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Proposed Recommended Practices
DECEMBER 1991, VOL 54, NO 6
AORN JOURNAL
Proposed Recommended Practices SANITATION IN THE SURGICAL PRACTICE SETTING
T
he following draft is being published for review and comment by AORN members. The AORN Recommended Practices Coordinating Committee (RPCC) is interested in receiving comments on this proposal from members and others. These recommended practices are intended as achievable recommendations representing what is believed to be an optimal level of practice. Policies and procedures will reflect variations in practice settings and/or clinical situations that determine the degree to which the recommended practices can be fulfilled. AORN recognizes the numerous different settings in which perioperative nurses practice. The recommended practices are intended as guidelines adaptable to various practice settings. These practice settings include traditional operating rooms, ambulatory surgery units, physicians’ offices, cardiac catheterization laboratories, endoscopy rooms, radiology departments, and all other areas where surgery may be performed. Although nonmembers may submit comments, the intent of the Committee is to reach a consensus among AORN members. All comments will be acknowledged and considered by RPCC before final approval of these recommendations by the Committee and the AORN Board of Directors. Comments should be sent to: Recommended Practices Coordinating Committee AORN, Inc 10170 E Mississippi Ave Denver, CO 80231
Attention: Mary O’Neale, RN, BS, CNOR The deadline for comments is Jan 6, 1992. Purpose. These recommended practices provide a guideline for sanitation within the surgical practice setting. Sanitation practices should provide a clean environment for the surgical patient and be carried out in such a manner that health care worker and patient exposure to infectious waste is minimal. A basic premise of these recommended practices is that all surgical cases are considered contaminated.
Recommended Practice Z Patients should be provided with a safe, clean environment free from dust and organic debris. Interpretive statement 1: Cleaning and removal of soil should be done on a scheduled basis. Rationale: Exogenous microorganisms can contaminate areas of the surgical practice setting. Cleaning is essential to reduce the risk of cross-infection between patient and personnel. I Interpretive statement 2: Furniture, surgical lights, and equipment should be damp dusted before the first scheduled procedure of the day. Damp dusting should be done with a clean, lint-free material moistened with a hospital-grade chemical germicide. Rationale: Dust and lint are deposited on horizontal surfaces in the surgical practice setting. Proper 1251
AORN JOURNAL
cleaning of these surfaces will help to control airborne microorganisms that may travel on dust and lint.? Interpretive statement 3: Preparation of the surgical practice setting should include a visual inspection of the room for cleanliness before the case carts, supplies, and instrument sets are brought into the room. Rationale: Even though it is difficult to define the level of contamination necessary to increase infection rates, a clean environment will minimize and control the number of pathogens present?
Recommended Practice II During the surgical procedure, activities should be directed to confine and contain contamination. Interpretive statement I : Areas outside the sterile field contaminated by organic debris should be cleaned as contamination occurs. Rationale: Prompt cleanup of blood, organic debris, or other potentially infectious material using a tuberculocidal, hospital-grade chemical germicide helps maintain a safe, clean environment.4 Discussion: If diluted household bleach is used for disinfection, medical devices may become damaged. Therefore, it is preferable to use readily available, commercially prepared chemical germicides.5 Interpretive statement 2: Contaminated disposable items should be discarded into leakproof containers. Rationale: Contaminated disposable articles are placed into leakproof, tear-resistant containers to prevent exposure of personnel to articles contaminated with potentially infectious material and to prevent contamination of the environment.6 Interpretive statement 3: Items contaminated with infectious waste should be handled using protective barriers. Rationale: Because i t is unknown which patients may 1252
DECEMBER 1991, VOL 54, NO 6
harbor bloodborne viruses or pathogenic bacteria, the use of personal protective equipment protects the health care worker from direct exposure to blood or other potentially infectious materials. Personal protective equipmentlattire can include gloves, gowns, face shields or masks, and protective eye wear.’ Discussion: The no-touch technique of using an instrument to touch or handle infectious waste may be substituted for gloves. Interpretive statement 4: All blood, body fluids, and tissue specimens should be placed in a clean leakproof container for transport. The exterior surfaces of specimen containers received from the operative field should be cleaned with a tuberculocidal hospital-grade chemical germicide if visibly contaminated. Rationale: Inanimate objects contaminated with blood and body fluids may expose the health care worker to pathogens.* Discussion: Contamination of inanimate objects such as laboratory slips, x-rays, and patient charts should be prevented.
