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OR Fact and Principle
OR FACT AND PRINCIPLE Lucy J o Atkinson, R.N.
Q. Is the use of Ioprepm without a preceding ptIisofiexT1l scrub effective for pre-op skin preparation of the patient? A. loprep is an iodophor detergent-disinfectant. It is an effective preoperative skin preparation agent with or without a preceding scrub with a hexachlorophene detergent, such as pHisoHex. Q. I s a pHisoHex scrub 8-15 hours prior to surgery more effective than only a n application of a detergent-disinfectant immediately prior to the incision? I s there a n advantage t o leaving a film of pHisoHex on the skin over this 8-15 hour period? A. A thorough cleansing of the skin with a hexachlorophene soap or detergent 8-15 hours preop is better than no cleansing at all. Ideally, the elective surgical patient should bathe daily with a hexachlorophene containing soap or synthetic detergent for five to ten days prior to surgery. The gram-positive resident bacteria will be reduced by the continuing bacteriostatic action of the hexachloropherie in the residual film left on the skin. Q. Does a scrub with pHisoHex in the OR immediately preceding an application of loprep have any advantage? A. Mechanical cleansing of the skin with a hexachlorophene soap or detergent as the first step of the skin preparation in the OR
M a y 1968
a
0 0
will help remove dirt, grease and desquamating epithelium. The thoroughness of the mechanical action is more important than the agent used, however. The same degree of cleanliness can be achieved using Ioprep, for example, as the cleansing agent.
Q. I s pHisoHex effective as the only skin prep agent? A. Hexachlorophene, the active bacteriostatic agent in pHisoHex, is not an effective singleuse germicidal agent. Its bacteriostatic activity is accumulative over time. Therefore, a hexachlorophene agent should not be used alone for the preop skin prep. Any singleshot germicide that is effective against gramnegative organisms must be used to disinfect the skin of the transient contact bacteria. Q . Should the technique used for surgery o n the intestinal tract be a matter of OR policy or of the surgeon’s individual preference? A. The technique for handling gastric and intestinal surgery is established by OR policy, formulated by a surgical staff committee or OR committee, in many hospitals. Rather ‘than deviate procedures and routhes to each surgeon’s preference, standardized procedures adhered to by all surgeons and nurses are preferable so that every patient receives a high quality of care. Nurses are guided by policies and written procedures and there-
7‘)
fore will attempt to carry out the technique that they have been taught and know is accepted in their hospital. If they are expected to do procedures differently for each surgeon, confusion usually reigns supreme. It is d i 5 cult enough to keep track of individual surgeons’ suture and instrument preferences without the additional burden of varying procedures that can effectively be standardized to everyone’s advantage. The technique used for surgery on the intestinal tract should be no exception to this principle.
Q. Should a different technique be followed for surgery o n the upper gastrointestinal tract than that used for surgery o n the lower intestinal tract?
A. “Gastric routine” or “bowel technique’’ is the procedure to prevent the spread of contamination within the peritoneal cavity while the gastrointestinal tract is open and, secondly, to provide a clean closure of the abdominal incision following closure of the
gastrointestinal tract. Even though the rationale for carrying out this technique is different for the upper and lower gastrointestinal tract, the same procedure can be established for the entire tract. A chemical contamination and irritation can result from the spillage of the contents of the stomach or small intestine into the peritoneal cavity. A bacterial contamination ( E . coli) may cause infection as a result of spillage of contents from the colon and large intestine. Many surgeons prescribe an oral antibiotic, such as Neomycin, preoperatively to reduce the bacterial flora in the colon. The use of electro-cautery in cutting across the colon between the intestinal clamps also helps eliminate the bacteria on the stumps. When these techniques are employed, some surgeons do not think that additional precautions need be taken during large bowel surgery.
Q. Should the technique used for surgery on the gastroirrtestinal tract include a change of drapes, gloves andlor instruments once the tract is closed?
