- Email: [email protected]
Flipping suture packs onto the sterile field, cold sterilization procedure questioned
AORN JOURNAL
JANUARY 1988, VOL. 47, NO 1
Clinical Issues Flipping suture packs onto the sterile field, cold sterilization procedure questioned
Q
uestion. Recently, when a suture packet was opened and flipped onto the sterile back table by a circulating nurse, the inner pack hit her hand. The corner of the sterile setup was contaminated. The scrub person just covered the contaminated area and continued to use the rest of the setup. Was this appropriate aseptic technique?
A
nswer. This action was inappropriate. The AORN “Recommended practices for basic aseptic technique” state that “all items used within a sterile field should be sterile.”’ Flipping the packet and hitting the nurse’s hand contaminated the item. When it landed on the setup, the whole setup became contaminated. Covering one section with a sterile drape did not take into account the rest of the instruments. The circulating nurse should not flip items onto the sterile field, if possible, because contamination often occurs as a result of this practice. Correct aseptic practice requires the circulating nurse to open the outer wrapper and present the inner package to the scrub nurse. The circulating nurse should also be careful not to reach over the sterile field. If the item is large enough, the inner package can be placed on the back table by the circulating nurse. If a setup becomes contaminated, the surgeon should be informed. In this case, the scrub nurse should have worked from the Mayo stand while sterile replacement items were gathered and opened onto a new sterile field and counted.
Q
uestion. I question the cold sterilization of arthroscopes and laparoscopes using steril-
izing solutions in a soaking pan, which holds the solution for the lifetime of the solution (usually 14 to 28 days). The soaking pan has a sterile area below the solution line and an unsterile area above the solution line. Does retrieving the sterile items raise the solution line up into the unsterile area and gather contaminates that have not been subjected to the sterilizing solution for the prescribed time? Is it better to open a sterile soaking pan for each case?
A
nswer. A new sterile soaking container can be used to disinfect instruments for each procedure or one soaking container can be used for a specific length of time for several procedures. Either approach can contaminatethe surgical items being disinfected, if improperly used. Using a new soaking pan for each use requires pouring the activated glutaraldehyde solution through a strainer into its original container after each use or discarding the used solution.2 This latter method could be costly. The container must be properly labeled with the original activation date and its expiration date. Using the same soaking pan for a specified time is also possible as long as it is used correctly. This method must also be subjected to the same guidelines as the single use method, which include: strict adherence to the manufacturers’ recommendations, keeping the inside of the container and its lid sterile, meticulous cleaning and drying of the
JANUARY 1988, VOL. 47, NO I
instruments before soaking to prevent dilution of the activated glutaraldehyde, cautious handling of drippy, rinsed instruments, and careful placement and removal of the instruments into and out of the container.3 Each facility would have to decide on the most appropriate method for their use. Questions you should address are: How many times each day are surgical items disinfected? Is there a controlled environment in which the disinfection process occurs? Are the soaking containers moved during the day? How reasonable is returning the soaking pan solution to its original container after each use? What method can be established to monitor adherence to the proper use of either approach? A policy regarding high-level disinfection of instruments must be individualized for each facility, and the procedure should state the exact steps needed to accomplish the process.
Q
uestion. When the patient is supine or prone on the O R bed, we always place the safety strap across the patient’s thighs. Should we also place the safety strap on the patient before he or she is placed in another position, such as lithotomy?
