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Committee Addresses OR Hazards
JANUARY 1988, VOL. 47. NO I
A O R N JOURNAL
Committee Addresses OR Hazards
P
rotecting the patient and the surgeon in the O R from acquired immune deficiency syndrome (AIDS) and electrical and chemical hazards was the focus of the American College of Surgeons (ACS) Committee on Operating Room Environment panel discussion at the ACS Clinical Congress held in San Francisco, Oct 11 to 16. Clifford H. Jordan, RN, EdD, FAAN, AORN executive director, is the AORN liaison to that committee. Members of the panel were: Ronald Lee Nichols, MD, FACS, Henderson professor and vice chairman in the department of surgery, and professor at the Tulane University Medical Center, New Orleans, Mark A. Malangoni, MD, FACS, attending surgeon, Humana Hospital-University, Louisville, and associate professor, University of Louisville, Russell A. Williams, MB, FACS, associate professor, University of California at Los Angeles (UCLA), and attending surgeon, UCLA Medical Center, Bruce E. Stabile, MD, FACS, associate professor, UCLA, and assistant chairman, the Veterans Administration Wadsworth Medical Center, Los Angeles, and Samuel E. Wilson, MD, FACS, professor of surgery, UCLA, chairman of surgery, Los Angeles County-Harbor-UCLA Medical Center, ‘Torrance, Calif. Dr Wilson moderated the panel discussion. The panelists discussed the effectiveness of ultraclean ORs on postoperative infection rates, what precautions to take against AIDS and hepatitis B, how to minimize electrical and chemical hazards in the OR, and the use of antibiotics before and after surgery. The following is a summary of key points.
The Efficacy of Laminar Airflow
D
r Malangoni addressed the effect of the ultraclean operating room (ie, one in which a high energy, particulate air [HEPA] filter and laminar airflow are used) on postoperative infection. His opinion is that using proper surveillance methods in a conventional O R can achieve the same results. “If the guidelines for prevention of surgical wound infection are followed, we see no benefit derived from ultraclean air in reducing surgical wound infection,” Dr Malangoni said. “The expense does not seem to be justified at present.” The ultraclean air system was developed to reduce bacteria in the OR to less than 1 particle per cubic foot. In contrast, a conventional OR has between 15 and 20 particles per cubic foot. according to Dr Malangoni. Dr Malangoni questioned whether an ultraclean air system is absolutely necessary. He said that reduced bacterial counts can be achieved by using good techniques, including wearing hair covers, gowns, and gloves, performing preoperative scrubs, and administering antibiotic prophylactics. He cited a British study on the rate of infection in deep-joint orthopedic procedures. One important point in the study, Dr Malangoni said, was that the patients in the experimental group did not receive any antimicrobial prophylactics. Results showed that when ultraclean air was used, the infection rate was reduced by one half. The same results were achieved in the control group patients who had their surgery in a conventional O R when the surgical team wore exhaust suits, and the patients were placed in isolators and received antibiotics, he said. 287
AORN J O U R N A L
JANUARY 1988, VOL. 47, NO 1
Health care workers experience fear in the OR by not knowing which patients may have the HIV antibody. Dr Malangoni concluded that appropriate air quality does have an effect on wound infection; however, he added that even ultraclean air has no effect when the source of infection is the patient’s own flora.