Recommended Practice III Disposable items that have come in contact with the patient and/or sterile field should be considered contaminated and their disposal should comply with local, state, and federal regulations. Interpretive statement 1: Disposable items contaminated with blood and body fluids are placed in closeable, leakproof containers or bags that are colorcoded, labeled, or tagged. Rationale: Contaminated disposable items are placed in leakproof containers to prevent exposure of personnel to blood andlor body fluids and to prevent contamination of the envir~nrnent.~ Interpretive statement 2: Gowns and gloves should be removed (inside out) and placed into a leakproof con-
DECEMBER 1991,VOLS4,NO6
tainer before health care workers leave the practice setting. Rationale: Gowns and gloves are removed in a manner that confines contamination.l o Interpretive statement 3: Contaminated linen should be handled as little as possible and with minimal agitation. Rationale: Minimal handling and agitation of contaminated linen prevents wide distribution of contaminated l i n t and debris into the environment." Interpretive statement 4: Contaminated linen should be placed in leakproof bags or containers that are labeled or color-coded and transported in washable carts or vehicles. Rationale: Enclosure in leakproof bags that are colorcoded or labeled identifies the presence of infectious waste and prevents exposure of personnel to infectious waste and contamination of the environment.I2 Interpretive statement 5: All disposable sharps should be placed in puncture-resistant containers. Rationale: Injuries caused by needles, scalpels, and other sharp devices are a source of transmission of human immunodeficiency virus, hepatitis B virus, and other pathogens.I3 Interpretive statement 6: Contaminated instruments, basins, trays, and other items are handled by personnel who should wear personal protective equipment and/or attire until the items are decontaminated. Rationale: Use of personal protective equipment and/or attire reduces the health care worker's risk of exposure to blood or other potentially infectious material when handling contaminated items. l4 Interpretive statement 7: Disposable suction tubing should be used. Rationale: Disposable suction tubing eliminates the difficulty encountered in cleaning the lumen of
AORN JOURNAL
reusable suction tubing and the possibility of cross-contamination.Is Interpretive statement 8: If reusable suction containers are used, they should be carefully emptied by the health care worker wearing personal protective equipment and/or attire. Rationale: Any item that has had contact with blood or body fluids is potentially infectious.l6 Discussion: Disposable suction containers may be disposed of intact, or the contents may be emptied into a sanitary sewer system and the containers then disposed of. Disposable suction containers are emptied in the same way as reusable containers. Disposal methods will vary depending on state and local waste management regulations and hospital policy." Interpretive statement 9: Equipment and furniture used during the surgical procedure should be cleaned with a tuberculocidal hospital-grade chemical germicide. Rationale: Equipment and furniture used for the surgical procedure are considered contaminated from patient contact.lS Interpretive statement 10: Mechanical friction should be used while cleaning. Rationale: Effectiveness of the cleaning depends on the use of a frictional, scrubbing action.'' Interpretive statement 11: Patient transport vehicles should be cleaned with a detergent germicide. Rationale: Transport vehicles may become contaminated through patient contact.*' Interpretive statement 12: Floors should be cleaned using a detergent germicide. Rationale: Floor cleaning is essential to remove soil, organic debris, and dust.2' Discussion: The preferred method of floor cleaning is use of a wet-vacuum system, either centrally built1253
AORN JOURNAL
in or portable. If a wet-vacuum system is not available, a two-bucket or one-bucket mop system may be used. A clean mop head and fresh detergent germicide solution should be used for each case. For end-of-case cleaning, it is only necessary to clean a 3- to 4-foot perimeter around the operative site. The area cleaned is extended as necessary to adjacent areas of contamination. For terminal daily cleaning, the entire floor area is cleaned.'?