A
nswer. The purpose of the safety strap is to prevent injury to the patient while he or she is on the O R bed. The patient is at greatest risk while lying on the bed awake before induction, during induction of anesthesia, during positioning, and during reversal of anesthesia. A patient, who is to be placed in lithotomy position, should have the safety strap applied over the thighs before the legs are placed in the stirrups. Also, at the end of the procedure, the strap should be reapplied when the legs are placed back on the bed, before transfer to the stretcher. A patient’s torso should also be secured when positioned on a fracture bed for a hip pinning. The strap can be placed loosely on a bath blanket
AORN JOURNAL
over the patient’s waist! The strap is never placed directly on the patient’s skin. A patient on a fracture bed is at increased risk because of the small bed surface and the instability of the patient before his or her feet are placed in the traction footrests.
a
uestion. I recently started working in a different OR. In the O R where I used to wor , I always documented the patient’s surgical position and the positioning aids used. At this new hospital, the only documentation of the surgical position involves boxes that are checked to indicate the standard positions. I am uncomfortable with this lack of documentation. Should I be?
A
nswer. You have a right to be uncomfortable. Positioning the patient for surgery reflects the nurse’s professional knowledge and experience. Principles of anatomy and physiology, the requirements of the surgical procedure, and the outcomes of the patient assessment are all incorporated into positioning the patient. Documentation of the position and aids used provide a reference for evaluating the patient’s outcomes from the surgical position. The AORN “Recommended practice for documentation of perioperative nursing care” states that this documentation includes “the position, support and/or restraints used during the surgical pr~cedure.”~ My concern with only checking a box to indicate the surgical position is that it may lack the variations of the standard positions. Without a means to record the variations in the supine position for a patient with contractures in both legs, for example, the medical record would not reflect this nursing intervention. If the patient incurred an injury as a result of the surgical position, the incomplete documentation would weaken the support of nursing actions for this patient.6 You can be a change agent and educate your peers on the necessity of documenting positioning aids as well as the surgical position.
Q
uestion. A new plastic surgeon has joined our staff. When he does a skin graft and 28 I
AORN JOURNAL
does not use the whole harvested segment, he asks us to save it for future use. How can we do this?
A
nswer. I assume from your question that the skin is to be used as an autograft (ie, taken from one part of the patient’s body and used on another part of the same patient’s body). The skin should be placed in sterile normal saline in a sterile jar. The container is then sealed and labeled with the patient’s name, hospital number, type of skin harvested, site, and date of surgery. The skin is stored in a refrigerator designed specifically for this use at 1 “C to 10 OC (33.8 O F to 50 OF), for up to 14 days. The refrigerator should be monitored for deviations in temperature that might damage the skin. A daily record should be maintained to validate the storage temperature and/or an automatic temperature alarm should be used.’ Other methods are also available, such as freezedrying or storing in a cryoprotectant. ROSEMARY ANNROTH,RN, MSN, CNOR ASSISTANTDIRECTOROF NURSINGPRACTICE, OR/PAC/ASU GENESEEHOSPITAL,ROCHESTER,NY Notes 1. “Recommended practices for basic aseptic technique,” AORN Standards and Recommended Practices for Perioperative Nursing (Denver: Associ-
ation of Operating Room Nurses, Inc, 1987), III:22. 2. D Fogg, “Use of shoe covers represents optimum practice; storage of glutaraldehyde questioned,” AORN Journal 44 (July 1986) 95. 3. J Ricards, “Who is responsible for the qualifications of surgical assistants?“ AORN Journal 41 (May 1985) 922. 4. B Gruendemann, Positioning Plus: A Clinical
Handbook on Patient Positioning for Perioperative Nurses (Chatsworth, Calif: Education Department of
Devon Industries, 1987) 86. 5. “Recommended practices for documentation of perioperative nursing care,” AORN Standardr and Recommended Practices for Perioperative Nursing (Denver: Association of Operating Room Nurses, Inc,
1987) III:3-1. 6. E Murphy, “OR nurses ‘recovering’ patients; reporting an unsafe practice,” AORN Journal 43 (May 1986) 1146-1147. 7. “Recommended practices for storing, preserving, and maintaining skin, bone, cartilage, and blood 282
JANUARY 1988, VOL. 47, N O 1
vessel tissue,” AORN Standards and Recommended Practices f o r Perioperative Nursing (Denver: Association of Operating Room Nurses, Inc, 1987) III:13-2 to 13-3.
