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New, patched gowns no bargain for OR
The experts research
New, patched gowns no bargain for OR
4
When you think you have seen everything, a new problem comes along. Our purchasing agent has recently purchased ”patched” surgical gowns for use in our OR. Does AORN approve using such patched surgical gowns in the operating room? These patched surgical gowns are new, never-used, reusable gowns that have not passed quality control inspection due to imperfections in the quality of the barrier material in certain areas. That area is simply patched. Is this a safe cost containment practice?
A
Before your letter, 1 had not heard of using patched surgical gowns. Because I could find no information on this subject, I turned to William Beck, MD, president of the Donald Guthrie Foundation for Medical Research, Sayre, Pa, for assistance. Dr Beck investigated and found that several companies are taking rejected surgical gowns, applying patches, and selling them at a reduced cost. These companies said they have a definite protocol and a standard they follow to avoid destroying the barrier quality. They said they will provide a copy of this to any purchaser on request. One company told Dr Beck that it \imits sales of these low-cost gowns to “teaching” hospitals only, saying this group would be most careful in allocating their use. In Dr Beck’s opinion, this is a very dangerous attitude, as these institutions already have high infection
a:
rates. Furthermore, the operations performed in these hospitals would represent the highest challenge, and their patients would be the most susceptible to surgical infection. Dr Beck called companies selling secondrate, repaired materials “so penurious that I would be concerned about their product. One could say that their inspections quality control is high so as to reveal defects. But in our business I believe we have little room for the use of ‘seconds.’” Dr Beck and I agree that the materials in question were designed specifically to our standards and to lower them directly by using “retreads” would be unacceptable.
Q We have been asked to turn off the air conditioner or heating systems in our operating rooms during the hours at night when we are not staffing the OR. As a result, we have temperature and humidity fluctuations. The purpose of shutting off the air conditioner is to conserve energy and contain costs, but I have concerns about this practice. Does AORN have a recommendation concerning shutting down the air conditioner or heat systems during hours when the OR is not in use?
A
This is a controversial subject. AORN does not have a recommended practice for heating, ventilating, and air conditioning (HVAC) systems. I am adamantly opposed, however, to shutting down the HVAC system during hours when the operating rooms are not in use. My opinion is based on two concerns. The first is that the potential for contamination may be increased. Second, I am not convinced that this energy conservation is effective cost containment.
AORN Journal, February 1982, Vol35, A;o 2
279
I consulted with James Woods, Department of Architecture and Engineering, Engineering Research Institute, Iowa State University, Ames, who shared his concerns on HVAC system shutdowns in ORs. Woods said one of his concerns is the possible contamination caused by the inbalance between sterile and nonsterile zones when the positive OR air pressure relative to the air pressure of adjoining areas is not present. He also voiced concern over the settling of microbes in the HVAC system during the off periods. When the system is turned back on, this heavily contaminated air blows into the ORs. Woods suggested that before turning off the HVAC system during these hours an air balance specialist evaluate your HVAC system and operating room suite to avoid contamination of the OR air. There are several code requirements for air quality published by the National Fire Protection Association (NFPA), the United States Public Health Service, and the American Society of Heating, Refrigeration, and Air Conditioning Engineers (ASHRAE). NFPA Code 56A-70 requires that ventilation air of operating rooms, delivery rooms, and special procedure rooms be supplied from several outlets located on the ceiling or high on the walls of the room. Air should be exhausted by several inlets located near the floor on opposite walls. The air distribution pattern should move air down and through the location, with a minimum of draft, to the floor exhaust. NFPA requires an air change rate equivalent to 25 room volumes of air per hour, which will dilute bacteria dispersed into the room by human activity.’ The code further requires that a positive air pressure relative to the air pressure in surrounding corridors or halls be maintained in anesthetizing locations. This positive pressure in the operating rooms will prevent contaminated air from outside corridors from entering the OR. Additionally, ventilation systems should incorporate air filters with an efficiency of not less than 90% when tested in accordance with methods established by ASHRAE. Regarding humidity control, the NFPA code states that the ventilation system must incorporate humidity equipment and controls to maintain 50% relative humidity.’