Recommended Practice IV At the conclusion of the day's schedule, operating rooms, scrubhtility areas, corridors, furnishings, and equipment should be terminally cleaned. Interpretive statement I : Mechanical friction and a detergent germicide are used to clean equipment and areas that should include 0 surgical lights and tracks, fixed and ceiling-mounted equipment, all furniture including wheels and casters, handles of cabinets and push plates, face plates of vents, horizontal surfaces (eg, tops of counters, autoclaves, fixed shelving), the entire floor. kick buckets, and scrub sinks. Rationale: Cleaning in the surgical practice setting is essential to minimize and control the number of pathogens present and reduce the risk of crossinfection between patient and personnel.13 Interpretive statement 2: Refillable soap dispensers should be disassembled and cleaned before being filled with fresh agent. Rationale: Liquid soap dispensers can become contaminated and serve as reservoirs for microorganisms.'J Interpretive statement 3: Cleaning equipment should be disassembled, cleaned with a detergent germicide, and dried before storage. 1254
DECEMBER 1991, VOL 54, NO 6 .
Rationale: Equipment is cleaned to prevent growth of microorganisms during storage and to prevent subsequent contamination of the surgical practice setting.?'
Recommended Practice V All areas and equipment in the surgical practice setting should be cleaned according to an established routine. Interpretive statement I : Areas and equipment to be cleaned should include 0 air conditioning grills andor filters, 0 cabinets, shelves, walls, ceilings, 0 offices, lounges, and 0 locker rooms. Rationale: A clean environment will minimize and control the number of pathogens present.26
Recommended Practice VI Policies and procedures for sanitation should be written, reviewed annually, and readily available within the practice setting; Discussion: These recommended practices should be used as guidelines for the development of policies and procedures within the practice setting. Policies and procedures establish authority, responsibility, and accountability and serve as operational guidelines. The AORN recommended practices that deal with sanitation should be consulted when developing those policies and procedures. Introduction and review of policies and procedures should be included in the orientation and ongoing education of personnel to assist in the development of knowledge, skills, and attitudes that affect patient care. Policies and procedures also assist i n the development of quality assessmenthmprovement activities.
DECEMBER 1991, VOL 54, NO 6
AORN JOURNAL
Recommended Practices Comment Form AORN recommended practices represent what is believed to be an achievable and optimal level of practice. Because of differences in practice settings, recommended practices are necessarily broad to meet the needs of the membership. Recommended practices are meant to serve as guidelines to develop policies and procs dures. The Recommended Practices Coordinating Committee highly values all comments from the AORN membership regarding these proposed recommended practices. Please complete this comment form and return it to AORN Headquarters at the address below by Jan 6,1992.
Please attach additional pages of comments and/or suggestions as needed. All comments will be considered. Proposed recommended practices: 1. What is your overall opinion of these recommended practices?
Excellent
Fair
Good
Poor
Explain: 2. Will these recommended practices be useful in your practice setting? Yes Explain:
No
~
3. Do these recommended practices address the major elements of this practice? Yes No Explain: 4. Please comment on particular areas of concern in these recommended practices and submit supporting documentation. 5. Is the format workable and easy to understand? Yes ~~
No
Explain:
~
6. What is your general impression of AORN Standards and Recommended Practicesfor Perioperative Nursing? 7. How could the Recommended Practices Coordinating Committee further assist you?
8. Please list suggestions for future recommended practices. Thank you for your assistance. Return to: Recommended Practices Coordinating Committee AORN, Inc 10170E Mississippi Ave, Denver, CO 80231 Am: Mary ONeale, RN, BS, CNOR Name (optional): Address: City: State:
Zip 1255
AORN JOURNAL
DECEMBER 1991, VOL 54, NO 6
Glossary Chemical germicide: A generic term for an Environmental Protection Agency (EPA)-registered agent that destroys microorganisms. The EPA classifies germicides as sporicides, general disinfectants, hospital disinfectants, sanitizers, and others. Confine and contain: A principle that recommends that patient microorganisms be restricted to an area of three feet around the patient. When patient microorganisms escape that limited area. they are confined in a leakproof or impervious container or destroyed. Procedures designed to implement this principle will prevent cross-contamination of patients and personnel. Contaminated: The presence of pathogenic microorganisms on or in an animate or inanimate object. Cross-infection: An infection spread from one source to another (eg, person to person). Detergent germicide: A detergent-disinfectant combination with an unregulated combination (ratio) of soap to chemical germicide that is registered with the EPA. Disinfection: A process that destroys most forms of microorganisms on inanimate surfaces. High-level disinfection: A process that destroys all microorganisms with the exception of high numbers of bacterial spores. Intermediate-level disinfection: A process that inactivates M y c o b a c t e r i u m tuberculosis, vegetative bacteria, most viruses, and most fungi, but does not necessarily kill bacterial spores. Low-level disinfection: A process that kills most bacteria, some viruses, and some fungi, but cannot be relied on to kill resistant microorganisms such as tubercle bacilli or bacterial spores. End-of-case cleaning: Cleaning that is performed at the end of one surgical procedure. Exogenous: From a source other than the patient (eg, personnel. equipment, the environment, instruments, supplies, dust).
