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Clinical Issues—September 2013
CONTINUING EDUCATION Clinical Issues
1.7
SHARON A. VAN WICKLIN, MSN, RN, CNOR, CRNFA, CPSN, PLNC; CYNTHIA SPRY, MA, MS, RN, CNOR, CSPDT; RAMONA CONNER, MSN, RN, CNOR
www.aorn.org/CE Continuing Education Contact Hours 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. Event: #13525 Session: #0001 Fee: Members $10.20, Nonmembers $20.40 The CE contact hours for this article expire September 30, 2016.
Purpose/Goal The purpose of this activity is to provide the reader with knowledge of AORN recommended practices related to sterilization and surgical attire.
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 Sharon A. Van Wicklin, MSN, RN, CNOR, CRNFA, CPSN, PLNC, has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. Ramona Conner, MSN, RN, CNOR, has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. Cynthia Spry, MA, MS, RN, CNOR, CSPDT, as an independent clinical consultant for sterilization, disinfection, and related infection control issues, has declared an 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.
Sponsorship or Commercial Support
Accreditation
No sponsorship or commercial support was received for this article.
AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
Disclaimer
Approvals This program meets criteria for CNOR and CRNFA recertification, as well as other CE requirements.
AORN recognizes these activities as CE for registered nurses. 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.2013.06.003
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Ó AORN, Inc, 2013
CLINICAL ISSUES
1.7
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This Month Requirements for immediate use steam sterilization (IUSS) Key words: immediate use steam sterilization, IUSS.
Gravity-displacement and dynamic air-removal cycles for steam sterilizers located outside of the sterile processing area Key words: gravity displacement, dynamic air removal, flash cycles, immediate use steam sterilization, IUSS.
Terminal sterilization using steam sterilizers located outside of the sterile processing area Key words: terminal sterilization, physical monitors, chemical indicators, biological indicators.
Physical, chemical, and biological monitoring tools for steam sterilizers located outside of the sterile processing area and used for immediate use steam sterilization (IUSS) Key words: physical monitors, chemical indicators, biological indicators, gravity displacement, dynamic air removal.
Unscrubbed personnel wearing long-sleeved jackets Key words: long-sleeved jackets, recommended practices, skin squames, preoperative skin antisepsis, skin prep.
Unscrubbed personnel wearing blankets over surgical attire Key words: blankets, low-linting, surgical attire, skin squames, trips and falls, professional appearance.
Requirements for immediate use steam sterilization (IUSS) QUESTION: What are the requirements for IUSS? ANSWER: Immediate use is considered the shortest time possible between a sterilized item’s removal from
the sterilizer and its aseptic transfer to the sterile field. The term IUSS has been endorsed by AORN, the Association for Professionals in Infection Control and Epidemiology, the International Association of Healthcare Central Service Materiel Management, the Accreditation Association of
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Ambulatory Healthcare, the Association of Surgical Technologists, and the ASC Quality Collaboration.1 The term flash sterilization has historically been used to describe steam sterilization of unwrapped items intended for immediate use. This term no longer describes the processes and cycles used to sterilize items not intended to be stored for later use. For this reason, the more appropriate term is IUSS.1 Items being subjected to IUSS should undergo the same decontamination processes as would be performed if the items were being terminally sterilized. Decontamination should be performed in an area intended, designed, and equipped for decontamination activities.2 Additionally, the following conditions should be met:
n
n
n n
n
The device manufacturer’s written instructions should be readily available, and the parameters to be used for IUSS as well as for cleaning, cycle type, exposure times, temperature settings, and drying times (if required) should be defined and followed.2 n When the device manufacturer does not provide instructions for IUSS, the device should not be sterilized in this manner.1 n When the device manufacturer’s instructions are unclear or in conflict with the instructions for the sterilizer or container, the device manufacturer should be contacted for additional guidance.1 n If the instructions for a device’s container call for a longer exposure time than the device, the container manufacturer should be contacted for additional guidance.1 n If conflicting instructions cannot be reconciled and the device is urgently required, the device manufacturer’s instructions should be followed.1 n The item should be placed in a containment device that has been validated for IUSS and cleared by the US Food and Drug Administration for this purpose.2 n The item should be positioned in the container in a manner that allows for steam contact with 312 j AORN Journal
all surfaces, and the manufacturer’s instructions for use of the containment device should be readily available and followed.2 The sterilizer manufacturers’ written instructions should be readily available and followed.2 Each sterilization cycle should be monitored with physical monitors (eg, printouts, graphs) and chemical indicators to verify that sterilization parameters have been met. Biological indicators should be included as required for load release purposes (eg, loads containing an implant) to confirm sterilizer efficacy.2 The item should be transported to the point of use in a manner that prevents contamination.2 The item should be used immediately, not stored for later use or held from one procedure to another.2
Immediate use steam sterilization cycle information and monitoring results should be maintained in an electronic or manual log that includes the n n n n n n n
n
items processed, identity of the patient on whom the items were used, type of cycle (eg, gravity-displacement, dynamic air-removal), cycle parameters used (eg, temperature, duration of cycle), monitoring results, date and time the cycle was run, operator information (ie, the name of the person who initiated the cycle, the name of the person who retrieved the items from the sterilizer), and reason for IUSS.2
Use of IUSS should be kept to a minimum, it should be used only in selected clinical situations, and it should be conducted in a controlled manner. It should not be used as a substitute for sufficient instrument inventory. Immediate use steam sterilization should not be used to sterilize implantable devices except in cases of defined emergency, when no other option is available.2
CLINICAL ISSUES
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SHARON A. VAN WICKLIN MSN, RN, CNOR, CRNFA, CPSN, PLNC PERIOPERATIVE NURSING SPECIALIST AORN NURSING DEPARTMENT
Perioperative personnel performing IUSS should receive education and should complete competency verification activities regarding the different types of steam sterilizers (ie, gravity-displacement, dynamic air-removal) and the different types of sterilization cycles that are in use within the organization, including n n n n
n
procedures for decontamination of devices before sterilization; operation and maintenance of sterilization equipment; selection of sterilization cycles; monitoring of sterilization cycles, including use of chemical and biological indicators and physical monitors; and documentation requirements.2
Immediate use steam sterilization involves much more than simply pushing a pre-programmed button on a sterilizer. Reprocessing of surgical instruments is a complex process that should be taken seriously. All of the steps required for achieving a sterile device and safely delivering it to the sterile field without contamination should be carefully followed, even when the device is needed immediately.
