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OR Nurse Responsible for Safety of Patient in Holding Area
JANUARY 1984, VOL 39, NO 1
AORN JOURNAL
Clinical Issues OR Nurse Responsible for Safety of Patient in Holding Area
Q
Who is responsible for the safety of patients in the holding area? In our hospital in San Juan, Puerto Rico, prernedicated patients wait in the holding area or waiting area for intravenous infusions to be started by the anesthesia department. We check identificationand consent and make sure that the side rails and straps are in place, but who should take care of the patient while he is waiting? Does AORN have standards or guidelines for this situation?
A
AORN doesn’t have such guidelines, but the situation you describe occurs frequently. Patients are left unattended in open corridors until the operating room is available to facilitate quick room turnaround. These facilities do not have holdinglwaiting areas, but the concept is the same. A preoperative patient holding area is, in the truest sense, a special care area. As such, it should be equipped for cardiopulmonary resuscitation, and good surveillance should be available. I strongly recommend assigning a registered nurse to the holding area whenever patients are present. AORN has describedperioperative nursing as the role of the operating room nurse during three surgical phases-preoperative, intraoperative, and postoperative. The period immediately before surgery is stressful for patients both physiologically and psychologically.The patient is usually reassured by the concern the OR team shows for his welfare.’ Preoperative medications can precipitate respiratory depression and hypotension. These pa20
tients should be cared for by a nurse who can assess their condition and take prompt and appropriate action when necessary. Patients often express fears of real and imagined events before surgery. The registered nurse hearing these reactions knows how to intervene with knowledgeable and realistic reassurances to minimize the patient’s distress. One major advantage of the holding area is that the patient can be medicated and transported to the OR well before incision time, giving a cushion so the patient is ready when the OR is. Also procedures that consume OR time, such as starting an intraventricular pressure or central venous pressure, can be done in the holding area. Many operating room nurses shave or prepare the patient’s skin in this area. If there are deficiencies in the patient’s chart, these can be corrected. Similarly, it allows the nurse time to assess the premedication’s effect and the patient’s physical state.
Q
A nurse from our operating room is assigned to endoscopic retrograde cholangiogram pancreatography (ERCP) procedures to monitor and position the patient and to assist the surgeon. These procedures are performed in the x-ray department, which is away from the operating room area. Approximately two ERCP procedures are done a day. Since raising the question of hazards from exposure to radiation, the nurses have been issued protective gloves, goggles, and thyroid collars. Badges are worn over our lead aprons to
AORN JOURNAL
record exposure. Despite these precautions, some members of the staff still fear hazards of radiation. The staffing policy has also changed. Previously, two nurses from the OR staff were assigned. One nurse monitored the patient, and the other nurse helped the physician shoot dye through the endoscopic tubing. Now only one nurse will be assigned during such procedures. The OR nurses think this is insufficient because of recent cardiac arrests and one death. We think two nurses should be assigned at all times. Do you think the OR staff should b t assigned to these cases, and if so, how many?
A
To fully answer your questions, I would need to know the acuity of the average patient having the procedure. Are these usually local anesthetic procedures? Why did the patient die? What was the cause of the cardiac arrest (if known)? The most frequent practice for such procedures is to assign a special procedure nurse to the x-ray department. This nurse assists with all special procedures requiring x-ray or fluoroscopy done in the x-ray department. Of course, assigning a full-time registered nurse for this job description mandates a workload that justifies this cost. Assignment of two staff nurses for ERCP procedures is unusual in most hospitals. I would encourage you to ask how hospitals in your area handle this situation. Certainly, a nurse should monitor the patient’s condition, but a nurse should not be required to assist the physician. X-ray personnel may be able to assist the physician if necessary. I believe your current staff pattern is unnecessary; the patient’s condition, however, certainly should determine staffing assignments. As a general rule, OR nurses have little knowledge about the environment where radiological equipment is used, creating fear they may become sterile, produce deformed fetuses, or eventually develop leukemia or other cancer. The best protection is avoiding excessive exposure to ionizing radiation. The National 22
JANUARY 1984, VOL 39, NO 1
Council on Radiation Protection established the maximum permissible dose as 5 roentgen equivalent man (rem) per year for occupationally exposed persons. OR personnel rarely receive more than 2 to 3 rem per year. Lead aprons, gloves, goggles, and a thyroid collar should provide adequate protection to the OR nurse assisting with these procedures. Badges should be worn to monitor x-ray exposure. I suggest that a radiologist inform OR nurses about the hazards from diagnostic x-ray and about precautionary measures.
s
Two nurses on our staff insist the proper hand scrub procedure requires holding the han s and the forearms lower than the elbows during the washing period so soiled water does not run up the arms. I am to teach the hand scrub technique in our OR, and I need to know the proper technique.
A
Your nurses are confused, but it is no surprise. There are two different procedures for hand scrubbing-one for surgical asepsis and one for personnel in direct contact with patients. The proper technique for the surgical hand scrub requires holding the hands higher than the elbows to allow water to run from the cleanest area, the hands, down to the elbow. The surgical hand scrub identifies the hands as the area requiring surgically clean skin. The hand washing technique for personnel in direct patient contact requires holding the hands and the forearms lower than the elbows during hand washing so soiled water will not run up the ckns. This technique is based on the premise that the hands have touched blood, purulent material, mucus, saliva, or secretions from patient wounds. It prevents spreading contamination from the hands up the arm. COLLEEN K HARVEY, RN AND THE PROPESSIONAL
ADVISORY COMMITTEE Note 1. H Bolognes, “Justification of a holding area in the OR suite,”Surgicul Rounds 4 (October 1981) 48.