Hospital-grade chemical germicide: A chemical germicide labeled as effective against S a l m o n e l l a , S t a p h y l o c o c c u s aureus, o r Pseudoinonas aeruginosa that performs low- or intermediate-level disinfection. Infectious waste: Waste that is capable of producing an infectious disease. Five factors must be present simultaneously for an infection to o c c u r . T h e s e f a c t o r s a r e : p r e s e n c e of a pathogen, sufficient virulence and quantity of the pathogen, a portal of entry, and a susceptible host.” No-touch technique: The use of an extension (eg, sponge forcep) rather than hands to handle or touch contaminated or sterile items. Organic debris: Blood and tissue. Personal protective equipment: Specialized equipment or clothing used by individuals to protect themselves from direct exposure to blood or other potentially infectious materials. Personal protective equipment includes gloves; gowns; fluid-resistant aprons; head and foot coverings; laboratory coats; f a c e shields, masks, and eye protection; and ventilation devices (eg, mouth pieces, resuscitation bags, pocket masks). Terminal cleaning: Cleaning that is performed at the completion of the day’s surgical schedule. Notes 1 . W A Altemeier et al, eds, Manual on Control of In,fection in Surgical Patients, second ed (Philadelphia: J B Lippincott Co, 1984) 11 ; M H Meeker, J C Rothrock, Alexander’s Care of the Patient in Surgery, ninth ed (St Louis: Mosby Year
Book, Inc, 1991) 101. 2. P Wells, ‘‘ ‘Confine and contain’ approach to OR cleanup,” AORN Journal 25 (January 1977) 6162. 3 . Altemeier et al, Manual on Control of Injection in Surgical Patients, 28 1. 4. U S Department of Health and Human Services, Guidelines for Prevention of Transmission qf Human Immunodeficiency Virus and Hepatitis B Virus to Health-Care and Public-Safety Workers
(Atlanta: Centers for Disease Control, February 1989) 40,4 1 ; US Department of Labor Occupational Safety and Health Administration, Compliance Assistance Guideline f o r the February 27, 1990, OSHA Instruction, C P L 2-2.44B Enforcement
DECEMBER 199I , VOL 54, NO 6
Procedures for Occupational Exposure to Hepatitis B Virus and Human Immunodeficiency Virus, (Washington, DC: US Government Printing Office, 1991) 5, 8. 5. US Department of Health and Human Services, Guidelines for Prevention of Transmission of Human Intinunodeficiency Virus and Hepatitis B Virus to Health-Care and Public-Safety Workers, 40. 6. US Department of Labor Occupational Safety and Health Administration, Compliance Assistance Guideline f o r the February 27, 1990 OSHA Instruction CPL 2-2.44B Enforcement Procedures for Occupational Exposure to Hepatitis B Virus and Human Immunodeficiency Virus, 7. 7. Ibid, 6; US Department of Health and Human Services, Guidelines for Prevention of Transmission of Human Immunodeficiency Virus and Hepatitis B Virus to Health-Care and Public-Safety Workers, 31, 32. 8. US Department of Health and Human Services, Guidelines for Prevention of Transmission of Human Immunodeficiency Virus and Hepatitis B Virus to Health-Care and Public-Safety Workers, 37. 9. US Department of Labor Occupational Safety and Health Administration, Compliance Assistance Guideline f o r the February 27, 1990 OSHA Instruction CPL 2-244B Enforcement Proceduresfor Occupational Exposure to Hepatitis B Virus and Human Immunodeficiency Virus, 7 10. L J Atkinson, M L Kohn, eds, Berry and Kohn ’s Introduction to Operating Room Technique, sixth ed (New York City: McGraw-Hill, 1986) 183. 11. J S Garner, M S Favero, “Guideline for handwashing and hospital environmental control, 1985,” (Washington, DC: US Government Printing Office, 1985) 18. 12. US Department of Labor Occupational Safety and Health Administration, Compliance Assistance Guideline f o r the February 27, 1990 OSHA Instruction CPL 2-2.44B Enforcement Procedures for Occupational Exposure to Hepatitis B Virus and Human Immunodeficiency Virus, 9. 13. Ibid, 7; US Department of Health and Human Services, Guidelines for Prevention of Transmission of Human Immunodeficiency Virus and Hepatitis B Virus to Health-Care and Public-Safety Workers, 3 1, 37. 14. US. Department of Labor Occupational Safety and Health Administration, Compliance Assistance Guideline f o r the February 27, I990 OSHA Instruction CPL 2-2.448 Enforcement Procedures for Occupational Exposure to Hepatitis B Virus and Human Immunodeficiency Virus, 5,6. 15. L K Groah, Operating Room Nursing: Perioperative Practice (Norwalk, Conn: Appleton & Lange, 1990) 162; US Department of Health and Human Services, Guidelines f o r Prevention of