CYNTHIA SPRY MA, MS, RN, CNOR, CSPDT INDEPENDENT CLINICAL CONSULTANT NEW YORK, NY RAMONA CONNER MSN, RN, CNOR MANAGER, STANDARDS AND RECOMMENDED PRACTICES AORN NURSING DEPARTMENT
References 1. Association for the Advancement of Medical Instrumentation, Accreditation Association for Ambulatory Health Care, AORN, Association for Professionals in Infection Control and Epidemiology, ASC Quality Collaboration, International Association of Healthcare Central Service Materiel Management. Immediate-use steam sterilization. Association for the Advancement of Medical Instrumentation. https://www.aami.org/publications/standards/ ST79_Immediate_Use_Statement.pdf. Accessed May 10, 2013. 2. Recommended practices for sterilization. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:513-540.
Gravity-displacement and dynamic air-removal cycles for steam sterilizers located outside of the sterile processing area QUESTION: A colleague told me that if we convert the cycles on the steam sterilizers located outside of the sterile processing area (eg, between two ORs) from gravity-displacement to dynamic airremoval, they are no longer considered to be flash cycles. Is this true? ANSWER: The type of cycle (ie, gravity-displacement or dynamic air-removal) that is used for steam sterilization does not determine whether an item is being flash sterilized. Immediate use steam sterilization (IUSS), formerly known as flash sterilization, can
be accomplished using either a gravity-displacement or a dynamic air-removal cycle. The difference between the cycles is in the mechanism of action used to achieve sterilization. n
Gravity displacement is a method of steam sterilization in which the incoming air displaces the residual air through a port or drain near the bottom of the sterilizer chamber. Air is heavier than steam, so gravity forces the air to the bottom of the sterilizer as the steam rises to the top.1,2 n Dynamic air removal is a method of steam sterilization in which air removal is mechanically AORN Journal j 313
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assisted by a vacuum pump. The vacuum pump removes the air before the steam is injected into the sterilizer. Because of the vacuum that is created, when the steam enters the sterilizer, there is almost immediate contact with all surfaces of the items in the sterilizer.1,2 Both gravity-displacement and dynamic airremoval cycles may be used to achieve either IUSS or terminal sterilization.2 In the past, steam sterilizers allowed the use of gravity-displacement cycles only. Current steam sterilizers may be designed to provide either gravity-displacement or dynamic air-removal cycles, depending on how they are set. Some facilities may have policies that mandate setting the steam sterilizers located outside of the sterile processing area on a dynamic air-removal cycle because these cycles are more efficient than gravity-displacement cycles. In a dynamic air-removal cycle, the chamber is heated with greater speed and this allows for a shorter exposure time for the items to achieve sterilization.1,2 Dynamic air-removal cycles often are identified by the device manufacturer’s instructions for use as the cycle to be used for devices being sterilized. Rigid sterilization containers designated for IUSS are commonly designed to
permit the use of a dynamic air-removal cycle. The only reason to choose a gravity-displacement cycle over a dynamic air-removal cycle is if it is the specific cycle recommended by the device manufacturer.
SHARON A. VAN WICKLIN MSN, RN, CNOR, CRNFA, CPSN, PLNC PERIOPERATIVE NURSING SPECIALIST AORN NURSING DEPARTMENT CYNTHIA SPRY MA, MS, RN, CNOR, CSPDT INDEPENDENT CLINICAL CONSULTANT NEW YORK, NY RAMONA CONNER MSN, RN, CNOR MANAGER, STANDARDS AND RECOMMENDED PRACTICES AORN NURSING DEPARTMENT References 1. Goodman T, Spry C. Prevention of infection: preparation of instruments and items used in surgery: sterilization and disinfection. In: Essentials of Perioperative Nursing. 5th ed. Burlington, MA: Jones & Bartlett Learning; 2013: 37-68. 2. Recommended practices for sterilization. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:513-540.