A. When the surgeon is ready to open the
Identification comes first before surgery, before medication, before any patient procedure. Ident-A-Band makes it quick and easy to be sure; it offers positive identification . . . strong, nontransferable, yet soft and gentle to wear. Write for samples.
HOLLISTER INC.. 211
80
E. CHICAGO AVE., CHICAGO 60611
gastrointestinal tract, warm, moist laparotomy tapes are placed around the site of incision to protect the viscera and tissues of the abdominal wall. Clean towels are also placed around the operative area. Once the gastrointestinal tract is closed, these towels and tapes are discarded from the field. All used sponges and instruments are also discarded. The team changes gown and gloves. The patient is redraped with four towels and a laparotomy sheet over the original drapes. The abdomen is then closed. The scrub nurse can remain outside the contaminated area while the gastrointestinal tract is open and keep herself and the instrument table sterile. She can do this by dropping all sponges, instruments and sutures onto a towel placed below the incision. The surgical team members can help themselves to what they need. They can touch anything placed
AORN Jou,rnnE
onto the field for them, but the scruh nurse does not touch anything on the field. Soiled sponges and grossly contaminated instruments can be discarded into a basin placed on the field for this purpose. The surgeons then hand this basin, along with the rest of the instruments, etc., off the field to the circulating nurse when the gastrointestinal tract closure is completed, before they change gown and gloves. If the scrub nurse handles instruments, sutures, sponges, etc., while the gastrointestinal tract is open, she should refrain from contaminating the instrument table and Mayo stand that will be used for the abdominal closure. She may do this by setting up a second sterile Mayo stand or table with all the necessary supplies for regowning and regloving of the team, redraping of the patient, and closing of the abdominal incision. This set-up, prepared before the operation begins, should remain covered until it is needed. As an alternative method, the scrub nurse may obtain supplies from the instrument table with transfer forceps while the gastrointestinal tract is open and then remove the contaminated Mayo stand before she regowns and regloves. The latter is not a commonly used procedure.
Q. Should we institute instrument and needle counts?
A. If the other hospitals in your community are taking instrument and needle counts on all surgical procedures, then your hospital should also. However, if this is not the standard practice in your community, and you think that control is maintained by each member of your nursing staff without these formal procedures, there probably is no necessity to institute them. On the other hand, if the loss of needles or instruments has been a persistent problem, resulting in lawsuits, you would be wise to adopt these procedures as OR policy. Needle counts are more widely taken around the country than are instrument
M n y 1968
counts. Needles, conceivably, are more easily lost or broken in the incision than are surgical instruments. However, if each needle is conscientiously retrieved after use from the surgeon before another one is given to him, control can be maintained. When standard instrument sets are prepared, the scrub nurse can make a rapid check of her instruments to ascertain that they are all accounted for before wound closure is begun or completed.
0. Do the duties or responsibilities
of a scrub nurse permit her to function as first assistant.? What legal technicalities are involved in this issue.?
A. The Joint Commission on Accreditation of Hospitals recommends that, “In any procedure with unusual hazard to life, there must be a qualified physician prezent and scrubbed as first assistant. A qualified assistant is defined as a physician designated by the credentials committee of his respective hospital as being qualified to assist.” Further, the JCAH suggests that this practice be reviewed by medical staff committees and that corrective measures be taken through an authoritative body of the hospital to censure any surgeon who repeatedly abuses this practice. “Unusual hazard to life” is generally interpreted as applying to surgical procedures in which major body cavities are entered and/or extensive surgical incisions are made into body tissues. Piurses or technicians may act as second or third assistants at these operations. These persons can also be used as first assistants at operations of lesser magnitude and hazard to the patient. In a court of law, the recommendations of the JCAH and the standard of practice adhered to by other hospitals in the community would establish the criteria by which the hospital personnel and surgeons involved in a lawsuit would be judged. A nurse or technician who assumes the responsibilities and functions that should be delegated to a physician would be considered a n illegal practitioner of medicine.