NCB Information Available at Congress The National Certification Board Perioperative Nursing, Inc, (NCB) will staff a booth in the registration area at Congress. Pam Gibson, NCB certification program specialist, and members of the NCB board of directors will be available to talk with you about the certification and recertification programs for perioperative nursing. More than 9,000 registered nurses are certified for professional achievement in perioperative nursing. In 1987, 1,746 nurses became certified, and 545 CNORs were recertified. Certification is valid for five years. Applications for certification and recertification will be available at the NCB Booth. The deadline for application for the 1988 certjicution examination is April 20, and application for recertijicution must be made before May 1. For the first time, CNOR pins can be purchased in the Bookstore with verification of certification from the NCB Booth. The NCB Booth will be staffed during registration hours on Saturday (10 AM to 6 PM) and Sunday (7:30 AM to 6 PM). The remainder of the week, NCB board members will be available before education sessions and during lunch hours. The Booth will be open the following hours: Saturday, March 5-10 AM to 6 PM, Sunday, March 6-7:30 AM to 6 PM, 0 Monday, March 7-7 to 8 AM and 11:15 AM to 1:15 PM, Tuesday, March 8-7 to 9 AM and 1 1 AM to 3 PM, Wednesday, March 9-7 to 9 AM, 11 AM to 3 PM, and 4 3 0 to 5 3 0 PM, and Thursday, March 10-7 to 9 AM and 1 1 AM to 3 PM.
JANUARY 1988. VOL. 47, NO 1
Removing Aneurysms in Cavernous Sinus Site Aneurysms arising from the internal carotid artery in the cavernous sinus region are rare. At Henry Ford Hospital, Detroit, only about 2% 01 the 500 aneurysms treated in the last 10 years have occurred in the cavernous sinus, which is located at the base of the skull behind the eye socket and around the pituitary gland. These aneurysms can become extremely largc and range in size from 2 to 4 cm in diameter. If the aneurysm exerts pressure on the optic nerve the patient experiences partial or total loss of vision; if pressure is exerted on the facial nerves the patient experiences pain or loss of feeling. Although rare, surgery has been used to remove aneurysms in the cavernous sinus-can has to be taken because of their proximity to th cranial nerves. Two procedures have been used (1) tying off the carotid artery above and below the sinus as the aneurysm is being dissected or (2) tying off the artery in the neck and head anc performing a bypass around the sinus and the aneurysm. These procedures interrupted normal circulation in the head and neck, leading to stroke-like complications. A new procedure that directly approaches thl aneurysm in the sinus was described by Fernando G . Diaz, MD, PhD, at the 73rd Annual Clinical Congress of the American College of Surgeons, San Francisco, Oct 11 to 16. has been tested on 32 patients at Henry Ford Hospital and has produced positive results. The surgeons expose the sinus region by surg a l l y removing part of the skull and isolating th cranial nerves. After locating the carotid artery and the aneurysm, the surgeons clamp the aneu rysm where it attaches itself to the artery. This stops the circulation of blood into the aneurysm but maintains circulation through the artery. Th aneurysm is then surgically removed. Of the 32 patients, four have had complications. One patient lost his vision, and two other continue to see double. Another patient had some muscle weakness on one side of the body which resolved itself six weeks postoperatively.
Daily scheduling, logistic, or materials management O.R. problems lead to wasted time and lost revenues. As the use of O.R. suites becomes more sophisticated, associated management problems grow disproportionately more complicated. Now Medinvent can help to simplify and energize O.R. management with SUITE OPERATIONS, the mainframebased multiuser simultaneous-access software system, incorporating
CORLS, CORPAL and CORMS are designed to make an already efficient O.R. staff operate all phases of surgical suite management more efficiently with proven cost effectiveness. And, no extensive training is required to run the easy-to-use menu-driven programs. Write or call for reprint and brochure.