AORN JOURNAL
Transmission of Human Immunodeficiency Virus and Hepatitis B Virus to Health-Care and PublicSafety Workers, 3 1. 16. US Department of Health and Human Services, Guidelines for Prevention of Transmission of Human Immunodeficiency Virus and Hepatitis B Virus to Health-Care and Public-Safety Workers, 31. 17. E R Hedrick, “Infectious waste managementWill science prevail?’ Infection Control Hospital Epidemiology 9 (November 1988) 489. 18. Groah, Operating Room Nursing: Perioperative Practice, 170; R E Condon, E J Quebbeman, “Preparing the operating room,” in Care of the Surgical Patient, vol2, ed D W Wilmore, et a1 (New York City: Scientific American, Inc, 1988) 6. 19. Atkinson, Kohn, Berry and Kohn’s Introduction to Operating Room Technique, 186. 20. Groah, Operating Room Nursing: Perioperalive Practice, 172. 21. Altemeier et al, ed, Manual on Control of Infection in Surgical Patients, 112; Groah, Operating Room Nursing: Perioperative Practice, 161. 22. Groah, Operating Room Nursing: Perioperative Practice, 170; Altemeier et al, Manual on Control of Infection in Surgical Patients, 114. 23. Altemeier et al, Manual on Control of Infection in Surgical Patients, 281; Meeker, Rothrock, Alexander’s Care of the Patient in Surgery, 101. 24. Garner, Favero, “Guidelines for handwashing and hospital environmental control, 1985,” 8. 25. Groah, Operating Room Nursing: Perioperative Practice, 172. 26. Altemeier et al, Manual on Control of Infection in Surgical Patients, 281. 27. WA Rutala, RL Odette, G P Samsa, “Management of infectious waste by U S hospitals,” Journal of the American Medical Association 262 (Sept 22-29, 1989) 1639.
1257
AORN JOURNAL
Proposed Recommended Practices SANITATION IN THE SURGICAL PRACTICE SETTING
T
he following draft is being published for review and comment by AORN members. The AORN Recommended Practices Coordinating Committee (RPCC) is interested in receiving comments on this proposal from members and others. These recommended practices are intended as achievable recommendations representing what is believed to be an optimal level of practice. Policies and procedures will reflect variations in practice settings and/or clinical situations that determine the degree to which the recommended practices can be fulfilled. AORN recognizes the numerous different settings in which perioperative nurses practice. The recommended practices are intended as guidelines adaptable to various practice settings. These practice settings include traditional operating rooms, ambulatory surgery units, physicians’ offices, cardiac catheterization laboratories, endoscopy rooms, radiology departments, and all other areas where surgery may be performed. Although nonmembers may submit comments, the intent of the Committee is to reach a consensus among AORN members. All comments will be acknowledged and considered by RPCC before final approval of these recommendations by the Committee and the AORN Board of Directors. Comments should be sent to: Recommended Practices Coordinating Committee AORN, Inc 10170 E Mississippi Ave Denver, CO 80231
Attention: Mary O’Neale, RN, BS, CNOR The deadline for comments is Jan 6, 1992. Purpose. These recommended practices provide a guideline for sanitation within the surgical practice setting. Sanitation practices should provide a clean environment for the surgical patient and be carried out in such a manner that health care worker and patient exposure to infectious waste is minimal. A basic premise of these recommended practices is that all surgical cases are considered contaminated.
