wearing a wet lead apron may cause the surgical attire to become wet, necessitating a change in attire.4 If the wet
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apron is not changed, it can create a wicking effect through a sterile gown worn over it, thus contaminating the sterile gown.4 AMBER WOOD MSN, RN, CNOR, CIC, CPN PERIOPERATIVE NURSING SPECIALIST AORN NURSING DEPARTMENT References 1. Occupational Safety and Health Standards: Toxic and Hazardous Substances: Bloodborne Pathogens, 29 CFR x1910.1030 (2012). United States Department of Labor Occupational Safety and Health Administration. http:// www.osha.gov/pls/oshaweb/owadisp.show_document? p_table¼STANDARDS&p_id¼10051. Accessed June 5, 2013. 2. Recommended practices for prevention of transmissible infections in the perioperative practice setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:331-363. 3. Recommended practices for sterile technique. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:91-120. 4. Recommended practices for surgical attire. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:51-62.
Terminal cleaning of sterile processing areas QUESTION: How should sterile processing areas be terminally cleaned? ANSWER: Sterile processing areas, including satellite locations, should be terminally cleaned every 24 hours during the regularly scheduled work week when the area is being used.1 When the areas are not occupied with scheduled personnel (eg, weekends), a multidisciplinary team, including representatives from the sterile processing department, environmental services, and infection prevention, should determine the frequency and extent of required cleaning. In deciding this, team members should consider that the presence of perioperative employees in sterile processing areas generates dust from shed skin squames, which can harbor bacteria.2 All areas that have traffic, however transient, should be considered occupied and cleaned because people shed skin squames.
For example, if the sterile processing areas are closed and no personnel are performing sterile processing activities, the team may determine that no terminal cleaning during these hours is necessary. If perioperative team members enter the sterile processing areas to retrieve instrumentation and supplies for on-call procedures and then return to the decontamination area to process soiled instrumentation, the team may determine that the decontamination areas should be terminally cleaned during nonscheduled hours while the clean areas (eg, sterile storage) may only need damp dusting of horizontal surfaces. Comparatively, if personnel are performing decontamination and sterilization procedures on a routine basis outside the regularly scheduled work week (eg, in a trauma center), the team may determine that thorough terminal cleaning of all sterile processing areas is necessary every 24 hours. The team should reevaluate terminal cleaning procedures in the sterile processing areas periodically to AORN Journal j 421
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determine whether the terminal cleaning plan needs adjustment based on departmental activity. Terminal cleaning should not commence when personnel are actively decontaminating instruments or packaging items for sterilization. When cleaning the sterile processing areas, the clean work areas (eg, the packaging area, sterile storage area) should be cleaned before moving to dirty work areas (eg, the decontamination area) to reduce the opportunity for contaminating the clean areas.1 For routine terminal cleaning, personnel who perform environmental cleaning should use a US Environmental Protection Agencyeregistered disinfectant and a clean, lint-free cloth to damp dust all horizontal surfaces, such as sterilizers, countertops, furniture, and shelving.1 Team members should clean frequently touched objects (eg, control panels, computer keyboards, magnifying glasses) and work area surfaces according to manufacturers’ instructions. The cleaning team also should remove trash from receptacles in the sterile processing areas daily or when trash receptacles are full. Environmental services cleaning personnel should mop all floors in the sterile processing areas daily, or when soiled, with a US Environmental Protection Agencyeregistered disinfectant, taking extreme caution not to generate spray, splash, or splatter near sterile supplies or instruments. The multidisciplinary team (eg, representatives from sterile processing, environmental services, infection prevention) should determine which mopping materials and tools are appropriate for use. For example, the team should decide whether to use
reusable or single-use mops made of either string or microfiber or mops that dispense cleaning solutions.2 Regardless of the type of mopping materials or tools used for cleaning, cleaning personnel should change the cleaning material after each use and not return it to the cleaning solution container to prevent contamination of the solution.2 Wetvacuuming floors in sterile processing areas is unnecessary. Perioperative team members completing the terminal cleaning procedures in sterile processing areas should document cleaning activities on a log sheet or checklist that is on display in the sterile processing department. A checklist format may be beneficial to outline specific cleaning activities to both guide cleaning personnel in performing the pre-determined terminal cleaning procedures and provide written communication that each activity was completed. Documentation of terminal cleaning on a log sheet facilitates communication of cleaning procedures among sterile processing and environmental services personnel. AMBER WOOD MSN, RN, CNOR, CIC, CPN PERIOPERATIVE NURSING SPECIALIST AORN NURSING DEPARTMENT References 1. ANSI/AAMI ST79:2010/A2:2011: Comprehensive Guide to Steam Sterilization and Sterility Assurance in Health Care Facilities. Arlington, VA: Association for the Advancement of Medical Instrumentation; 2011. 2. Recommended practices for environmental cleaning in the perioperative setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013: 243-254.