Preventing AIDS Transmission
A
cquired immune deficiency syndrome is the biological equivalent of the atomic bomb, according to Dr Williams. “It enters cells, takes over multiplication functions, and utilizes them to reproduce itself in large numbers, destroying the cells,” he said. “It then re-invades another cell in this orchestrated fashion.” Dr Williams talked about the fear that many health workers experience in the OR-not knowing which patients may or may not have the human immunodeficiency virus (HIV) antibody or which precautions they should take. He said that additional protection is not necessary when conducting a physical examination; however, he recommends wearing gloves, a mask, eye goggles, and an impervious gown and apron when involved in invasive procedures. He did not recommend double-gloving because a needlestick can easily slice through two layers, but he did suggest eliminating the hand-to-hand passing of instruments. He also presented figures from the Centers for Disease Control (CDC), Atlanta, that as of July 1987, there were 32,395 people in the United States who had AIDS; 1,875, or 5.8%, of these people were health care workers. Furthermore, he said that the risk of health care workers getting AIDS is less than 1%. Dr Williams recommended that all patients undergoing elective surgery be tested for HIV. He said that health care workers should be worried about the patients who do not have symptoms, but carry the HIV antibody in their blood. Dr Williams explained that the enzyme-linked 288
immunosorbent assay (ELISA) test and the Western blot analysis can detect HIV antibodies but there is no test available to detect the presence of the HIV antigen. Such a test will be more accurate, said Dr Williams. Most patients prefer to donate their own blood, even though bank blood is safe; the prevalence of the HIV antibody is less than 1%in bank blood in the United States. He cited a study conducted in Southern California that found 361 out of 750,000 units of blood contained HIV. Blood spills are not a threat to health care workers, Dr Williams said. He cited a study by the CDC that showed that blood drying causes a 90% to 99% reduction in HIV concentration, and that the HIV antibody is less likely to survive at body temperature than at room temperature. He recommended using regular germicidal solution to clean blood spills. Dr Williams also discussed the risk of transmitting HIV with transplanted organs. The patient receiving an organ can contract HIV because the antibody is attracted to T cells, which are inherent in a transplant patient. According to Dr Williams, HIV has been transmitted in transplanted kidneys, and the virus has been isolated but not transplanted in corneal tissue.
A voiding Physical,
Chemical Hazards
T
he physical and chemical hazards in the OR include electrosurgical units, lasers, radiation, and ethylene oxide, according to Dr Stabile. Electrical. Electrosurgical units can cause electrocution, burns, fires, explosions, and macroand microshocks. He called these units the singlemost hazardous equipment in the OR. He explained that improper grounding has the potential to produce a macroshock, which may lead to burns and tissue necrosis. Microshock is less common than macroshock, he said. Micro-
AORN JOURNAL
JANUARY 1988, VOL. 47, NO 1
The most significant safety hazard of lasers to both patient and OR personnel is retinal damage. shock occurs when there is a low-resistance conduit to the heart, such as the improperly grounded patient who has a pacemaker or a catheter coming in contact with a low-frequency current. To prevent improper grounding, Dr Stabile recommended: avoiding alcohol or acetate skin preparation, using gel on the pad, placing the ground on a convex, smooth skin surface that is close to the surgical site, and checking the ground before increasing the power if there is a poor cut or coagulation. Lasers. Lasers can present a safety hazard because they can cause ocular burns, skin burns, smoke inhalation, explosion, electrical shock, and a potential for fire. The most significant safety hazard of lasers to both patient and OR personnel is retinal damage. Wearing eye protection that has side protectors and low-reflection capability is important. Choosing nonflammable anesthetics and using oxygen mixed with nonflammable gases can prevent fire and explosion, according to Dr Stabile. This includes using a minimal amount of oxygen, nitrous oxide, and halogenated gases. When a laser is used in endotracheal procedures, explosions and melting can occur. These problems can be minimized by using saline-filled cuffs, wet cottonoid packing, or jet ventilation. Radiation. Ionizing radiation is more of a hazard in other parts of the hospital than in the OR; however, OR personnel may be at risk from patients who have undergone nuclear studies. In those cases, surgery should be delayed for two days. Anesthetic gases. Long-term exposure to low concentrations of anesthetic agents have been reported to affect mental and motor skills and cause spontaneous abortion, teratogenicity, cancer, hepatic renal disease; however, studies have been inconclusive. Dr Stabile reported that there is no 290
clear evidence of reproductive harm, and that the cancer data is weak and inadequate. Ethylene oxide. If instruments and products are not properly aerated following ethylene oxide sterilization, they may cause severe chemical burns on the skin or mucous membranes. An exposure limit of 1 ppm or less over eight hours is recommended, according to Dr Stabile.
