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New recommended practices for a safe environment of care, part II released
New recommended practices for a safe environment of care, part II released Leslie Knudson Managing Editor he “Recommended practices for a safe environment of care, part II”1 were electronically released in May and are now available via the Perioperative Standards and Recommended Practices eBook mobile app and eSubscription. The new recommended practices (RP) replace the previous recommendations related to traffic patterns in the perioperative practice setting and primarily address the structural components of a safe environment of care. The RP provides guidance for the “design of the building structure; movement of patients, personnel, supplies, and equipment through the suite; safety during construction; environmental controls; maintenance of structural surfaces; power failure response planning; security; and control of noise and distractions.”1
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According to Byron L. Burlingame, MS, RN, CNOR, perioperative nursing specialist and lead author of the RP, the majority of the RP relates to construction considerations. “The RP provides guidelines for the design and construction of hospitals and outpatient facilities, but state regulations may be more stringent than AORN guidelines and must be followed. The RP also provides guidance and knowledge regarding the roles of perioperative staff members at the time of construction and renovation for those involved in a construction project.” The following are highlights from the new RP for a safe environment of care, part II. Planning and designing The RP states that a multidisciplinary team
should be established with responsibility for overseeing a surgical suite construction or renovation project. The multidisciplinary team should include individuals from the health care facility, including perioperative nurses and an infection preventionist, and external representatives from the design team (e.g., architects, interior designers) and the equipment manufacturer(s). The RP recommends that the perioperative RN provide input into equipment selection, the flow of people and equipment, and the use of space. In addition, the RP recommends that the multidisciplinary team be involved in all phases of the project, including the creation of a functional plan. When planning and designing a surgical suite, the RP recommends using evidence-based design concepts, which can have a positive effect on the safety, quality, and efficiency of patient care.1 Specifically, the RP recommends using a simulated room or suite setup and highlights evidence that simulation can help determine factors that may affect how tasks are performed in the suite. “Simulation gives a realistic estimation of square footage and a good visual of components to help identify missing equipment,” said Burlingame. The RP also calls out the responsibility of the perioperative RN on the multidisciplinary team to verify that the necessary OR components are present in the simulated OR. In addition, the RP emphasizes the importance of designing traffic patterns to help facilitate movement of patients, personnel, supplies, and equipment in and out of the surgical suite. The RP outlines considerations for three designated ENVIRONMENT OF CARE Continued on C9
http://dx.doi.org/10.1016/S0001-2092(14)00516-X
© AORN, Inc, 2014
June 2014 Vol 99 No 6 • AORN Connections | C1
ENVIRONMENT OF CARE Continued from C1
areas that should be included in the surgical suite design: unrestricted, semi-restricted, and restricted areas. The RP defines an unrestricted area as an area without access restrictions that includes a central control point for monitoring the entrance of patients, personnel, and materials into semi-restricted areas. Such areas may include locker rooms, waiting rooms, and offices. According to the RP, semi-restricted areas include peripheral support areas (e.g., equipment and supply storage areas, sterilization processing rooms) with specific heating, ventilation, and air conditioning (HVAC) design requirements and limited access to authorized personnel. The restricted area includes the OR and any other room where operative or other invasive procedures are performed and requires specific HVAC design elements and proper surgical attire. Restricted areas should only allow authorized personnel and patients accompanied by authorized personnel. The RP also addresses other considerations to take into account during the planning and design phase, such as laminar airflow, a ventilation setback strategy for when an OR is unoccupied, ultraviolet light for air purification in the restricted area, an environmental impact assessment based on construction materials and design features, electrical safeguards, and the OR lighting system. In addition, the RP specifies that the building design provide “functionally equivalent space for decontamination and sterilization of surgical instruments” wherever sterilization processes are performed.1 The RP also outlines requirements for a sterile processing room when instrument sterilization is performed within the surgical suite. These requirements include separate clean and decontamination spaces, provisions for sterilization equipment and storage of related supplies, and separate sinks for washing instruments and hands. Environmental and HVAC considerations The RP states that during renovation and construction, measures for preventing environmental contamination should be established, maintained, and monitored by perioperative team members and the infection preventionist, and cites evidence that shows contamination of the internal environment from infectious agents in the external environment during renovation and construction.1 The RP recommends infection prevention measures