Medinvent, Inc. 163 Engle Street, Englewood, NJ 07631 201-569-4280
JANUARY 1988, VOL. 47, NO 1
Clinical Issues Flipping suture packs onto the sterile field, cold sterilization procedure questioned
Q
uestion. Recently, when a suture packet was opened and flipped onto the sterile back table by a circulating nurse, the inner pack hit her hand. The corner of the sterile setup was contaminated. The scrub person just covered the contaminated area and continued to use the rest of the setup. Was this appropriate aseptic technique?
A
nswer. This action was inappropriate. The AORN “Recommended practices for basic aseptic technique” state that “all items used within a sterile field should be sterile.”’ Flipping the packet and hitting the nurse’s hand contaminated the item. When it landed on the setup, the whole setup became contaminated. Covering one section with a sterile drape did not take into account the rest of the instruments. The circulating nurse should not flip items onto the sterile field, if possible, because contamination often occurs as a result of this practice. Correct aseptic practice requires the circulating nurse to open the outer wrapper and present the inner package to the scrub nurse. The circulating nurse should also be careful not to reach over the sterile field. If the item is large enough, the inner package can be placed on the back table by the circulating nurse. If a setup becomes contaminated, the surgeon should be informed. In this case, the scrub nurse should have worked from the Mayo stand while sterile replacement items were gathered and opened onto a new sterile field and counted.
Q
uestion. I question the cold sterilization of arthroscopes and laparoscopes using steril-
izing solutions in a soaking pan, which holds the solution for the lifetime of the solution (usually 14 to 28 days). The soaking pan has a sterile area below the solution line and an unsterile area above the solution line. Does retrieving the sterile items raise the solution line up into the unsterile area and gather contaminates that have not been subjected to the sterilizing solution for the prescribed time? Is it better to open a sterile soaking pan for each case?
A
nswer. A new sterile soaking container can be used to disinfect instruments for each procedure or one soaking container can be used for a specific length of time for several procedures. Either approach can contaminatethe surgical items being disinfected, if improperly used. Using a new soaking pan for each use requires pouring the activated glutaraldehyde solution through a strainer into its original container after each use or discarding the used solution.2 This latter method could be costly. The container must be properly labeled with the original activation date and its expiration date. Using the same soaking pan for a specified time is also possible as long as it is used correctly. This method must also be subjected to the same guidelines as the single use method, which include: strict adherence to the manufacturers’ recommendations, keeping the inside of the container and its lid sterile, meticulous cleaning and drying of the
JANUARY 1988, VOL. 47, NO I
instruments before soaking to prevent dilution of the activated glutaraldehyde, cautious handling of drippy, rinsed instruments, and careful placement and removal of the instruments into and out of the container.3 Each facility would have to decide on the most appropriate method for their use. Questions you should address are: How many times each day are surgical items disinfected? Is there a controlled environment in which the disinfection process occurs? Are the soaking containers moved during the day? How reasonable is returning the soaking pan solution to its original container after each use? What method can be established to monitor adherence to the proper use of either approach? A policy regarding high-level disinfection of instruments must be individualized for each facility, and the procedure should state the exact steps needed to accomplish the process.
Q
uestion. When the patient is supine or prone on the O R bed, we always place the safety strap across the patient’s thighs. Should we also place the safety strap on the patient before he or she is placed in another position, such as lithotomy?
A
nswer. The purpose of the safety strap is to prevent injury to the patient while he or she is on the O R bed. The patient is at greatest risk while lying on the bed awake before induction, during induction of anesthesia, during positioning, and during reversal of anesthesia. A patient, who is to be placed in lithotomy position, should have the safety strap applied over the thighs before the legs are placed in the stirrups. Also, at the end of the procedure, the strap should be reapplied when the legs are placed back on the bed, before transfer to the stretcher. A patient’s torso should also be secured when positioned on a fracture bed for a hip pinning. The strap can be placed loosely on a bath blanket
AORN JOURNAL
over the patient’s waist! The strap is never placed directly on the patient’s skin. A patient on a fracture bed is at increased risk because of the small bed surface and the instability of the patient before his or her feet are placed in the traction footrests.
a
uestion. I recently started working in a different OR. In the O R where I used to wor , I always documented the patient’s surgical position and the positioning aids used. At this new hospital, the only documentation of the surgical position involves boxes that are checked to indicate the standard positions. I am uncomfortable with this lack of documentation. Should I be?