Terminal sterilization using steam sterilizers located outside of the sterile processing area QUESTION: One of our steam sterilizers in the sterile processing area is disabled. Can an instrument set be terminally sterilized in a steam sterilizer that is located outside of the sterile processing area (eg, between two ORs) and stored for later use? ANSWER: An instrument set may be terminally sterilized in a steam sterilizer that is located outside of the sterile processing area and stored for later use if the following conditions have been met:
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The item n has been subjected to the same decontamination processes as would be performed if the item was being terminally sterilized in the sterile processing area, and the decontamination process is performed in an area intended, designed, and equipped for decontamination activities1; n is packaged and labeled in the same manner it would be if the item were being terminally sterilized in the sterile processing area, and the sterilization container has been cleared
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n n
n
n
n
by the US Food and Drug Administration for terminal sterilization1; and n is sterilized according to the device manufacturer’s instructions for use and is sterilized using the same cycle, exposure time, and dry time as would be used if the item were being terminally sterilized in the sterile processing area.1 Physical monitors (eg, printouts, graphs) are used to verify cycle parameters.1 Biological and chemical indicators are used to monitor sterilizer efficacy and assess whether conditions of sterilization have been achieved.1 The completed documentation for the sterilized item is the same as it would be if the item had been terminally sterilized in the sterile processing area. This documentation includes the n contents of each load; n load identification; n exposure parameters; n operator’s name or initials; and n results of physical, chemical, and biological monitors.1 The personnel performing the terminal sterilization of the item have received education and completed competency verification activities related to the terminal sterilization process.1 The item is stored under environmentally controlled conditions (ie, room temperature, humidity, ventilation) that are monitored and
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compliant with local, state, and federal policies and regulations, and the n access to sterile supply areas is limited to personnel who are educated in handling sterile supplies, and n supplies are stored in a manner that allows adequate air circulation in compliance with local fire code and in a manner that allows ease of cleaning and reduces the risk of contamination.1
SHARON A. VAN WICKLIN MSN, RN, CNOR, CRNFA, CPSN, PLNC PERIOPERATIVE NURSING SPECIALIST AORN NURSING DEPARTMENT CYNTHIA SPRY MA, MS, RN, CNOR, CSPDT INDEPENDENT CLINICAL CONSULTANT NEW YORK, NY RAMONA CONNER MSN, RN, CNOR MANAGER, STANDARDS AND RECOMMENDED PRACTICES AORN NURSING DPEARTMENT
Reference 1. Recommended practices for sterilization. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:513-540.
Physical, chemical, and biological monitoring tools for steam sterilizers located outside of the sterile processing area and used for immediate use steam sterilization (IUSS) QUESTION: We are changing the IUSS cycles in our steam sterilizers located outside of the sterile processing area (eg, between two ORs) from gravitydisplacement cycles to dynamic air-removal cycles. Can we continue to use the same physical, chemical, and biological monitoring tools?
ANSWER: With the exception of the biological indicator, the monitoring tools for a gravity-displacement cycle and a dynamic air-removal cycle are the same. Physical monitors are automated devices such as printouts, digital readings, graphs, or gauges that record cycle parameters and can provide a rapid
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means of identification of sterilizer failure.1 The physical monitors on the steam sterilizer located outside of the sterile processing area will remain the same whether the cycle used for IUSS is gravity displacement or dynamic air removal. Chemical indicators are used to verify that one or more of the conditions necessary for sterilization have been achieved within each package.1 The chemical indicators used in the steam sterilizer located outside of the sterile processing area will remain the same whether the cycle used for IUSS is gravity displacement or dynamic air removal. n
A class 1 chemical indicator (ie, process indicator) should be placed on the outside of every package unless the internal indicator is visible through the package material.1 n A class 5 chemical indicator (ie, integrating indicator) or class 6 chemical indicator (ie, emulating indicator) should be placed inside every package.1 Biological indicators are monitoring devices commercially prepared with a known population of highly resistant spores that test the effectiveness of the method of sterilization being used during the sterilizer cycle that is being monitored.1 The
biological indicator used in the steam sterilizer located outside of the sterile processing area may be different for a gravity-displacement cycle than for a dynamic air-removal cycle. Personnel with assigned responsibility for monitoring sterilizer efficacy should verify that the correct biological indicator is used.
SHARON A. VAN WICKLIN MSN, RN, CNOR, CRNFA, CPSN, PLNC PERIOPERATIVE NURSING SPECIALIST AORN NURSING DEPARTMENT CYNTHIA SPRY MA, MS, RN, CNOR, CSPDT INDEPENDENT CLINICAL CONSULTANT NEW YORK, NY RAMONA CONNER MSN, RN, CNOR MANAGER, STANDARDS AND RECOMMENDED PRACTICES AORN NURSING DEPARTMENT
Reference 1. Recommended practices for sterilization. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:513-540.
Unscrubbed personnel wearing long-sleeved jackets QUESTION: Recently my employer began implementing AORN’s recommendation that unscrubbed personnel in the OR or invasive procedure room should wear a long-sleeved jacket, snapped closed at all times. Long sleeves make it difficult to perform the preoperative patient skin antisepsis without the sleeve touching the prepped area on the patient. Do you have any suggestions to help with this? ANSWER: The recommendation for nonscrubbed personnel to wear long-sleeved jackets in the OR or invasive 316 j AORN Journal
procedure room is not a new recommendation. It has been a part of the AORN “Recommended practices for surgical attire” since 1994.1 Wearing long-sleeved attire helps contain skin squames shed from bare arms.2 Consequently, if the RN circulator performs the preoperative skin antisepsis without wearing a long-sleeved jacket, skin squames from his or her bare arms may drop onto the area that is being prepped and may increase the patient’s risk of a surgical site infection. To prevent the jacket sleeve from touching the area on the patient that is being prepped, it may be helpful to wear a smaller jacket so the sleeves are not so bulky. Another solution might be to use one
CLINICAL ISSUES hand to perform the preoperative skin antisepsis and use the opposite hand (placed in a position that is not directly over the area being prepped) to hold the sleeve up and out of the way while performing the preoperative skin prep. Your question illustrates the importance of, and the need for, perioperative personnel to communicate their concerns regarding the design of longsleeved jackets and other surgical attire not only to managers or other personnel responsible for ordering surgical attire but also to manufacturers designing the attire. It may be that a jacket designed by a different company is more suitable and, if not, there may be a market for manufacturers to create more suitable jackets. Longsleeved scrub tops with close fitting sleeves are currently available. When evaluating long-sleeved jackets or scrub tops, perioperative personnel should review the manufacturer’s literature and verify that the jacket material is sufficiently tightly woven, stain resistant, and durable for use in the perioperative environment. Fabrics with pore sizes greater than 80 microns may allow microorganisms attached to skin squames to pass through the interstices of the material’s weave.3 Additionally, it is necessary to determine whether the material can be commercially laundered after each daily use in a health careeaccredited laundry facility. There also may be regulatory requirements
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regarding the flammability of the material or the application of a fire-retardant chemical that must be adhered to.4 Following the AORN “Recommended practices for surgical attire”5 and collaborating with facility infection prevention personnel will help determine best practices for surgical attire that may decrease the risk of surgical site infection in perioperative patients.