Pros and Cons of Prophylactic Antibiotics
D
r Nichols made recommendations concerning the use of prophylactic antibiotics in the following surgical categories. Gastrointestinal surgery. A common error is using prophylactic antibiotics much longer than necessary, he said. A single dose is all that is needed to protect this group of patients from surgical wound infection. Clean surgery with prostheses. Staphlococcus aureus and Staphlococcus epidermis are the usual infecting organisms in the prosthetic surgery in the United States. Cefazolin sodium is the recommended agent, and vancomycin is the alternate agent recommended if organisms are resistant to cefazolin sodium or if there is an allergy, according to Dr Nichols. Head and neck. Studies disagree on the efficacy of prophylactic antibiotics in this group of patients, and therefore, surgeons will have to decide for themselves, according to Dr Nichols. The Streptococcus family and oral anaerobes are the usual infecting organisms of the pharnyx. Cefazolin sodium is the recommended agent, and clindamycin hydrochloride is the alternate agent recommended. Dr Nichols cited a study in which researchers looked at the importance of administering antibiotics for gram-negative organisms before major head and neck procedures. One hundred four patients were treated-one half were given
AORN JOURNAL
clindamycin hydrochloride alone and the other half received clindamycin hydrochloride with gentamicin sulfate. Dr Nichols reported that the infection rate was the same, and therefore, specific prophylactic treatment for gram-negative organisms does not appear necessary. The same researchers also reported that the length of the treatment did not matter-whether the patients received prophylactics for one day or for five days produced the same results, according to Nichols. Gastric surgery. Gram-negative organisms and oral anaerobes are the usual infecting organisms. The recommended agent is cefazolin sodium, and the alternate agent is cephalosporin. Cholecystectomy. Dr Nichols recommended giving each patient one dose of cephalosporin before cholecystectomy; cefazolin sodium is the
JANUARY 1988, VOL. 47, NO 1
recommended agent to use. Colorectal surgery. Escherichia coli is the usual infecting organism. Neomycin sulfate and erythromycin oral agents are still recommended; however, surgeons have to decide whether to administer one or two grams. Alternative agents can achieve the same results-oral kanamycin sulfate for the aerobes, and tetracycline hydrochloride for the anaerobes. Nichols also suggests that patients be brought in the day before surgery for a gastrointestinal purge followed by an antibiotic treatment. The ACS Committee on Operating Room Environment will present another panel discussion during the 1988 ACS Clinical Congress, Oct 2328, in Chicago. SUSAN SCHLEPP ASSISTANT EDITOR
Tipping Guidelines How much and who to tip puzzles some people. A tip is not an obligation, but a reward for prompt, courteous, and reasonable service. The following are some general guidelines those attending Congress can follow. Hotel personnel. Doormen are generally tipped between 50 cents and $1 if they handle your luggage, regardless of whether you are arriving or departing the hotel. They are also tipped if they assist you in hailing a taxi. Remember to tip the bellmen $1 per bag when they take your luggage to your room. Room maids can be tipped between 50 cents and $1 per day, depending on service. Restaurant and lounge personnel. Waiters and waitresses are generally tipped 15% of the bill (not including tax) and 20%if the service has been outstanding. The same 15%and 20% rule follows for room service. Captains at finer restaurants are tipped 5%of the dinner bill if they prepare food at the table. Wine stewards are tipped $2 per bottle at the better restaurants. Attendants and valets. Attendants who provide services that take only a few minutes (eg, rest room, shoe shine, and coat check) should be tipped between 25 and 75 cents. Valets are 292
tipped 25 cents per garment if it was a rush job or done outside usual hours; you do not have to tip if the charge has been added to the hotel bill. Parking attendants and drivers. You should tip a parking attendant between 50 and 75 cents each way; however, no tip is necessary if you are being charged for parking. Taxi drivers are tipped 20 cents for each dollar or 15%on fares of $15 or more. Drivers for an airport limousine, charter bus, or sightseeing bus are not tipped.
OR Nursing Courses Directory Available The Directory of Specialty Nursing Courses: OR is available free by writing to the AORN Education Department, CE Division, 10170 E Mississippi Ave, Denver, C O 80231. The directory lists RN first assistant courses in addition to undergraduate and postgraduate perioperative nursing courses. The Directory was updated in August 1987.