A
nswer. You have a right to be uncomfortable. Positioning the patient for surgery reflects the nurse’s professional knowledge and experience. Principles of anatomy and physiology, the requirements of the surgical procedure, and the outcomes of the patient assessment are all incorporated into positioning the patient. Documentation of the position and aids used provide a reference for evaluating the patient’s outcomes from the surgical position. The AORN “Recommended practice for documentation of perioperative nursing care” states that this documentation includes “the position, support and/or restraints used during the surgical pr~cedure.”~ My concern with only checking a box to indicate the surgical position is that it may lack the variations of the standard positions. Without a means to record the variations in the supine position for a patient with contractures in both legs, for example, the medical record would not reflect this nursing intervention. If the patient incurred an injury as a result of the surgical position, the incomplete documentation would weaken the support of nursing actions for this patient.6 You can be a change agent and educate your peers on the necessity of documenting positioning aids as well as the surgical position.
Q
uestion. A new plastic surgeon has joined our staff. When he does a skin graft and 28 I
AORN JOURNAL
does not use the whole harvested segment, he asks us to save it for future use. How can we do this?
A
nswer. I assume from your question that the skin is to be used as an autograft (ie, taken from one part of the patient’s body and used on another part of the same patient’s body). The skin should be placed in sterile normal saline in a sterile jar. The container is then sealed and labeled with the patient’s name, hospital number, type of skin harvested, site, and date of surgery. The skin is stored in a refrigerator designed specifically for this use at 1 “C to 10 OC (33.8 O F to 50 OF), for up to 14 days. The refrigerator should be monitored for deviations in temperature that might damage the skin. A daily record should be maintained to validate the storage temperature and/or an automatic temperature alarm should be used.’ Other methods are also available, such as freezedrying or storing in a cryoprotectant. ROSEMARY ANNROTH,RN, MSN, CNOR ASSISTANTDIRECTOROF NURSINGPRACTICE, OR/PAC/ASU GENESEEHOSPITAL,ROCHESTER,NY Notes 1. “Recommended practices for basic aseptic technique,” AORN Standards and Recommended Practices for Perioperative Nursing (Denver: Associ-
ation of Operating Room Nurses, Inc, 1987), III:22. 2. D Fogg, “Use of shoe covers represents optimum practice; storage of glutaraldehyde questioned,” AORN Journal 44 (July 1986) 95. 3. J Ricards, “Who is responsible for the qualifications of surgical assistants?“ AORN Journal 41 (May 1985) 922. 4. B Gruendemann, Positioning Plus: A Clinical
Handbook on Patient Positioning for Perioperative Nurses (Chatsworth, Calif: Education Department of
Devon Industries, 1987) 86. 5. “Recommended practices for documentation of perioperative nursing care,” AORN Standardr and Recommended Practices for Perioperative Nursing (Denver: Association of Operating Room Nurses, Inc,
1987) III:3-1. 6. E Murphy, “OR nurses ‘recovering’ patients; reporting an unsafe practice,” AORN Journal 43 (May 1986) 1146-1147. 7. “Recommended practices for storing, preserving, and maintaining skin, bone, cartilage, and blood 282
JANUARY 1988, VOL. 47, N O 1
vessel tissue,” AORN Standards and Recommended Practices f o r Perioperative Nursing (Denver: Association of Operating Room Nurses, Inc, 1987) III:13-2 to 13-3.