Preventing transmission of carbapenem-resistant Enterobacteriaceae (CRE) QUESTION: A patient who previously experienced a carbapenem-resistant Enterobacteriaceae (CRE) infection is coming to our facility for surgery. How should we manage this patient to prevent transmission of CRE? 422 j AORN Journal
ANSWER: Perioperative team members should collaborate with an infection preventionist to develop a plan for managing a patient diagnosed with an infection or colonized with any multidrug-resistant organism, including CRE.1 Colonization means that a person
CLINICAL ISSUES has microorganisms on or within his or her body without the body producing a detectable immune response, experiencing cellular damage, or displaying clinical symptoms of infection.2 When a microorganism overcomes the immune system of its host, the organism proliferates and invades host tissue, resulting in an infection.2 Evidence regarding when a patient with a previous CRE infection stops transmitting CRE is insufficient to determine when this occurs; therefore, perioperative nurses should manage a patient with a previous CRE infection or colonization the same as they would a currently infected or colonized patient.3 Enterobacteriaceae species often colonize the gastrointestinal tract.4 The most common carbapenemase-producing Enterobacteriaceae is Klebsiella pneumoniae carbapenemase (KPC), although several metallo-b-lactamaseeproducing strains also have emerged within the past four years, including New Delphi metallo-b-lactamase (NDM), n Verona integron-encoded metallo-b-lactamase (IVM), and 3 n imipenemase (IMP) metallo-b-lactamase. n
All of these forms of CRE should be managed in collaboration with an infection preventionist as a multidrug-resistant organism. The US Centers for Disease Control and Prevention recommend an aggressive approach to controlling CRE when it is identified, such as during a preoperative workup.3 Infection or colonization with CRE is associated with high mortality rates (ie, up to 40% to 50%) and the organism has the ability to become widespread, so CRE is a serious threat to public health in the United States.3 When facilities that have few cases of patients with CRE infection or colonization agree to accept patients from facilities with a higher population of these patients, all patients accepted from those facilities should be considered potentially colonized with CRE. These patients should be actively screened via stool, rectal, or perirectal cultures and
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placed in contact precautions until the results of the screening reveal otherwise.4 Identifying and managing patients with CRE is crucial to preventing transmission. Managing Patients With CRE Perioperative nurses should follow five core measures when managing a patient who is infected or colonized with CRE: hand hygiene, contact precautions, education, assigning designated care personnel, and environmental cleaning. These five measures are described in the Centers for Disease Control and Prevention CRE Toolkit.3 Hand hygiene. Perioperative leaders and infection preventionists should promote hand hygiene and ensure that personnel have access to hand hygiene stations.1,3 Perioperative leaders and infection preventionists also should monitor adherence to hand hygiene procedures and provide feedback to personnel.1,4 Contact precautions. Perioperative nurses should implement contact precautions for patients who are currently or were previously infected or colonized with CRE.1,3 After arrival in the perioperative area, the perioperative nurse should immediately transfer the patient to a private room with doors that close or a private area with curtains that can be closed, which helps avoid potentially exposing other people in the waiting room to CRE. If this is not possible, the perioperative nurse should collaborate with other health care providers to segregate the patient in a private area away from other patients in the waiting room to reduce the risk of CRE exposure and educate the patient on the importance of maintaining separation to reduce the risk of exposing other patients to CRE.2 Placing potentially infectious patients in a private area limits the number of exposed individuals in common areas, such as the waiting room.2 Perioperative personnel should follow standard precautions (eg, performing hand hygiene, wearing appropriate personal protective equipment) when potential exposure to blood, body fluids, or other AORN Journal j 423