++
81
Q. Is the use of Ioprepm without a preceding ptIisofiexT1l scrub effective for pre-op skin preparation of the patient? A. loprep is an iodophor detergent-disinfectant. It is an effective preoperative skin preparation agent with or without a preceding scrub with a hexachlorophene detergent, such as pHisoHex. Q. I s a pHisoHex scrub 8-15 hours prior to surgery more effective than only a n application of a detergent-disinfectant immediately prior to the incision? I s there a n advantage t o leaving a film of pHisoHex on the skin over this 8-15 hour period? A. A thorough cleansing of the skin with a hexachlorophene soap or detergent 8-15 hours preop is better than no cleansing at all. Ideally, the elective surgical patient should bathe daily with a hexachlorophene containing soap or synthetic detergent for five to ten days prior to surgery. The gram-positive resident bacteria will be reduced by the continuing bacteriostatic action of the hexachloropherie in the residual film left on the skin. Q. Does a scrub with pHisoHex in the OR immediately preceding an application of loprep have any advantage? A. Mechanical cleansing of the skin with a hexachlorophene soap or detergent as the first step of the skin preparation in the OR
M a y 1968
a
0 0
will help remove dirt, grease and desquamating epithelium. The thoroughness of the mechanical action is more important than the agent used, however. The same degree of cleanliness can be achieved using Ioprep, for example, as the cleansing agent.
Q. I s pHisoHex effective as the only skin prep agent? A. Hexachlorophene, the active bacteriostatic agent in pHisoHex, is not an effective singleuse germicidal agent. Its bacteriostatic activity is accumulative over time. Therefore, a hexachlorophene agent should not be used alone for the preop skin prep. Any singleshot germicide that is effective against gramnegative organisms must be used to disinfect the skin of the transient contact bacteria. Q . Should the technique used for surgery o n the intestinal tract be a matter of OR policy or of the surgeon’s individual preference? A. The technique for handling gastric and intestinal surgery is established by OR policy, formulated by a surgical staff committee or OR committee, in many hospitals. Rather ‘than deviate procedures and routhes to each surgeon’s preference, standardized procedures adhered to by all surgeons and nurses are preferable so that every patient receives a high quality of care. Nurses are guided by policies and written procedures and there-
7‘)
fore will attempt to carry out the technique that they have been taught and know is accepted in their hospital. If they are expected to do procedures differently for each surgeon, confusion usually reigns supreme. It is d i 5 cult enough to keep track of individual surgeons’ suture and instrument preferences without the additional burden of varying procedures that can effectively be standardized to everyone’s advantage. The technique used for surgery on the intestinal tract should be no exception to this principle.
Q. Should a different technique be followed for surgery o n the upper gastrointestinal tract than that used for surgery o n the lower intestinal tract?
A. “Gastric routine” or “bowel technique’’ is the procedure to prevent the spread of contamination within the peritoneal cavity while the gastrointestinal tract is open and, secondly, to provide a clean closure of the abdominal incision following closure of the
gastrointestinal tract. Even though the rationale for carrying out this technique is different for the upper and lower gastrointestinal tract, the same procedure can be established for the entire tract. A chemical contamination and irritation can result from the spillage of the contents of the stomach or small intestine into the peritoneal cavity. A bacterial contamination ( E . coli) may cause infection as a result of spillage of contents from the colon and large intestine. Many surgeons prescribe an oral antibiotic, such as Neomycin, preoperatively to reduce the bacterial flora in the colon. The use of electro-cautery in cutting across the colon between the intestinal clamps also helps eliminate the bacteria on the stumps. When these techniques are employed, some surgeons do not think that additional precautions need be taken during large bowel surgery.
Q. Should the technique used for surgery on the gastroirrtestinal tract include a change of drapes, gloves andlor instruments once the tract is closed?