SHARON A. VAN WICKLIN MSN, RN, CNOR, CRNFA, CPSN, PLNC PERIOPERATIVE NURSING SPECIALIST AORN NURSING DEPARTMENT
References 1. Recommended practices for surgical attire. In: Standards & Recommended Practices. Denver, CO: AORN, Inc; 1994:125-129. 2. Anderson BM, Solheim N. Occlusive scrub suits in operating theaters during cataract surgery: effect on airborne contamination. Infect Control Hosp Epidemiol. 2002; 23(4):218-220. 3. Whyte W, Hamblen DL, Kelly IG, Hambraeus AL, Laurell G. An investigation of occlusive polyester surgical clothing. J Hosp Infect. 1990;15(4):363-374. 4. US Department of Health and Human Services. Standard for the flammability of clothing textiles. 16 CFR x1610. http://www.ecfr.gov/cgi-bin/text-idx?c¼ecfr&tpl¼/ ecfrbrowse/Title16/16cfr1610_main_02.tpl. Accessed May 29, 2013. 5. Recommended practices for surgical attire. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:513-540.
Unscrubbed personnel wearing blankets over surgical attire QUESTION: I have noticed unscrubbed personnel wearing blankets over their surgical attire during operative and other invasive procedures. Is this acceptable? ANSWER: Unscrubbed personnel should not wear blankets over surgical attire for a variety of reasons. These include the potential for contamination of the surgical attire and sterile field and the potential for slips, trips, and falls.
According to the AORN “Recommended practices for surgical attire,” the scrub top should either be tucked in at the waist or fit close to the body, and the long-sleeved jacket should be snapped closed.1 Wearing surgical attire close to the body helps prevent skin squames from being shed into the environment and also helps to prevent contamination of sterile areas by inadvertent contact with the loose garments of a nonscrubbed team member. Blankets worn over surgical attire by nonscrubbed team members are bulky, and the ends and other portions of the AORN Journal j 317
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blankets have the potential to inadvertently contact and contaminate sterile areas. Blankets and other materials used in the OR or other invasive procedure room for patients should be low-linting. Lint particles are dispersed into the environment where microorganisms attach to them.1 The bacteria-laden lint can settle onto surgical sites and wounds and may increase postoperative patient complications. Blankets used in the perioperative areas may be considered low-linting; however, they are not as low-linting as surgical attire material. Wrapping blankets over surgical attire has the potential to transfer lint from the blanket to the scrub attire and other surfaces the blanket contacts. There also is a concern for cross-contamination because the blanket may touch the floor and the unscrubbed team member’s shoes, as well as the bottoms of chairs and rolling stools, all of which may not be as frequently or as thoroughly cleaned as other surfaces in the OR. Pathogens could be transferred from these surfaces to the blanket and then to the unscrubbed team member’s attire or hands when the blanket is adjusted or removed. This is especially true if the same blanket is used during multiple procedures. A wrapped blanket could possibly limit the unscrubbed person’s immediate access to the patient if he or she is unable to remove the blanket quickly. There also is the potential for perioperative personnel wearing blankets to accidentally trip or fall if the blanket gets in the way.
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The temperature in the OR and other invasive procedure rooms should be maintained between 68 F and 75 F (20 C and 24 C) to provide a safe and comfortable climate for both patients and perioperative personnel.2 If the temperature is not maintained within these recommended parameters during operative and other invasive procedures, unscrubbed perioperative personnel may resort to wearing blankets over their surgical attire because they are cold. A team approach should be taken to consider the reasons unscrubbed perioperative personnel are wearing blankets and create alternative solutions for comfort. Additional layers of clothing can be worn under surgical attire as long as they are completely covered by the surgical attire.1 This may be a better option for warmth and present a more professional image than having unscrubbed team members wrapped in blankets to stay warm.
SHARON A. VAN WICKLIN MSN, RN, CNOR, CRNFA, CPSN, PLNC PERIOPERATIVE NURSING SPECIALIST AORN NURSING DEPARTMENT
References 1. Recommended practices for surgical attire. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:513-540. 2. ANSI/ASHRAE/ASHE Standard 170-2008. Ventilation of health care facilities. Space ventilation. In: Guidelines for Design and Construction of Health Care Facilities, 2010. Chicago, IL: American Society for Healthcare Engineering (ASHE); 2010:7-9.
LEARNER EVALUATION
1.7
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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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.
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: _______________________________
PURPOSE/GOAL The purpose of this activity is to provide the reader with knowledge of AORN recommended practices related to sterilization and surgical attire. OBJECTIVES To what extent were the following objectives of this continuing education program achieved? 1. Discuss practices that could jeopardize safety in the perioperative area. Low 1. 2. 3. 4. 5. High 2. Discuss common areas of concern that relate to perioperative best practices. Low 1. 2. 3. 4. 5. High 3. Describe implementation of evidence-based practice in relation to perioperative nursing care. Low 1. 2. 3. 4. 5. High
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 5. To what extent were your individual objectives met? Low 1. 2. 3. 4. 5. High
8. Our accrediting body requires that we verify the time you needed to complete the 1.7 continuing education contact hour (102-minute) program: _______________________________
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SHARON A. VAN WICKLIN, MSN, RN, CNOR, CRNFA, CPSN, PLNC; CYNTHIA SPRY, MA, MS, RN, CNOR, CSPDT; RAMONA CONNER, MSN, RN, CNOR
www.aorn.org/CE Continuing Education Contact Hours 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. Event: #13525 Session: #0001 Fee: Members $10.20, Nonmembers $20.40 The CE contact hours for this article expire September 30, 2016.