280
The United States Public Health Service has issued a code (Pub No 930-A-7) for acceptable air pressures, air exchange, and permissible rates of recirculation in operating rooms.3This code requires positive pressure relationship to adjacent areas; and a minimum of 12 total air changes per hour (25for new facilities), and no recirculated air within this area. Turning off air handling systems during the unstaffed hours also creates a problem in that ORs have frequent emergency surgeries, usually covered by call-back personnel. If the suite has no air handling system functioning or if only one operating room is air conditioned, this could have a negative impact on emergency surgery. Given the costs of surgical infections (estimated to be $7,000 per infection, including additional hospitalization and lost work days), it doesn’t make sense to save money this way. I don’t believe that operating room air systems should be turned off.
Q I have been asked to plan for outpatient surgery in our operating room suite at our hospital. Although I have worked in an operating room for ten years, I am unsure of what to do about infection control in this type of surgery. What infection control policies are recommended for outpatient surgery?
A The same infection control policies used for inpatient surgical procedures should be used for outpatient surgical procedures. The Joint Commission on Accreditation of Hospitals has specific policies and procedures emphasizing the need for infection control in ambulatory s ~ r g e r y . ~ During consultations, I have observed several outpatient surgery units and have been dismayed to see inadequate cleaning of OR furniture, equipment, and floors; abbreviated hand scrubs; and perfunctory patient skin preparation. Surgical procedures performed on an outpatient basis require the same stringent infection control practices as do inpatient surgeries. The reduction in cost for outpatients should come from reduced hospital bed days, not from a reduced level of care. All presently accepted surgical, technical, and hygienic methods of surgical asepsis must
AORN Journal, February 1982, V o l 3 5 , N o 2
be rigidly maintained for any surgical patient regardless of inpatient or outpatient status. I suggest you consult the AORN Standards of Practice manua1.5
Colleen K Harvey, RN and the Professional Advisory Committee Notes 1 . Hospital Special-Care Facilities, Planning for User Needs, ed. Harold Laufman (New York: Academic Press, 1981) 161.
2. lbid, 162. 3. Harold Laufman, "The surgeon views environmental controls in the operating room," Bulletin of the American Colfege of Surgeons (May-June 1969). 4. Accreditation Manual for Hospitals (Chicago: Joint Commission on Accreditation of Hospitals, 1982) 75, statement 34. 5. "Standards for OR sanitation," "Standards for preoperative skin preparation of patients," and "Standards for surgical hand scrubs," in AORN Standards of Practice (Denver: Association of Operating Room Nurses, 1978) sections 3-14,3-17, 3-23.
'Angel dust' users need less anesthetic The common street drug called "angel dust" may increase a patient's risk of anesthetic overdose. Studies conducted at the University of Virginia School of Medicine at Charlottesville revealed that low doses of angel dust (phencyclidine PCP) markedly increased the susceptibility of rats to the effects of anesthesia. "Caution is advised in the anesthetic management of patients intoxicated with PCP, since their anesthetic requirement may be very much less than would be expected in the normal patient," said Srinivasa N Raja, MD, who is now an assistant professor of anesthesiology at the Johns Hopkins University School of Medicine, Baltimore. His coworkers at the University of Virginia, where the research was done, include Jeffrey C Moscicki, and Cosmo A DiFazio, MD. The findings suggest that the anesthetic requirements of PCP-intoxicated patients may be much less than would be expected for the same patient in the nonintoxicated state, he reported at the recent annual meeting of the American Society of Anesthesiologists in New Orleans. "A significant potential for anesthetic overdose exists in PCP-intoxicated patients," said Dr Raja. In the past decade, angel dust has emerged as a street drug. In small doses it produces agitation, excitement, disorientation, and bizarre hallucinations.
282
Larger doses can cause stupor, convulsions, coma, and even death. Psychotic and violent self-destructive behavior commonly seen in victims of angel dust intoxication increases their risk of injury, often resulting in emergency room visits. Doses of PCP that evoked behavioral disturbances in the experimental animals decreased their need for general anesthesia by 32% to 42%, said Dr Raja.
Pat Jones to head ANA Washington office Patricia Jones, RN, has been appointed deputy executive director for government relations of the American Nurses' Association (ANA). She will be in charge of the organization's Washington office. Jones succeeds Connie Holleran, RN, who resigned last spring to become executive director of the International Council of Nurses in Geneva. On the ANA staff since 1978, Jones was acting director of the Washington office until her appointment. She has been an instructor at the Georgetown University School of Nursing and acting director of staff development at the Georgetown University Hospital. A graduate of King's County Hospital Center, Brooklyn, NY, she received bachelor's and master's degrees in nursing from Catholic University, Washington, DC.