Recommended Practice Z Patients should be provided with a safe, clean environment free from dust and organic debris. Interpretive statement 1: Cleaning and removal of soil should be done on a scheduled basis. Rationale: Exogenous microorganisms can contaminate areas of the surgical practice setting. Cleaning is essential to reduce the risk of cross-infection between patient and personnel. I Interpretive statement 2: Furniture, surgical lights, and equipment should be damp dusted before the first scheduled procedure of the day. Damp dusting should be done with a clean, lint-free material moistened with a hospital-grade chemical germicide. Rationale: Dust and lint are deposited on horizontal surfaces in the surgical practice setting. Proper 1251
AORN JOURNAL
cleaning of these surfaces will help to control airborne microorganisms that may travel on dust and lint.? Interpretive statement 3: Preparation of the surgical practice setting should include a visual inspection of the room for cleanliness before the case carts, supplies, and instrument sets are brought into the room. Rationale: Even though it is difficult to define the level of contamination necessary to increase infection rates, a clean environment will minimize and control the number of pathogens present?
Recommended Practice II During the surgical procedure, activities should be directed to confine and contain contamination. Interpretive statement I : Areas outside the sterile field contaminated by organic debris should be cleaned as contamination occurs. Rationale: Prompt cleanup of blood, organic debris, or other potentially infectious material using a tuberculocidal, hospital-grade chemical germicide helps maintain a safe, clean environment.4 Discussion: If diluted household bleach is used for disinfection, medical devices may become damaged. Therefore, it is preferable to use readily available, commercially prepared chemical germicides.5 Interpretive statement 2: Contaminated disposable items should be discarded into leakproof containers. Rationale: Contaminated disposable articles are placed into leakproof, tear-resistant containers to prevent exposure of personnel to articles contaminated with potentially infectious material and to prevent contamination of the environment.6 Interpretive statement 3: Items contaminated with infectious waste should be handled using protective barriers. Rationale: Because i t is unknown which patients may 1252
DECEMBER 1991, VOL 54, NO 6
harbor bloodborne viruses or pathogenic bacteria, the use of personal protective equipment protects the health care worker from direct exposure to blood or other potentially infectious materials. Personal protective equipmentlattire can include gloves, gowns, face shields or masks, and protective eye wear.’ Discussion: The no-touch technique of using an instrument to touch or handle infectious waste may be substituted for gloves. Interpretive statement 4: All blood, body fluids, and tissue specimens should be placed in a clean leakproof container for transport. The exterior surfaces of specimen containers received from the operative field should be cleaned with a tuberculocidal hospital-grade chemical germicide if visibly contaminated. Rationale: Inanimate objects contaminated with blood and body fluids may expose the health care worker to pathogens.* Discussion: Contamination of inanimate objects such as laboratory slips, x-rays, and patient charts should be prevented.