A O R N JOURNAL
Committee Addresses OR Hazards
P
rotecting the patient and the surgeon in the O R from acquired immune deficiency syndrome (AIDS) and electrical and chemical hazards was the focus of the American College of Surgeons (ACS) Committee on Operating Room Environment panel discussion at the ACS Clinical Congress held in San Francisco, Oct 11 to 16. Clifford H. Jordan, RN, EdD, FAAN, AORN executive director, is the AORN liaison to that committee. Members of the panel were: Ronald Lee Nichols, MD, FACS, Henderson professor and vice chairman in the department of surgery, and professor at the Tulane University Medical Center, New Orleans, Mark A. Malangoni, MD, FACS, attending surgeon, Humana Hospital-University, Louisville, and associate professor, University of Louisville, Russell A. Williams, MB, FACS, associate professor, University of California at Los Angeles (UCLA), and attending surgeon, UCLA Medical Center, Bruce E. Stabile, MD, FACS, associate professor, UCLA, and assistant chairman, the Veterans Administration Wadsworth Medical Center, Los Angeles, and Samuel E. Wilson, MD, FACS, professor of surgery, UCLA, chairman of surgery, Los Angeles County-Harbor-UCLA Medical Center, ‘Torrance, Calif. Dr Wilson moderated the panel discussion. The panelists discussed the effectiveness of ultraclean ORs on postoperative infection rates, what precautions to take against AIDS and hepatitis B, how to minimize electrical and chemical hazards in the OR, and the use of antibiotics before and after surgery. The following is a summary of key points.
The Efficacy of Laminar Airflow
D
r Malangoni addressed the effect of the ultraclean operating room (ie, one in which a high energy, particulate air [HEPA] filter and laminar airflow are used) on postoperative infection. His opinion is that using proper surveillance methods in a conventional O R can achieve the same results. “If the guidelines for prevention of surgical wound infection are followed, we see no benefit derived from ultraclean air in reducing surgical wound infection,” Dr Malangoni said. “The expense does not seem to be justified at present.” The ultraclean air system was developed to reduce bacteria in the OR to less than 1 particle per cubic foot. In contrast, a conventional OR has between 15 and 20 particles per cubic foot. according to Dr Malangoni. Dr Malangoni questioned whether an ultraclean air system is absolutely necessary. He said that reduced bacterial counts can be achieved by using good techniques, including wearing hair covers, gowns, and gloves, performing preoperative scrubs, and administering antibiotic prophylactics. He cited a British study on the rate of infection in deep-joint orthopedic procedures. One important point in the study, Dr Malangoni said, was that the patients in the experimental group did not receive any antimicrobial prophylactics. Results showed that when ultraclean air was used, the infection rate was reduced by one half. The same results were achieved in the control group patients who had their surgery in a conventional O R when the surgical team wore exhaust suits, and the patients were placed in isolators and received antibiotics, he said. 287
AORN J O U R N A L
JANUARY 1988, VOL. 47, NO 1
Health care workers experience fear in the OR by not knowing which patients may have the HIV antibody. Dr Malangoni concluded that appropriate air quality does have an effect on wound infection; however, he added that even ultraclean air has no effect when the source of infection is the patient’s own flora.