AORN Journal, February 1982, V o l 3 5 , No 2
New, patched gowns no bargain for OR
4
When you think you have seen everything, a new problem comes along. Our purchasing agent has recently purchased ”patched” surgical gowns for use in our OR. Does AORN approve using such patched surgical gowns in the operating room? These patched surgical gowns are new, never-used, reusable gowns that have not passed quality control inspection due to imperfections in the quality of the barrier material in certain areas. That area is simply patched. Is this a safe cost containment practice?
A
Before your letter, 1 had not heard of using patched surgical gowns. Because I could find no information on this subject, I turned to William Beck, MD, president of the Donald Guthrie Foundation for Medical Research, Sayre, Pa, for assistance. Dr Beck investigated and found that several companies are taking rejected surgical gowns, applying patches, and selling them at a reduced cost. These companies said they have a definite protocol and a standard they follow to avoid destroying the barrier quality. They said they will provide a copy of this to any purchaser on request. One company told Dr Beck that it \imits sales of these low-cost gowns to “teaching” hospitals only, saying this group would be most careful in allocating their use. In Dr Beck’s opinion, this is a very dangerous attitude, as these institutions already have high infection
a:
rates. Furthermore, the operations performed in these hospitals would represent the highest challenge, and their patients would be the most susceptible to surgical infection. Dr Beck called companies selling secondrate, repaired materials “so penurious that I would be concerned about their product. One could say that their inspections quality control is high so as to reveal defects. But in our business I believe we have little room for the use of ‘seconds.’” Dr Beck and I agree that the materials in question were designed specifically to our standards and to lower them directly by using “retreads” would be unacceptable.
Q We have been asked to turn off the air conditioner or heating systems in our operating rooms during the hours at night when we are not staffing the OR. As a result, we have temperature and humidity fluctuations. The purpose of shutting off the air conditioner is to conserve energy and contain costs, but I have concerns about this practice. Does AORN have a recommendation concerning shutting down the air conditioner or heat systems during hours when the OR is not in use?
A
This is a controversial subject. AORN does not have a recommended practice for heating, ventilating, and air conditioning (HVAC) systems. I am adamantly opposed, however, to shutting down the HVAC system during hours when the operating rooms are not in use. My opinion is based on two concerns. The first is that the potential for contamination may be increased. Second, I am not convinced that this energy conservation is effective cost containment.
AORN Journal, February 1982, Vol35, A;o 2
279
I consulted with James Woods, Department of Architecture and Engineering, Engineering Research Institute, Iowa State University, Ames, who shared his concerns on HVAC system shutdowns in ORs. Woods said one of his concerns is the possible contamination caused by the inbalance between sterile and nonsterile zones when the positive OR air pressure relative to the air pressure of adjoining areas is not present. He also voiced concern over the settling of microbes in the HVAC system during the off periods. When the system is turned back on, this heavily contaminated air blows into the ORs. Woods suggested that before turning off the HVAC system during these hours an air balance specialist evaluate your HVAC system and operating room suite to avoid contamination of the OR air. There are several code requirements for air quality published by the National Fire Protection Association (NFPA), the United States Public Health Service, and the American Society of Heating, Refrigeration, and Air Conditioning Engineers (ASHRAE). NFPA Code 56A-70 requires that ventilation air of operating rooms, delivery rooms, and special procedure rooms be supplied from several outlets located on the ceiling or high on the walls of the room. Air should be exhausted by several inlets located near the floor on opposite walls. The air distribution pattern should move air down and through the location, with a minimum of draft, to the floor exhaust. NFPA requires an air change rate equivalent to 25 room volumes of air per hour, which will dilute bacteria dispersed into the room by human activity.’ The code further requires that a positive air pressure relative to the air pressure in surrounding corridors or halls be maintained in anesthetizing locations. This positive pressure in the operating rooms will prevent contaminated air from outside corridors from entering the OR. Additionally, ventilation systems should incorporate air filters with an efficiency of not less than 90% when tested in accordance with methods established by ASHRAE. Regarding humidity control, the NFPA code states that the ventilation system must incorporate humidity equipment and controls to maintain 50% relative humidity.’