Purpose/Goal The purpose of this activity is to provide the reader with knowledge of AORN recommended practices related to sterilization and surgical attire.
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 Sharon A. Van Wicklin, MSN, RN, CNOR, CRNFA, CPSN, PLNC, has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. Ramona Conner, MSN, RN, CNOR, has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. Cynthia Spry, MA, MS, RN, CNOR, CSPDT, as an independent clinical consultant for sterilization, disinfection, and related infection control issues, has declared an 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.
Sponsorship or Commercial Support
Accreditation
No sponsorship or commercial support was received for this article.
AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
Disclaimer
Approvals This program meets criteria for CNOR and CRNFA recertification, as well as other CE requirements.
AORN recognizes these activities as CE for registered nurses. 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.2013.06.003
310 j AORN Journal
September 2013 Vol 98 No 3
Ó AORN, Inc, 2013
CLINICAL ISSUES
1.7
www.aorn.org/CE
This Month Requirements for immediate use steam sterilization (IUSS) Key words: immediate use steam sterilization, IUSS.
Gravity-displacement and dynamic air-removal cycles for steam sterilizers located outside of the sterile processing area Key words: gravity displacement, dynamic air removal, flash cycles, immediate use steam sterilization, IUSS.
Terminal sterilization using steam sterilizers located outside of the sterile processing area Key words: terminal sterilization, physical monitors, chemical indicators, biological indicators.
Physical, chemical, and biological monitoring tools for steam sterilizers located outside of the sterile processing area and used for immediate use steam sterilization (IUSS) Key words: physical monitors, chemical indicators, biological indicators, gravity displacement, dynamic air removal.
Unscrubbed personnel wearing long-sleeved jackets Key words: long-sleeved jackets, recommended practices, skin squames, preoperative skin antisepsis, skin prep.
Unscrubbed personnel wearing blankets over surgical attire Key words: blankets, low-linting, surgical attire, skin squames, trips and falls, professional appearance.
Requirements for immediate use steam sterilization (IUSS) QUESTION: What are the requirements for IUSS? ANSWER: Immediate use is considered the shortest time possible between a sterilized item’s removal from
the sterilizer and its aseptic transfer to the sterile field. The term IUSS has been endorsed by AORN, the Association for Professionals in Infection Control and Epidemiology, the International Association of Healthcare Central Service Materiel Management, the Accreditation Association of
http://dx.doi.org/10.1016/j.aorn.2013.06.003
Ó AORN, Inc, 2013
September 2013
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Ambulatory Healthcare, the Association of Surgical Technologists, and the ASC Quality Collaboration.1 The term flash sterilization has historically been used to describe steam sterilization of unwrapped items intended for immediate use. This term no longer describes the processes and cycles used to sterilize items not intended to be stored for later use. For this reason, the more appropriate term is IUSS.1 Items being subjected to IUSS should undergo the same decontamination processes as would be performed if the items were being terminally sterilized. Decontamination should be performed in an area intended, designed, and equipped for decontamination activities.2 Additionally, the following conditions should be met:
n
n
n n
n
The device manufacturer’s written instructions should be readily available, and the parameters to be used for IUSS as well as for cleaning, cycle type, exposure times, temperature settings, and drying times (if required) should be defined and followed.2 n When the device manufacturer does not provide instructions for IUSS, the device should not be sterilized in this manner.1 n When the device manufacturer’s instructions are unclear or in conflict with the instructions for the sterilizer or container, the device manufacturer should be contacted for additional guidance.1 n If the instructions for a device’s container call for a longer exposure time than the device, the container manufacturer should be contacted for additional guidance.1 n If conflicting instructions cannot be reconciled and the device is urgently required, the device manufacturer’s instructions should be followed.1 n The item should be placed in a containment device that has been validated for IUSS and cleared by the US Food and Drug Administration for this purpose.2 n The item should be positioned in the container in a manner that allows for steam contact with 312 j AORN Journal
all surfaces, and the manufacturer’s instructions for use of the containment device should be readily available and followed.2 The sterilizer manufacturers’ written instructions should be readily available and followed.2 Each sterilization cycle should be monitored with physical monitors (eg, printouts, graphs) and chemical indicators to verify that sterilization parameters have been met. Biological indicators should be included as required for load release purposes (eg, loads containing an implant) to confirm sterilizer efficacy.2 The item should be transported to the point of use in a manner that prevents contamination.2 The item should be used immediately, not stored for later use or held from one procedure to another.2
Immediate use steam sterilization cycle information and monitoring results should be maintained in an electronic or manual log that includes the n n n n n n n
n
items processed, identity of the patient on whom the items were used, type of cycle (eg, gravity-displacement, dynamic air-removal), cycle parameters used (eg, temperature, duration of cycle), monitoring results, date and time the cycle was run, operator information (ie, the name of the person who initiated the cycle, the name of the person who retrieved the items from the sterilizer), and reason for IUSS.2
Use of IUSS should be kept to a minimum, it should be used only in selected clinical situations, and it should be conducted in a controlled manner. It should not be used as a substitute for sufficient instrument inventory. Immediate use steam sterilization should not be used to sterilize implantable devices except in cases of defined emergency, when no other option is available.2
CLINICAL ISSUES
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SHARON A. VAN WICKLIN MSN, RN, CNOR, CRNFA, CPSN, PLNC PERIOPERATIVE NURSING SPECIALIST AORN NURSING DEPARTMENT
Perioperative personnel performing IUSS should receive education and should complete competency verification activities regarding the different types of steam sterilizers (ie, gravity-displacement, dynamic air-removal) and the different types of sterilization cycles that are in use within the organization, including n n n n
n
procedures for decontamination of devices before sterilization; operation and maintenance of sterilization equipment; selection of sterilization cycles; monitoring of sterilization cycles, including use of chemical and biological indicators and physical monitors; and documentation requirements.2
Immediate use steam sterilization involves much more than simply pushing a pre-programmed button on a sterilizer. Reprocessing of surgical instruments is a complex process that should be taken seriously. All of the steps required for achieving a sterile device and safely delivering it to the sterile field without contamination should be carefully followed, even when the device is needed immediately.