Preventing AIDS Transmission
A
cquired immune deficiency syndrome is the biological equivalent of the atomic bomb, according to Dr Williams. “It enters cells, takes over multiplication functions, and utilizes them to reproduce itself in large numbers, destroying the cells,” he said. “It then re-invades another cell in this orchestrated fashion.” Dr Williams talked about the fear that many health workers experience in the OR-not knowing which patients may or may not have the human immunodeficiency virus (HIV) antibody or which precautions they should take. He said that additional protection is not necessary when conducting a physical examination; however, he recommends wearing gloves, a mask, eye goggles, and an impervious gown and apron when involved in invasive procedures. He did not recommend double-gloving because a needlestick can easily slice through two layers, but he did suggest eliminating the hand-to-hand passing of instruments. He also presented figures from the Centers for Disease Control (CDC), Atlanta, that as of July 1987, there were 32,395 people in the United States who had AIDS; 1,875, or 5.8%, of these people were health care workers. Furthermore, he said that the risk of health care workers getting AIDS is less than 1%. Dr Williams recommended that all patients undergoing elective surgery be tested for HIV. He said that health care workers should be worried about the patients who do not have symptoms, but carry the HIV antibody in their blood. Dr Williams explained that the enzyme-linked 288
immunosorbent assay (ELISA) test and the Western blot analysis can detect HIV antibodies but there is no test available to detect the presence of the HIV antigen. Such a test will be more accurate, said Dr Williams. Most patients prefer to donate their own blood, even though bank blood is safe; the prevalence of the HIV antibody is less than 1%in bank blood in the United States. He cited a study conducted in Southern California that found 361 out of 750,000 units of blood contained HIV. Blood spills are not a threat to health care workers, Dr Williams said. He cited a study by the CDC that showed that blood drying causes a 90% to 99% reduction in HIV concentration, and that the HIV antibody is less likely to survive at body temperature than at room temperature. He recommended using regular germicidal solution to clean blood spills. Dr Williams also discussed the risk of transmitting HIV with transplanted organs. The patient receiving an organ can contract HIV because the antibody is attracted to T cells, which are inherent in a transplant patient. According to Dr Williams, HIV has been transmitted in transplanted kidneys, and the virus has been isolated but not transplanted in corneal tissue.
A voiding Physical,
Chemical Hazards
T
he physical and chemical hazards in the OR include electrosurgical units, lasers, radiation, and ethylene oxide, according to Dr Stabile. Electrical. Electrosurgical units can cause electrocution, burns, fires, explosions, and macroand microshocks. He called these units the singlemost hazardous equipment in the OR. He explained that improper grounding has the potential to produce a macroshock, which may lead to burns and tissue necrosis. Microshock is less common than macroshock, he said. Micro-
AORN JOURNAL
JANUARY 1988, VOL. 47, NO 1
The most significant safety hazard of lasers to both patient and OR personnel is retinal damage. shock occurs when there is a low-resistance conduit to the heart, such as the improperly grounded patient who has a pacemaker or a catheter coming in contact with a low-frequency current. To prevent improper grounding, Dr Stabile recommended: avoiding alcohol or acetate skin preparation, using gel on the pad, placing the ground on a convex, smooth skin surface that is close to the surgical site, and checking the ground before increasing the power if there is a poor cut or coagulation. Lasers. Lasers can present a safety hazard because they can cause ocular burns, skin burns, smoke inhalation, explosion, electrical shock, and a potential for fire. The most significant safety hazard of lasers to both patient and OR personnel is retinal damage. Wearing eye protection that has side protectors and low-reflection capability is important. Choosing nonflammable anesthetics and using oxygen mixed with nonflammable gases can prevent fire and explosion, according to Dr Stabile. This includes using a minimal amount of oxygen, nitrous oxide, and halogenated gases. When a laser is used in endotracheal procedures, explosions and melting can occur. These problems can be minimized by using saline-filled cuffs, wet cottonoid packing, or jet ventilation. Radiation. Ionizing radiation is more of a hazard in other parts of the hospital than in the OR; however, OR personnel may be at risk from patients who have undergone nuclear studies. In those cases, surgery should be delayed for two days. Anesthetic gases. Long-term exposure to low concentrations of anesthetic agents have been reported to affect mental and motor skills and cause spontaneous abortion, teratogenicity, cancer, hepatic renal disease; however, studies have been inconclusive. Dr Stabile reported that there is no 290
clear evidence of reproductive harm, and that the cancer data is weak and inadequate. Ethylene oxide. If instruments and products are not properly aerated following ethylene oxide sterilization, they may cause severe chemical burns on the skin or mucous membranes. An exposure limit of 1 ppm or less over eight hours is recommended, according to Dr Stabile.