280
The United States Public Health Service has issued a code (Pub No 930-A-7) for acceptable air pressures, air exchange, and permissible rates of recirculation in operating rooms.3This code requires positive pressure relationship to adjacent areas; and a minimum of 12 total air changes per hour (25for new facilities), and no recirculated air within this area. Turning off air handling systems during the unstaffed hours also creates a problem in that ORs have frequent emergency surgeries, usually covered by call-back personnel. If the suite has no air handling system functioning or if only one operating room is air conditioned, this could have a negative impact on emergency surgery. Given the costs of surgical infections (estimated to be $7,000 per infection, including additional hospitalization and lost work days), it doesn’t make sense to save money this way. I don’t believe that operating room air systems should be turned off.
Q I have been asked to plan for outpatient surgery in our operating room suite at our hospital. Although I have worked in an operating room for ten years, I am unsure of what to do about infection control in this type of surgery. What infection control policies are recommended for outpatient surgery?
A The same infection control policies used for inpatient surgical procedures should be used for outpatient surgical procedures. The Joint Commission on Accreditation of Hospitals has specific policies and procedures emphasizing the need for infection control in ambulatory s ~ r g e r y . ~ During consultations, I have observed several outpatient surgery units and have been dismayed to see inadequate cleaning of OR furniture, equipment, and floors; abbreviated hand scrubs; and perfunctory patient skin preparation. Surgical procedures performed on an outpatient basis require the same stringent infection control practices as do inpatient surgeries. The reduction in cost for outpatients should come from reduced hospital bed days, not from a reduced level of care. All presently accepted surgical, technical, and hygienic methods of surgical asepsis must
AORN Journal, February 1982, V o l 3 5 , N o 2
be rigidly maintained for any surgical patient regardless of inpatient or outpatient status. I suggest you consult the AORN Standards of Practice manua1.5
Colleen K Harvey, RN and the Professional Advisory Committee Notes 1 . Hospital Special-Care Facilities, Planning for User Needs, ed. Harold Laufman (New York: Academic Press, 1981) 161.
2. lbid, 162. 3. Harold Laufman, "The surgeon views environmental controls in the operating room," Bulletin of the American Colfege of Surgeons (May-June 1969). 4. Accreditation Manual for Hospitals (Chicago: Joint Commission on Accreditation of Hospitals, 1982) 75, statement 34. 5. "Standards for OR sanitation," "Standards for preoperative skin preparation of patients," and "Standards for surgical hand scrubs," in AORN Standards of Practice (Denver: Association of Operating Room Nurses, 1978) sections 3-14,3-17, 3-23.
'Angel dust' users need less anesthetic The common street drug called "angel dust" may increase a patient's risk of anesthetic overdose. Studies conducted at the University of Virginia School of Medicine at Charlottesville revealed that low doses of angel dust (phencyclidine PCP) markedly increased the susceptibility of rats to the effects of anesthesia. "Caution is advised in the anesthetic management of patients intoxicated with PCP, since their anesthetic requirement may be very much less than would be expected in the normal patient," said Srinivasa N Raja, MD, who is now an assistant professor of anesthesiology at the Johns Hopkins University School of Medicine, Baltimore. His coworkers at the University of Virginia, where the research was done, include Jeffrey C Moscicki, and Cosmo A DiFazio, MD. The findings suggest that the anesthetic requirements of PCP-intoxicated patients may be much less than would be expected for the same patient in the nonintoxicated state, he reported at the recent annual meeting of the American Society of Anesthesiologists in New Orleans. "A significant potential for anesthetic overdose exists in PCP-intoxicated patients," said Dr Raja. In the past decade, angel dust has emerged as a street drug. In small doses it produces agitation, excitement, disorientation, and bizarre hallucinations.
282
Larger doses can cause stupor, convulsions, coma, and even death. Psychotic and violent self-destructive behavior commonly seen in victims of angel dust intoxication increases their risk of injury, often resulting in emergency room visits. Doses of PCP that evoked behavioral disturbances in the experimental animals decreased their need for general anesthesia by 32% to 42%, said Dr Raja.
Pat Jones to head ANA Washington office Patricia Jones, RN, has been appointed deputy executive director for government relations of the American Nurses' Association (ANA). She will be in charge of the organization's Washington office. Jones succeeds Connie Holleran, RN, who resigned last spring to become executive director of the International Council of Nurses in Geneva. On the ANA staff since 1978, Jones was acting director of the Washington office until her appointment. She has been an instructor at the Georgetown University School of Nursing and acting director of staff development at the Georgetown University Hospital. A graduate of King's County Hospital Center, Brooklyn, NY, she received bachelor's and master's degrees in nursing from Catholic University, Washington, DC.
AORN Journal, February 1982, V o l 3 5 , No 2