Access the eSubscription or eBook mobile app The Perioperative Standards and Recommended Practices eBook mobile app and eSubscription are two convenient ways to access the most up-to-date content related to recommended practices online. For information on ordering an eSubscription, please visit http://www.aorn. org/esubscription/. For information on purchasing the AORN eBook, please visit http://www.aorn.org/ RecommendedPracticeseBook/. related to barriers, surgical attire, special traffic pathways, and other prevention and surveillance measures. The RP also describes the responsibilities specific to perioperative RNs who are part of the multidisciplinary team involved in the construction process, such as verifying the presence and integrity of barriers and infection prevention measures, monitoring the project’s progress, and communicating project updates to other perioperative team members. The RP also covers recommendations related to HVAC systems, including establishing a systematic process for monitoring HVAC performance parameters and resolving variances. The RP recommends performing a risk assessment of the surgical suite if there is a variance in the HVAC system parameters and lists corrective measures that can be taken based on the risk assessment. “If there is variation in the HVAC parameters, personnel should do a risk assessment and determine what corrective measures should be followed,” said Burlingame. “AORN no longer states that the HVAC system has to be monitored on a daily basis, but each facility has to decide how often to do monitoring and their methods of monitoring.” The RP also includes a detailed table on HVAC design parameters that lists different functional areas (e.g., OR, decontamination room, clean/sterile storage) and the suggested air changes per hour, humidity, temperature, and settings for airflow patterns for each area. Burlingame said that facilities should check with their state department of health or other regulatory agencies regarding specific parameters that should be followed. Policies and plans The RP recommends that health care facilities’ emergency preparedness plans include a power ENVIRONMENT OF CARE Continued on C10 June 2014 Vol 99 No 6 • AORN Connections | C9
ENVIRONMENT OF CARE Continued from C9
failure plan that addresses procedures to follow when the emergency generator works and does not work and identifies alternate power sources. The RP includes a table on assessments and interventions after a power failure that provides specific guidance related to environmental cleanliness, integrity of sterile supplies, functionality of power supply, and availability of water. The RP also recommends including specific security measures for the surgical suite within a facility-wide security plan. According to the RP, the security plan should be developed in consultation with security personnel or law enforcement representatives and should address workplace violence and methods for protecting patients’ health information and personal identifiable information. Lastly, the RP also includes a detailed section on minimizing noise and distractions that are unrelated to patient care, such as those caused by conversation, clinical and alert alarms, HVAC systems, and communication devices. The RP provides a list of specific sources of noise and distraction that should be minimized, including portable communication devices (e.g., cellphones, pagers), fixed communication devices
C10 | AORN Connections
(e.g., overhead paging systems, computers), electronic music devices (e.g., radios), and other sources. Significant evidence is cited within the RP that shows the negative effects of noise and distractions on the performance of health care personnel. References 1. Recommended practices for a safe environment of care, part II. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2015. In press.
Featured webinar A webinar scheduled for June 11, 2014 will highlight the new evidence-based recommendations for a safe environment of care, part II, including recommended practices for traffic, heating and cooling, construction, noise and distractions, and more. Sign up for the webinar at: http://www.aorn.org/ Events/Webinars/Upcoming_Webinars.aspx. After June 11, the webinar can be found at: http://www.aorn.org/ Events/Webinars/Previously_Recorded_Webinars.aspx.
T
According to Byron L. Burlingame, MS, RN, CNOR, perioperative nursing specialist and lead author of the RP, the majority of the RP relates to construction considerations. “The RP provides guidelines for the design and construction of hospitals and outpatient facilities, but state regulations may be more stringent than AORN guidelines and must be followed. The RP also provides guidance and knowledge regarding the roles of perioperative staff members at the time of construction and renovation for those involved in a construction project.” The following are highlights from the new RP for a safe environment of care, part II. Planning and designing The RP states that a multidisciplinary team
should be established with responsibility for overseeing a surgical suite construction or renovation project. The multidisciplinary team should include individuals from the health care facility, including perioperative nurses and an infection preventionist, and external representatives from the design team (e.g., architects, interior designers) and the equipment manufacturer(s). The RP recommends that the perioperative RN provide input into equipment selection, the flow of people and equipment, and the use of space. In addition, the RP recommends that the multidisciplinary team be involved in all phases of the project, including the creation of a functional plan. When planning and designing a surgical suite, the RP recommends using evidence-based design concepts, which can have a positive effect on the safety, quality, and efficiency of patient care.1 Specifically, the RP recommends using a simulated room or suite setup and highlights evidence that simulation can help determine factors that may affect how tasks are performed in the suite. “Simulation gives a realistic estimation of square footage and a good visual of components to help identify missing equipment,” said Burlingame. The RP also calls out the responsibility of the perioperative RN on the multidisciplinary team to verify that the necessary OR components are present in the simulated OR. In addition, the RP emphasizes the importance of designing traffic patterns to help facilitate movement of patients, personnel, supplies, and equipment in and out of the surgical suite. The RP outlines considerations for three designated ENVIRONMENT OF CARE Continued on C9
http://dx.doi.org/10.1016/S0001-2092(14)00516-X
© AORN, Inc, 2014
June 2014 Vol 99 No 6 • AORN Connections | C1
ENVIRONMENT OF CARE Continued from C1