CYNTHIA SPRY MA, MS, RN, CNOR, CSPDT INDEPENDENT CLINICAL CONSULTANT NEW YORK, NY RAMONA CONNER MSN, RN, CNOR MANAGER, STANDARDS AND RECOMMENDED PRACTICES AORN NURSING DEPARTMENT
References 1. Association for the Advancement of Medical Instrumentation, Accreditation Association for Ambulatory Health Care, AORN, Association for Professionals in Infection Control and Epidemiology, ASC Quality Collaboration, International Association of Healthcare Central Service Materiel Management. Immediate-use steam sterilization. Association for the Advancement of Medical Instrumentation. https://www.aami.org/publications/standards/ ST79_Immediate_Use_Statement.pdf. Accessed May 10, 2013. 2. Recommended practices for sterilization. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:513-540.
Gravity-displacement and dynamic air-removal cycles for steam sterilizers located outside of the sterile processing area QUESTION: A colleague told me that if we convert the cycles on the steam sterilizers located outside of the sterile processing area (eg, between two ORs) from gravity-displacement to dynamic airremoval, they are no longer considered to be flash cycles. Is this true? ANSWER: The type of cycle (ie, gravity-displacement or dynamic air-removal) that is used for steam sterilization does not determine whether an item is being flash sterilized. Immediate use steam sterilization (IUSS), formerly known as flash sterilization, can
be accomplished using either a gravity-displacement or a dynamic air-removal cycle. The difference between the cycles is in the mechanism of action used to achieve sterilization. n
Gravity displacement is a method of steam sterilization in which the incoming air displaces the residual air through a port or drain near the bottom of the sterilizer chamber. Air is heavier than steam, so gravity forces the air to the bottom of the sterilizer as the steam rises to the top.1,2 n Dynamic air removal is a method of steam sterilization in which air removal is mechanically AORN Journal j 313
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assisted by a vacuum pump. The vacuum pump removes the air before the steam is injected into the sterilizer. Because of the vacuum that is created, when the steam enters the sterilizer, there is almost immediate contact with all surfaces of the items in the sterilizer.1,2 Both gravity-displacement and dynamic airremoval cycles may be used to achieve either IUSS or terminal sterilization.2 In the past, steam sterilizers allowed the use of gravity-displacement cycles only. Current steam sterilizers may be designed to provide either gravity-displacement or dynamic air-removal cycles, depending on how they are set. Some facilities may have policies that mandate setting the steam sterilizers located outside of the sterile processing area on a dynamic air-removal cycle because these cycles are more efficient than gravity-displacement cycles. In a dynamic air-removal cycle, the chamber is heated with greater speed and this allows for a shorter exposure time for the items to achieve sterilization.1,2 Dynamic air-removal cycles often are identified by the device manufacturer’s instructions for use as the cycle to be used for devices being sterilized. Rigid sterilization containers designated for IUSS are commonly designed to
permit the use of a dynamic air-removal cycle. The only reason to choose a gravity-displacement cycle over a dynamic air-removal cycle is if it is the specific cycle recommended by the device manufacturer.
SHARON A. VAN WICKLIN MSN, RN, CNOR, CRNFA, CPSN, PLNC PERIOPERATIVE NURSING SPECIALIST AORN NURSING DEPARTMENT CYNTHIA SPRY MA, MS, RN, CNOR, CSPDT INDEPENDENT CLINICAL CONSULTANT NEW YORK, NY RAMONA CONNER MSN, RN, CNOR MANAGER, STANDARDS AND RECOMMENDED PRACTICES AORN NURSING DEPARTMENT References 1. Goodman T, Spry C. Prevention of infection: preparation of instruments and items used in surgery: sterilization and disinfection. In: Essentials of Perioperative Nursing. 5th ed. Burlington, MA: Jones & Bartlett Learning; 2013: 37-68. 2. Recommended practices for sterilization. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:513-540.