NCB Information Available at Congress The National Certification Board Perioperative Nursing, Inc, (NCB) will staff a booth in the registration area at Congress. Pam Gibson, NCB certification program specialist, and members of the NCB board of directors will be available to talk with you about the certification and recertification programs for perioperative nursing. More than 9,000 registered nurses are certified for professional achievement in perioperative nursing. In 1987, 1,746 nurses became certified, and 545 CNORs were recertified. Certification is valid for five years. Applications for certification and recertification will be available at the NCB Booth. The deadline for application for the 1988 certjicution examination is April 20, and application for recertijicution must be made before May 1. For the first time, CNOR pins can be purchased in the Bookstore with verification of certification from the NCB Booth. The NCB Booth will be staffed during registration hours on Saturday (10 AM to 6 PM) and Sunday (7:30 AM to 6 PM). The remainder of the week, NCB board members will be available before education sessions and during lunch hours. The Booth will be open the following hours: Saturday, March 5-10 AM to 6 PM, Sunday, March 6-7:30 AM to 6 PM, 0 Monday, March 7-7 to 8 AM and 11:15 AM to 1:15 PM, Tuesday, March 8-7 to 9 AM and 1 1 AM to 3 PM, Wednesday, March 9-7 to 9 AM, 11 AM to 3 PM, and 4 3 0 to 5 3 0 PM, and Thursday, March 10-7 to 9 AM and 1 1 AM to 3 PM.
JANUARY 1988. VOL. 47, NO 1
Removing Aneurysms in Cavernous Sinus Site Aneurysms arising from the internal carotid artery in the cavernous sinus region are rare. At Henry Ford Hospital, Detroit, only about 2% 01 the 500 aneurysms treated in the last 10 years have occurred in the cavernous sinus, which is located at the base of the skull behind the eye socket and around the pituitary gland. These aneurysms can become extremely largc and range in size from 2 to 4 cm in diameter. If the aneurysm exerts pressure on the optic nerve the patient experiences partial or total loss of vision; if pressure is exerted on the facial nerves the patient experiences pain or loss of feeling. Although rare, surgery has been used to remove aneurysms in the cavernous sinus-can has to be taken because of their proximity to th cranial nerves. Two procedures have been used (1) tying off the carotid artery above and below the sinus as the aneurysm is being dissected or (2) tying off the artery in the neck and head anc performing a bypass around the sinus and the aneurysm. These procedures interrupted normal circulation in the head and neck, leading to stroke-like complications. A new procedure that directly approaches thl aneurysm in the sinus was described by Fernando G . Diaz, MD, PhD, at the 73rd Annual Clinical Congress of the American College of Surgeons, San Francisco, Oct 11 to 16. has been tested on 32 patients at Henry Ford Hospital and has produced positive results. The surgeons expose the sinus region by surg a l l y removing part of the skull and isolating th cranial nerves. After locating the carotid artery and the aneurysm, the surgeons clamp the aneu rysm where it attaches itself to the artery. This stops the circulation of blood into the aneurysm but maintains circulation through the artery. Th aneurysm is then surgically removed. Of the 32 patients, four have had complications. One patient lost his vision, and two other continue to see double. Another patient had some muscle weakness on one side of the body which resolved itself six weeks postoperatively.
Daily scheduling, logistic, or materials management O.R. problems lead to wasted time and lost revenues. As the use of O.R. suites becomes more sophisticated, associated management problems grow disproportionately more complicated. Now Medinvent can help to simplify and energize O.R. management with SUITE OPERATIONS, the mainframebased multiuser simultaneous-access software system, incorporating
CORLS, CORPAL and CORMS are designed to make an already efficient O.R. staff operate all phases of surgical suite management more efficiently with proven cost effectiveness. And, no extensive training is required to run the easy-to-use menu-driven programs. Write or call for reprint and brochure.
Medinvent, Inc. 163 Engle Street, Englewood, NJ 07631 201-569-4280