AORN JOURNAL
Clinical Issues OR Nurse Responsible for Safety of Patient in Holding Area
Q
Who is responsible for the safety of patients in the holding area? In our hospital in San Juan, Puerto Rico, prernedicated patients wait in the holding area or waiting area for intravenous infusions to be started by the anesthesia department. We check identificationand consent and make sure that the side rails and straps are in place, but who should take care of the patient while he is waiting? Does AORN have standards or guidelines for this situation?
A
AORN doesn’t have such guidelines, but the situation you describe occurs frequently. Patients are left unattended in open corridors until the operating room is available to facilitate quick room turnaround. These facilities do not have holdinglwaiting areas, but the concept is the same. A preoperative patient holding area is, in the truest sense, a special care area. As such, it should be equipped for cardiopulmonary resuscitation, and good surveillance should be available. I strongly recommend assigning a registered nurse to the holding area whenever patients are present. AORN has describedperioperative nursing as the role of the operating room nurse during three surgical phases-preoperative, intraoperative, and postoperative. The period immediately before surgery is stressful for patients both physiologically and psychologically.The patient is usually reassured by the concern the OR team shows for his welfare.’ Preoperative medications can precipitate respiratory depression and hypotension. These pa20
tients should be cared for by a nurse who can assess their condition and take prompt and appropriate action when necessary. Patients often express fears of real and imagined events before surgery. The registered nurse hearing these reactions knows how to intervene with knowledgeable and realistic reassurances to minimize the patient’s distress. One major advantage of the holding area is that the patient can be medicated and transported to the OR well before incision time, giving a cushion so the patient is ready when the OR is. Also procedures that consume OR time, such as starting an intraventricular pressure or central venous pressure, can be done in the holding area. Many operating room nurses shave or prepare the patient’s skin in this area. If there are deficiencies in the patient’s chart, these can be corrected. Similarly, it allows the nurse time to assess the premedication’s effect and the patient’s physical state.
Q
A nurse from our operating room is assigned to endoscopic retrograde cholangiogram pancreatography (ERCP) procedures to monitor and position the patient and to assist the surgeon. These procedures are performed in the x-ray department, which is away from the operating room area. Approximately two ERCP procedures are done a day. Since raising the question of hazards from exposure to radiation, the nurses have been issued protective gloves, goggles, and thyroid collars. Badges are worn over our lead aprons to
AORN JOURNAL
record exposure. Despite these precautions, some members of the staff still fear hazards of radiation. The staffing policy has also changed. Previously, two nurses from the OR staff were assigned. One nurse monitored the patient, and the other nurse helped the physician shoot dye through the endoscopic tubing. Now only one nurse will be assigned during such procedures. The OR nurses think this is insufficient because of recent cardiac arrests and one death. We think two nurses should be assigned at all times. Do you think the OR staff should b t assigned to these cases, and if so, how many?
A
To fully answer your questions, I would need to know the acuity of the average patient having the procedure. Are these usually local anesthetic procedures? Why did the patient die? What was the cause of the cardiac arrest (if known)? The most frequent practice for such procedures is to assign a special procedure nurse to the x-ray department. This nurse assists with all special procedures requiring x-ray or fluoroscopy done in the x-ray department. Of course, assigning a full-time registered nurse for this job description mandates a workload that justifies this cost. Assignment of two staff nurses for ERCP procedures is unusual in most hospitals. I would encourage you to ask how hospitals in your area handle this situation. Certainly, a nurse should monitor the patient’s condition, but a nurse should not be required to assist the physician. X-ray personnel may be able to assist the physician if necessary. I believe your current staff pattern is unnecessary; the patient’s condition, however, certainly should determine staffing assignments. As a general rule, OR nurses have little knowledge about the environment where radiological equipment is used, creating fear they may become sterile, produce deformed fetuses, or eventually develop leukemia or other cancer. The best protection is avoiding excessive exposure to ionizing radiation. The National 22
JANUARY 1984, VOL 39, NO 1
Council on Radiation Protection established the maximum permissible dose as 5 roentgen equivalent man (rem) per year for occupationally exposed persons. OR personnel rarely receive more than 2 to 3 rem per year. Lead aprons, gloves, goggles, and a thyroid collar should provide adequate protection to the OR nurse assisting with these procedures. Badges should be worn to monitor x-ray exposure. I suggest that a radiologist inform OR nurses about the hazards from diagnostic x-ray and about precautionary measures.
s
Two nurses on our staff insist the proper hand scrub procedure requires holding the han s and the forearms lower than the elbows during the washing period so soiled water does not run up the arms. I am to teach the hand scrub technique in our OR, and I need to know the proper technique.
A
Your nurses are confused, but it is no surprise. There are two different procedures for hand scrubbing-one for surgical asepsis and one for personnel in direct contact with patients. The proper technique for the surgical hand scrub requires holding the hands higher than the elbows to allow water to run from the cleanest area, the hands, down to the elbow. The surgical hand scrub identifies the hands as the area requiring surgically clean skin. The hand washing technique for personnel in direct patient contact requires holding the hands and the forearms lower than the elbows during hand washing so soiled water will not run up the ckns. This technique is based on the premise that the hands have touched blood, purulent material, mucus, saliva, or secretions from patient wounds. It prevents spreading contamination from the hands up the arm. COLLEEN K HARVEY, RN AND THE PROPESSIONAL
ADVISORY COMMITTEE Note 1. H Bolognes, “Justification of a holding area in the OR suite,”Surgicul Rounds 4 (October 1981) 48.