Terminal sterilization using steam sterilizers located outside of the sterile processing area QUESTION: One of our steam sterilizers in the sterile processing area is disabled. Can an instrument set be terminally sterilized in a steam sterilizer that is located outside of the sterile processing area (eg, between two ORs) and stored for later use? ANSWER: An instrument set may be terminally sterilized in a steam sterilizer that is located outside of the sterile processing area and stored for later use if the following conditions have been met:
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The item n has been subjected to the same decontamination processes as would be performed if the item was being terminally sterilized in the sterile processing area, and the decontamination process is performed in an area intended, designed, and equipped for decontamination activities1; n is packaged and labeled in the same manner it would be if the item were being terminally sterilized in the sterile processing area, and the sterilization container has been cleared
CLINICAL ISSUES
n n
n
n
n
by the US Food and Drug Administration for terminal sterilization1; and n is sterilized according to the device manufacturer’s instructions for use and is sterilized using the same cycle, exposure time, and dry time as would be used if the item were being terminally sterilized in the sterile processing area.1 Physical monitors (eg, printouts, graphs) are used to verify cycle parameters.1 Biological and chemical indicators are used to monitor sterilizer efficacy and assess whether conditions of sterilization have been achieved.1 The completed documentation for the sterilized item is the same as it would be if the item had been terminally sterilized in the sterile processing area. This documentation includes the n contents of each load; n load identification; n exposure parameters; n operator’s name or initials; and n results of physical, chemical, and biological monitors.1 The personnel performing the terminal sterilization of the item have received education and completed competency verification activities related to the terminal sterilization process.1 The item is stored under environmentally controlled conditions (ie, room temperature, humidity, ventilation) that are monitored and
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compliant with local, state, and federal policies and regulations, and the n access to sterile supply areas is limited to personnel who are educated in handling sterile supplies, and n supplies are stored in a manner that allows adequate air circulation in compliance with local fire code and in a manner that allows ease of cleaning and reduces the risk of contamination.1
SHARON A. VAN WICKLIN MSN, RN, CNOR, CRNFA, CPSN, PLNC PERIOPERATIVE NURSING SPECIALIST AORN NURSING DEPARTMENT CYNTHIA SPRY MA, MS, RN, CNOR, CSPDT INDEPENDENT CLINICAL CONSULTANT NEW YORK, NY RAMONA CONNER MSN, RN, CNOR MANAGER, STANDARDS AND RECOMMENDED PRACTICES AORN NURSING DPEARTMENT
Reference 1. Recommended practices for sterilization. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:513-540.
Physical, chemical, and biological monitoring tools for steam sterilizers located outside of the sterile processing area and used for immediate use steam sterilization (IUSS) QUESTION: We are changing the IUSS cycles in our steam sterilizers located outside of the sterile processing area (eg, between two ORs) from gravitydisplacement cycles to dynamic air-removal cycles. Can we continue to use the same physical, chemical, and biological monitoring tools?
ANSWER: With the exception of the biological indicator, the monitoring tools for a gravity-displacement cycle and a dynamic air-removal cycle are the same. Physical monitors are automated devices such as printouts, digital readings, graphs, or gauges that record cycle parameters and can provide a rapid
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means of identification of sterilizer failure.1 The physical monitors on the steam sterilizer located outside of the sterile processing area will remain the same whether the cycle used for IUSS is gravity displacement or dynamic air removal. Chemical indicators are used to verify that one or more of the conditions necessary for sterilization have been achieved within each package.1 The chemical indicators used in the steam sterilizer located outside of the sterile processing area will remain the same whether the cycle used for IUSS is gravity displacement or dynamic air removal. n
A class 1 chemical indicator (ie, process indicator) should be placed on the outside of every package unless the internal indicator is visible through the package material.1 n A class 5 chemical indicator (ie, integrating indicator) or class 6 chemical indicator (ie, emulating indicator) should be placed inside every package.1 Biological indicators are monitoring devices commercially prepared with a known population of highly resistant spores that test the effectiveness of the method of sterilization being used during the sterilizer cycle that is being monitored.1 The
biological indicator used in the steam sterilizer located outside of the sterile processing area may be different for a gravity-displacement cycle than for a dynamic air-removal cycle. Personnel with assigned responsibility for monitoring sterilizer efficacy should verify that the correct biological indicator is used.
SHARON A. VAN WICKLIN MSN, RN, CNOR, CRNFA, CPSN, PLNC PERIOPERATIVE NURSING SPECIALIST AORN NURSING DEPARTMENT CYNTHIA SPRY MA, MS, RN, CNOR, CSPDT INDEPENDENT CLINICAL CONSULTANT NEW YORK, NY RAMONA CONNER MSN, RN, CNOR MANAGER, STANDARDS AND RECOMMENDED PRACTICES AORN NURSING DEPARTMENT
Reference 1. Recommended practices for sterilization. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:513-540.
Unscrubbed personnel wearing long-sleeved jackets QUESTION: Recently my employer began implementing AORN’s recommendation that unscrubbed personnel in the OR or invasive procedure room should wear a long-sleeved jacket, snapped closed at all times. Long sleeves make it difficult to perform the preoperative patient skin antisepsis without the sleeve touching the prepped area on the patient. Do you have any suggestions to help with this? ANSWER: The recommendation for nonscrubbed personnel to wear long-sleeved jackets in the OR or invasive 316 j AORN Journal
procedure room is not a new recommendation. It has been a part of the AORN “Recommended practices for surgical attire” since 1994.1 Wearing long-sleeved attire helps contain skin squames shed from bare arms.2 Consequently, if the RN circulator performs the preoperative skin antisepsis without wearing a long-sleeved jacket, skin squames from his or her bare arms may drop onto the area that is being prepped and may increase the patient’s risk of a surgical site infection. To prevent the jacket sleeve from touching the area on the patient that is being prepped, it may be helpful to wear a smaller jacket so the sleeves are not so bulky. Another solution might be to use one
CLINICAL ISSUES hand to perform the preoperative skin antisepsis and use the opposite hand (placed in a position that is not directly over the area being prepped) to hold the sleeve up and out of the way while performing the preoperative skin prep. Your question illustrates the importance of, and the need for, perioperative personnel to communicate their concerns regarding the design of longsleeved jackets and other surgical attire not only to managers or other personnel responsible for ordering surgical attire but also to manufacturers designing the attire. It may be that a jacket designed by a different company is more suitable and, if not, there may be a market for manufacturers to create more suitable jackets. Longsleeved scrub tops with close fitting sleeves are currently available. When evaluating long-sleeved jackets or scrub tops, perioperative personnel should review the manufacturer’s literature and verify that the jacket material is sufficiently tightly woven, stain resistant, and durable for use in the perioperative environment. Fabrics with pore sizes greater than 80 microns may allow microorganisms attached to skin squames to pass through the interstices of the material’s weave.3 Additionally, it is necessary to determine whether the material can be commercially laundered after each daily use in a health careeaccredited laundry facility. There also may be regulatory requirements
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regarding the flammability of the material or the application of a fire-retardant chemical that must be adhered to.4 Following the AORN “Recommended practices for surgical attire”5 and collaborating with facility infection prevention personnel will help determine best practices for surgical attire that may decrease the risk of surgical site infection in perioperative patients.