areas that should be included in the surgical suite design: unrestricted, semi-restricted, and restricted areas. The RP defines an unrestricted area as an area without access restrictions that includes a central control point for monitoring the entrance of patients, personnel, and materials into semi-restricted areas. Such areas may include locker rooms, waiting rooms, and offices. According to the RP, semi-restricted areas include peripheral support areas (e.g., equipment and supply storage areas, sterilization processing rooms) with specific heating, ventilation, and air conditioning (HVAC) design requirements and limited access to authorized personnel. The restricted area includes the OR and any other room where operative or other invasive procedures are performed and requires specific HVAC design elements and proper surgical attire. Restricted areas should only allow authorized personnel and patients accompanied by authorized personnel. The RP also addresses other considerations to take into account during the planning and design phase, such as laminar airflow, a ventilation setback strategy for when an OR is unoccupied, ultraviolet light for air purification in the restricted area, an environmental impact assessment based on construction materials and design features, electrical safeguards, and the OR lighting system. In addition, the RP specifies that the building design provide “functionally equivalent space for decontamination and sterilization of surgical instruments” wherever sterilization processes are performed.1 The RP also outlines requirements for a sterile processing room when instrument sterilization is performed within the surgical suite. These requirements include separate clean and decontamination spaces, provisions for sterilization equipment and storage of related supplies, and separate sinks for washing instruments and hands. Environmental and HVAC considerations The RP states that during renovation and construction, measures for preventing environmental contamination should be established, maintained, and monitored by perioperative team members and the infection preventionist, and cites evidence that shows contamination of the internal environment from infectious agents in the external environment during renovation and construction.1 The RP recommends infection prevention measures
Access the eSubscription or eBook mobile app The Perioperative Standards and Recommended Practices eBook mobile app and eSubscription are two convenient ways to access the most up-to-date content related to recommended practices online. For information on ordering an eSubscription, please visit http://www.aorn. org/esubscription/. For information on purchasing the AORN eBook, please visit http://www.aorn.org/ RecommendedPracticeseBook/. related to barriers, surgical attire, special traffic pathways, and other prevention and surveillance measures. The RP also describes the responsibilities specific to perioperative RNs who are part of the multidisciplinary team involved in the construction process, such as verifying the presence and integrity of barriers and infection prevention measures, monitoring the project’s progress, and communicating project updates to other perioperative team members. The RP also covers recommendations related to HVAC systems, including establishing a systematic process for monitoring HVAC performance parameters and resolving variances. The RP recommends performing a risk assessment of the surgical suite if there is a variance in the HVAC system parameters and lists corrective measures that can be taken based on the risk assessment. “If there is variation in the HVAC parameters, personnel should do a risk assessment and determine what corrective measures should be followed,” said Burlingame. “AORN no longer states that the HVAC system has to be monitored on a daily basis, but each facility has to decide how often to do monitoring and their methods of monitoring.” The RP also includes a detailed table on HVAC design parameters that lists different functional areas (e.g., OR, decontamination room, clean/sterile storage) and the suggested air changes per hour, humidity, temperature, and settings for airflow patterns for each area. Burlingame said that facilities should check with their state department of health or other regulatory agencies regarding specific parameters that should be followed. Policies and plans The RP recommends that health care facilities’ emergency preparedness plans include a power ENVIRONMENT OF CARE Continued on C10 June 2014 Vol 99 No 6 • AORN Connections | C9
ENVIRONMENT OF CARE Continued from C9
failure plan that addresses procedures to follow when the emergency generator works and does not work and identifies alternate power sources. The RP includes a table on assessments and interventions after a power failure that provides specific guidance related to environmental cleanliness, integrity of sterile supplies, functionality of power supply, and availability of water. The RP also recommends including specific security measures for the surgical suite within a facility-wide security plan. According to the RP, the security plan should be developed in consultation with security personnel or law enforcement representatives and should address workplace violence and methods for protecting patients’ health information and personal identifiable information. Lastly, the RP also includes a detailed section on minimizing noise and distractions that are unrelated to patient care, such as those caused by conversation, clinical and alert alarms, HVAC systems, and communication devices. The RP provides a list of specific sources of noise and distraction that should be minimized, including portable communication devices (e.g., cellphones, pagers), fixed communication devices
C10 | AORN Connections
(e.g., overhead paging systems, computers), electronic music devices (e.g., radios), and other sources. Significant evidence is cited within the RP that shows the negative effects of noise and distractions on the performance of health care personnel. References 1. Recommended practices for a safe environment of care, part II. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2015. In press.
Featured webinar A webinar scheduled for June 11, 2014 will highlight the new evidence-based recommendations for a safe environment of care, part II, including recommended practices for traffic, heating and cooling, construction, noise and distractions, and more. Sign up for the webinar at: http://www.aorn.org/ Events/Webinars/Upcoming_Webinars.aspx. After June 11, the webinar can be found at: http://www.aorn.org/ Events/Webinars/Previously_Recorded_Webinars.aspx.