A. When the surgeon is ready to open the
Identification comes first before surgery, before medication, before any patient procedure. Ident-A-Band makes it quick and easy to be sure; it offers positive identification . . . strong, nontransferable, yet soft and gentle to wear. Write for samples.
HOLLISTER INC.. 211
80
E. CHICAGO AVE., CHICAGO 60611
gastrointestinal tract, warm, moist laparotomy tapes are placed around the site of incision to protect the viscera and tissues of the abdominal wall. Clean towels are also placed around the operative area. Once the gastrointestinal tract is closed, these towels and tapes are discarded from the field. All used sponges and instruments are also discarded. The team changes gown and gloves. The patient is redraped with four towels and a laparotomy sheet over the original drapes. The abdomen is then closed. The scrub nurse can remain outside the contaminated area while the gastrointestinal tract is open and keep herself and the instrument table sterile. She can do this by dropping all sponges, instruments and sutures onto a towel placed below the incision. The surgical team members can help themselves to what they need. They can touch anything placed
AORN Jou,rnnE
onto the field for them, but the scruh nurse does not touch anything on the field. Soiled sponges and grossly contaminated instruments can be discarded into a basin placed on the field for this purpose. The surgeons then hand this basin, along with the rest of the instruments, etc., off the field to the circulating nurse when the gastrointestinal tract closure is completed, before they change gown and gloves. If the scrub nurse handles instruments, sutures, sponges, etc., while the gastrointestinal tract is open, she should refrain from contaminating the instrument table and Mayo stand that will be used for the abdominal closure. She may do this by setting up a second sterile Mayo stand or table with all the necessary supplies for regowning and regloving of the team, redraping of the patient, and closing of the abdominal incision. This set-up, prepared before the operation begins, should remain covered until it is needed. As an alternative method, the scrub nurse may obtain supplies from the instrument table with transfer forceps while the gastrointestinal tract is open and then remove the contaminated Mayo stand before she regowns and regloves. The latter is not a commonly used procedure.
Q. Should we institute instrument and needle counts?
A. If the other hospitals in your community are taking instrument and needle counts on all surgical procedures, then your hospital should also. However, if this is not the standard practice in your community, and you think that control is maintained by each member of your nursing staff without these formal procedures, there probably is no necessity to institute them. On the other hand, if the loss of needles or instruments has been a persistent problem, resulting in lawsuits, you would be wise to adopt these procedures as OR policy. Needle counts are more widely taken around the country than are instrument
M n y 1968
counts. Needles, conceivably, are more easily lost or broken in the incision than are surgical instruments. However, if each needle is conscientiously retrieved after use from the surgeon before another one is given to him, control can be maintained. When standard instrument sets are prepared, the scrub nurse can make a rapid check of her instruments to ascertain that they are all accounted for before wound closure is begun or completed.
0. Do the duties or responsibilities
of a scrub nurse permit her to function as first assistant.? What legal technicalities are involved in this issue.?
A. The Joint Commission on Accreditation of Hospitals recommends that, “In any procedure with unusual hazard to life, there must be a qualified physician prezent and scrubbed as first assistant. A qualified assistant is defined as a physician designated by the credentials committee of his respective hospital as being qualified to assist.” Further, the JCAH suggests that this practice be reviewed by medical staff committees and that corrective measures be taken through an authoritative body of the hospital to censure any surgeon who repeatedly abuses this practice. “Unusual hazard to life” is generally interpreted as applying to surgical procedures in which major body cavities are entered and/or extensive surgical incisions are made into body tissues. Piurses or technicians may act as second or third assistants at these operations. These persons can also be used as first assistants at operations of lesser magnitude and hazard to the patient. In a court of law, the recommendations of the JCAH and the standard of practice adhered to by other hospitals in the community would establish the criteria by which the hospital personnel and surgeons involved in a lawsuit would be judged. A nurse or technician who assumes the responsibilities and functions that should be delegated to a physician would be considered a n illegal practitioner of medicine.
++
81