SHARON A. VAN WICKLIN MSN, RN, CNOR, CRNFA, CPSN, PLNC PERIOPERATIVE NURSING SPECIALIST AORN NURSING DEPARTMENT
References 1. Recommended practices for surgical attire. In: Standards & Recommended Practices. Denver, CO: AORN, Inc; 1994:125-129. 2. Anderson BM, Solheim N. Occlusive scrub suits in operating theaters during cataract surgery: effect on airborne contamination. Infect Control Hosp Epidemiol. 2002; 23(4):218-220. 3. Whyte W, Hamblen DL, Kelly IG, Hambraeus AL, Laurell G. An investigation of occlusive polyester surgical clothing. J Hosp Infect. 1990;15(4):363-374. 4. US Department of Health and Human Services. Standard for the flammability of clothing textiles. 16 CFR x1610. http://www.ecfr.gov/cgi-bin/text-idx?c¼ecfr&tpl¼/ ecfrbrowse/Title16/16cfr1610_main_02.tpl. Accessed May 29, 2013. 5. Recommended practices for surgical attire. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:513-540.
Unscrubbed personnel wearing blankets over surgical attire QUESTION: I have noticed unscrubbed personnel wearing blankets over their surgical attire during operative and other invasive procedures. Is this acceptable? ANSWER: Unscrubbed personnel should not wear blankets over surgical attire for a variety of reasons. These include the potential for contamination of the surgical attire and sterile field and the potential for slips, trips, and falls.
According to the AORN “Recommended practices for surgical attire,” the scrub top should either be tucked in at the waist or fit close to the body, and the long-sleeved jacket should be snapped closed.1 Wearing surgical attire close to the body helps prevent skin squames from being shed into the environment and also helps to prevent contamination of sterile areas by inadvertent contact with the loose garments of a nonscrubbed team member. Blankets worn over surgical attire by nonscrubbed team members are bulky, and the ends and other portions of the AORN Journal j 317
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blankets have the potential to inadvertently contact and contaminate sterile areas. Blankets and other materials used in the OR or other invasive procedure room for patients should be low-linting. Lint particles are dispersed into the environment where microorganisms attach to them.1 The bacteria-laden lint can settle onto surgical sites and wounds and may increase postoperative patient complications. Blankets used in the perioperative areas may be considered low-linting; however, they are not as low-linting as surgical attire material. Wrapping blankets over surgical attire has the potential to transfer lint from the blanket to the scrub attire and other surfaces the blanket contacts. There also is a concern for cross-contamination because the blanket may touch the floor and the unscrubbed team member’s shoes, as well as the bottoms of chairs and rolling stools, all of which may not be as frequently or as thoroughly cleaned as other surfaces in the OR. Pathogens could be transferred from these surfaces to the blanket and then to the unscrubbed team member’s attire or hands when the blanket is adjusted or removed. This is especially true if the same blanket is used during multiple procedures. A wrapped blanket could possibly limit the unscrubbed person’s immediate access to the patient if he or she is unable to remove the blanket quickly. There also is the potential for perioperative personnel wearing blankets to accidentally trip or fall if the blanket gets in the way.
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The temperature in the OR and other invasive procedure rooms should be maintained between 68 F and 75 F (20 C and 24 C) to provide a safe and comfortable climate for both patients and perioperative personnel.2 If the temperature is not maintained within these recommended parameters during operative and other invasive procedures, unscrubbed perioperative personnel may resort to wearing blankets over their surgical attire because they are cold. A team approach should be taken to consider the reasons unscrubbed perioperative personnel are wearing blankets and create alternative solutions for comfort. Additional layers of clothing can be worn under surgical attire as long as they are completely covered by the surgical attire.1 This may be a better option for warmth and present a more professional image than having unscrubbed team members wrapped in blankets to stay warm.
SHARON A. VAN WICKLIN MSN, RN, CNOR, CRNFA, CPSN, PLNC PERIOPERATIVE NURSING SPECIALIST AORN NURSING DEPARTMENT
References 1. Recommended practices for surgical attire. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:513-540. 2. ANSI/ASHRAE/ASHE Standard 170-2008. Ventilation of health care facilities. Space ventilation. In: Guidelines for Design and Construction of Health Care Facilities, 2010. Chicago, IL: American Society for Healthcare Engineering (ASHE); 2010:7-9.
LEARNER EVALUATION
1.7
CONTINUING EDUCATION PROGRAM
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his evaluation is used to determine the extent to which this continuing education program met your learning needs. The evaluation is printed here for your convenience. To receive continuing education credit, you must complete the Learner Evaluation online at http://www.aorn.org/CE. Rate the items as described below.
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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.
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: _______________________________
PURPOSE/GOAL The purpose of this activity is to provide the reader with knowledge of AORN recommended practices related to sterilization and surgical attire. OBJECTIVES To what extent were the following objectives of this continuing education program achieved? 1. Discuss practices that could jeopardize safety in the perioperative area. Low 1. 2. 3. 4. 5. High 2. Discuss common areas of concern that relate to perioperative best practices. Low 1. 2. 3. 4. 5. High 3. Describe implementation of evidence-based practice in relation to perioperative nursing care. Low 1. 2. 3. 4. 5. High
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 5. To what extent were your individual objectives met? Low 1. 2. 3. 4. 5. High
8. Our accrediting body requires that we verify the time you needed to complete the 1.7 continuing education contact hour (102-minute) program: _______________________________
Ó AORN, Inc, 2013
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