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potentially infectious materials can be reasonably anticipated.1 Perioperative personnel should don an isolation gown and gloves on room entry and discard the gown and gloves immediately before exiting the room of a patient who requires contact precautions.1 The discarded isolation gown and gloves should be placed in a receptacle within the patient’s room or holding area so that common areas and corridors are not contaminated. Scrubbed personnel in the OR or procedure room should wear a surgical gown in accordance with sterile technique, rather than an isolation gown. Perioperative team members should handle reusable noncritical equipment (eg, computers, personal electronic devices, commodes, IV pumps) in a manner that prevents personal or environmental contamination and that allows the equipment to be disinfected between patient uses.1 When feasible, the perioperative nurse should dedicate noncritical equipment (eg, stethoscopes, blood pressure cuffs, thermometers, electrocardiogram leads) to singlepatient use.1 Perioperative personnel should take measures to limit the transmission of CRE during transport, including preventing the contamination of environmental surfaces.1 When transport is necessary, the perioperative nurse should notify the receiving team members before transport that the patient requires contact precautions so that receiving personnel are prepared to care for the patient on arrival. Perioperative team members who transport the patient should n
cover any infectious skin lesions or draining wounds before transport and place clean linen over the patient, n clean any part of the transport vehicle that will be touched by personnel, n remove their contaminated gown and gloves and perform hand hygiene before touching the clean parts of the transport vehicle, and n transport the patient to his or her destination (eg, OR or procedure room, postanesthesia care unit, intensive care unit).
424 j AORN Journal
CLINICAL ISSUES If patient contact during transport is expected (eg, uncooperative patient, intubated patient), the team members transporting the patient should continue wearing a gown and gloves during transport and ensure that contact points in the environment (eg, door push plates, elevator buttons) are not contaminated. To prevent environmental contamination, perioperative team members should take advantage of no-touch or automated door openings; if these are not available, they may require an escort who can press push plates and elevator buttons. Perioperative nurses should educate the patient about contact precautions and have frequent communication with the patient.1 In addition, perioperative nurses should evaluate the patient who requires contact precautions for negative feelings (eg, anxiety, depression, decreased satisfaction) and improve social contact with the patient.1 Education. Perioperative leaders and infection preventionists should educate perioperative team members about CRE, proper hand hygiene, and contact precautions.1,3 As part of this education, perioperative leaders and infection preventionists should monitor personnel adherence to hand hygiene and contact precaution procedures and provide feedback to personnel.1,3 Designated patient care personnel. Perioperative managers may want to assign designated personnel to provide direct care to patients who are infected or colonized with CRE.3 If there are multiple patients with CRE infection or colonization, perioperative nurses may allow these patients and personnel to share the same area.1,3 Environmental cleaning. Personnel performing environmental cleaning and disinfection should wear an isolation gown and gloves when cleaning areas in which patients infected or colonized with CRE have been cared for.1,5 After the patient leaves the room or area (eg, bay), personnel should perform enhanced environmental cleaning that extends beyond routine cleaning for patients who are not in
CLINICAL ISSUES isolation precautions.1,5 In contrast to routine environmental cleaning (ie, cleaning of contaminated objects, some high-touch objects), enhanced environmental cleaning involves cleaning all touched objects regardless of visible contamination. For example, routine cleaning does not typically include light switches and door handles, but these surfaces would be cleaned as part of enhanced cleaning. Team members should use a US Environmental Protection Agencyeregistered disinfectant to clean and disinfect all high-touch surfaces (eg, control panels, switches, knobs, work areas, handles, door push plates, telephones, computers, chairs, receptacle lids) and specific items or surfaces that have been touched by the patient with CRE or personnel in the course of patient care.1,5 High-touch surfaces in the OR also include the anesthesia cart and equipment, the anesthesia machine, patient monitors, and the OR bed and safety strap. High-touch surfaces in the perioperative patient care areas include curtains, patient monitors, the patient bed, the over-bed table, the television remote control, and the call light. Members of the cleaning team also should remove trash and used linen from receptacles in the room. As part of routine cleaning procedures, perioperative team members should clean any items that are used, soiled, or potentially soiled (eg, splash, splatter, spray) during the procedure. These items may include n n n n n n
OR bed attachments (eg, arm boards, stirrups, headrests), positioning devices (eg, gel roll, donuts, bean bag), patient transfer devices (eg, roll boards), overhead procedure lights, tables and Mayo stands, and equipment that may be either mobile or mounted (eg, suction regulator, medical gas regulator, imaging viewer, viewing monitors, radiology equipment, electrosurgical unit, microscope, robot, laser).