Pros and Cons of Prophylactic Antibiotics
D
r Nichols made recommendations concerning the use of prophylactic antibiotics in the following surgical categories. Gastrointestinal surgery. A common error is using prophylactic antibiotics much longer than necessary, he said. A single dose is all that is needed to protect this group of patients from surgical wound infection. Clean surgery with prostheses. Staphlococcus aureus and Staphlococcus epidermis are the usual infecting organisms in the prosthetic surgery in the United States. Cefazolin sodium is the recommended agent, and vancomycin is the alternate agent recommended if organisms are resistant to cefazolin sodium or if there is an allergy, according to Dr Nichols. Head and neck. Studies disagree on the efficacy of prophylactic antibiotics in this group of patients, and therefore, surgeons will have to decide for themselves, according to Dr Nichols. The Streptococcus family and oral anaerobes are the usual infecting organisms of the pharnyx. Cefazolin sodium is the recommended agent, and clindamycin hydrochloride is the alternate agent recommended. Dr Nichols cited a study in which researchers looked at the importance of administering antibiotics for gram-negative organisms before major head and neck procedures. One hundred four patients were treated-one half were given
AORN JOURNAL
clindamycin hydrochloride alone and the other half received clindamycin hydrochloride with gentamicin sulfate. Dr Nichols reported that the infection rate was the same, and therefore, specific prophylactic treatment for gram-negative organisms does not appear necessary. The same researchers also reported that the length of the treatment did not matter-whether the patients received prophylactics for one day or for five days produced the same results, according to Nichols. Gastric surgery. Gram-negative organisms and oral anaerobes are the usual infecting organisms. The recommended agent is cefazolin sodium, and the alternate agent is cephalosporin. Cholecystectomy. Dr Nichols recommended giving each patient one dose of cephalosporin before cholecystectomy; cefazolin sodium is the
JANUARY 1988, VOL. 47, NO 1
recommended agent to use. Colorectal surgery. Escherichia coli is the usual infecting organism. Neomycin sulfate and erythromycin oral agents are still recommended; however, surgeons have to decide whether to administer one or two grams. Alternative agents can achieve the same results-oral kanamycin sulfate for the aerobes, and tetracycline hydrochloride for the anaerobes. Nichols also suggests that patients be brought in the day before surgery for a gastrointestinal purge followed by an antibiotic treatment. The ACS Committee on Operating Room Environment will present another panel discussion during the 1988 ACS Clinical Congress, Oct 2328, in Chicago. SUSAN SCHLEPP ASSISTANT EDITOR
Tipping Guidelines How much and who to tip puzzles some people. A tip is not an obligation, but a reward for prompt, courteous, and reasonable service. The following are some general guidelines those attending Congress can follow. Hotel personnel. Doormen are generally tipped between 50 cents and $1 if they handle your luggage, regardless of whether you are arriving or departing the hotel. They are also tipped if they assist you in hailing a taxi. Remember to tip the bellmen $1 per bag when they take your luggage to your room. Room maids can be tipped between 50 cents and $1 per day, depending on service. Restaurant and lounge personnel. Waiters and waitresses are generally tipped 15% of the bill (not including tax) and 20%if the service has been outstanding. The same 15%and 20% rule follows for room service. Captains at finer restaurants are tipped 5%of the dinner bill if they prepare food at the table. Wine stewards are tipped $2 per bottle at the better restaurants. Attendants and valets. Attendants who provide services that take only a few minutes (eg, rest room, shoe shine, and coat check) should be tipped between 25 and 75 cents. Valets are 292
tipped 25 cents per garment if it was a rush job or done outside usual hours; you do not have to tip if the charge has been added to the hotel bill. Parking attendants and drivers. You should tip a parking attendant between 50 and 75 cents each way; however, no tip is necessary if you are being charged for parking. Taxi drivers are tipped 20 cents for each dollar or 15%on fares of $15 or more. Drivers for an airport limousine, charter bus, or sightseeing bus are not tipped.
OR Nursing Courses Directory Available The Directory of Specialty Nursing Courses: OR is available free by writing to the AORN Education Department, CE Division, 10170 E Mississippi Ave, Denver, C O 80231. The directory lists RN first assistant courses in addition to undergraduate and postgraduate perioperative nursing courses. The Directory was updated in August 1987.