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Team members should mop the floor with a US Environmental Protection Agencyeregistered disinfectant after the patient leaves the room or bay if the floor is soiled or might have been soiled with splash, spray, or splatter during the procedure or patient care activities. If any item or article of linen that was previously in contact with the patient touches the floor, the floor should be cleaned. Theoretically, items that come into contact with a patient who is infected or colonized with CRE become contaminated. Team members should mop any soiled, potentially soiled, or contaminated areas of the floor, including the adjacent surrounding areas, taking care to mop the cleanest areas first to avoid cross-contamination from dirty areas. Cleaning personnel should inspect all areas of the floor for cleanliness, including under the OR bed and areas that were exposed to contamination during the procedure or patient care activities. If the area of potential soil or contamination is unknown, team members should mop the entire floor from the cleanest area to the dirtiest area, which may be determined by visible soil or proximity to the area of patient care. A multidisciplinary team (eg, representatives from perioperative services, environmental services, infection prevention) should determine which mopping materials and tools are appropriate for use in the OR or procedure room (eg, reusable or single-use mops made of either string or microfiber, mops that dispense cleaning solutions).5 Regardless of the type of mopping materials or tools used for cleaning in any perioperative area, cleaning team members should change the cleaning material after each use and not return it to the cleaning solution container to prevent contamination of the solution.5 Perioperative personnel involved in patient care activities should notify team members who perform environmental cleaning about potential areas of contamination, including the location of patient care activities if the care took place in an atypical location. For example, if the OR bed is turned to conduct the procedure and then returned to its original location, personnel performing environmental AORN Journal j 425
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cleaning may not be aware of areas of the room that were exposed to potential contamination because of the bed being moved. If perioperative team members adhere to these core measures, it is not necessary to perform extraordinary cleaning procedures (eg, cleaning walls and all surfaces of equipment or furniture, including wheels and casters; cleaning procedures for prion contamination such as Creutzfeldt-Jakob disease), to close the room, or to schedule the patient who is infected or colonized with CRE at the end of the day.5
AMBER WOOD MSN, RN, CNOR, CIC, CPN PERIOPERATIVE NURSING SPECIALIST AORN NURSING DEPARTMENT
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References 1. Recommended practices for prevention of transmissible infections in the perioperative practice setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:331-364. 2. Siegel JD, Rhinehart E, Jackson M, Chiarello L; the Healthcare Infection Control Practices Advisory Committee. 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Health Care Settings. Am J Infect Control. 2007;35(10 Suppl 2): S65-S164. 3. 2012 CRE toolkitdguidance for control of carbapenemresistant Enterobacteriaceae (CRE). Centers for Disease Control and Prevention. http://www.cdc.gov/hai/organ isms/cre/cre-toolkit/rCREprevention-AppendixC.html. Accessed July 8, 2013. 4. Recommended practices for environmental cleaning in the perioperative setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013: 243-254. 5. Carbapenem-resistant Enterobacteriaceae: Clinician’s FAQs. Centers for Disease Control and Prevention. http:// www.cdc.gov/hai/organisms/cre/cre-clinicianFAQ.html. Accessed June 11, 2013.
LEARNER EVALUATION
1.5
CONTINUING EDUCATION PROGRAM
Clinical Issues
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.
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5. To what extent were your individual objectives met?
Low
1.
2. 3.
4.
5.
High
6. Will you be able to use the information from this article in your work setting?
1.
Yes
2.
No
7. Will you change your practice as a result of reading this article? (If yes, answer question #7A. If no, answer question #7B.)
PURPOSE/GOAL
To enable the learner to understand AORN recommended practices related to the use of lead aprons, terminal cleaning of sterile processing areas, and caring for patients infected with or who are colonized with CRE. 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.
2.
Low 1. 2. 3. 4. 5. High 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
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/ 3.
implement a policy and procedure. 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: ________________________________ CONTENT
4. To what extent did this article increase your knowledge of the subject matter? Low 1. 2. 3. 4. 5. High
Ó AORN, Inc, 2013
8. Our accrediting body requires that we verify the time you needed to complete the 1.5 continuing education contact hour (90-minute) program: _________________________________
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