Recommended Practice III Disposable items that have come in contact with the patient and/or sterile field should be considered contaminated and their disposal should comply with local, state, and federal regulations. Interpretive statement 1: Disposable items contaminated with blood and body fluids are placed in closeable, leakproof containers or bags that are colorcoded, labeled, or tagged. Rationale: Contaminated disposable items are placed in leakproof containers to prevent exposure of personnel to blood andlor body fluids and to prevent contamination of the envir~nrnent.~ Interpretive statement 2: Gowns and gloves should be removed (inside out) and placed into a leakproof con-
DECEMBER 1991,VOLS4,NO6
tainer before health care workers leave the practice setting. Rationale: Gowns and gloves are removed in a manner that confines contamination.l o Interpretive statement 3: Contaminated linen should be handled as little as possible and with minimal agitation. Rationale: Minimal handling and agitation of contaminated linen prevents wide distribution of contaminated l i n t and debris into the environment." Interpretive statement 4: Contaminated linen should be placed in leakproof bags or containers that are labeled or color-coded and transported in washable carts or vehicles. Rationale: Enclosure in leakproof bags that are colorcoded or labeled identifies the presence of infectious waste and prevents exposure of personnel to infectious waste and contamination of the environment.I2 Interpretive statement 5: All disposable sharps should be placed in puncture-resistant containers. Rationale: Injuries caused by needles, scalpels, and other sharp devices are a source of transmission of human immunodeficiency virus, hepatitis B virus, and other pathogens.I3 Interpretive statement 6: Contaminated instruments, basins, trays, and other items are handled by personnel who should wear personal protective equipment and/or attire until the items are decontaminated. Rationale: Use of personal protective equipment and/or attire reduces the health care worker's risk of exposure to blood or other potentially infectious material when handling contaminated items. l4 Interpretive statement 7: Disposable suction tubing should be used. Rationale: Disposable suction tubing eliminates the difficulty encountered in cleaning the lumen of
AORN JOURNAL
reusable suction tubing and the possibility of cross-contamination.Is Interpretive statement 8: If reusable suction containers are used, they should be carefully emptied by the health care worker wearing personal protective equipment and/or attire. Rationale: Any item that has had contact with blood or body fluids is potentially infectious.l6 Discussion: Disposable suction containers may be disposed of intact, or the contents may be emptied into a sanitary sewer system and the containers then disposed of. Disposable suction containers are emptied in the same way as reusable containers. Disposal methods will vary depending on state and local waste management regulations and hospital policy." Interpretive statement 9: Equipment and furniture used during the surgical procedure should be cleaned with a tuberculocidal hospital-grade chemical germicide. Rationale: Equipment and furniture used for the surgical procedure are considered contaminated from patient contact.lS Interpretive statement 10: Mechanical friction should be used while cleaning. Rationale: Effectiveness of the cleaning depends on the use of a frictional, scrubbing action.'' Interpretive statement 11: Patient transport vehicles should be cleaned with a detergent germicide. Rationale: Transport vehicles may become contaminated through patient contact.*' Interpretive statement 12: Floors should be cleaned using a detergent germicide. Rationale: Floor cleaning is essential to remove soil, organic debris, and dust.2' Discussion: The preferred method of floor cleaning is use of a wet-vacuum system, either centrally built1253
AORN JOURNAL
in or portable. If a wet-vacuum system is not available, a two-bucket or one-bucket mop system may be used. A clean mop head and fresh detergent germicide solution should be used for each case. For end-of-case cleaning, it is only necessary to clean a 3- to 4-foot perimeter around the operative site. The area cleaned is extended as necessary to adjacent areas of contamination. For terminal daily cleaning, the entire floor area is cleaned.'?
Recommended Practice IV At the conclusion of the day's schedule, operating rooms, scrubhtility areas, corridors, furnishings, and equipment should be terminally cleaned. Interpretive statement I : Mechanical friction and a detergent germicide are used to clean equipment and areas that should include 0 surgical lights and tracks, fixed and ceiling-mounted equipment, all furniture including wheels and casters, handles of cabinets and push plates, face plates of vents, horizontal surfaces (eg, tops of counters, autoclaves, fixed shelving), the entire floor. kick buckets, and scrub sinks. Rationale: Cleaning in the surgical practice setting is essential to minimize and control the number of pathogens present and reduce the risk of crossinfection between patient and personnel.13 Interpretive statement 2: Refillable soap dispensers should be disassembled and cleaned before being filled with fresh agent. Rationale: Liquid soap dispensers can become contaminated and serve as reservoirs for microorganisms.'J Interpretive statement 3: Cleaning equipment should be disassembled, cleaned with a detergent germicide, and dried before storage. 1254
DECEMBER 1991, VOL 54, NO 6 .
Rationale: Equipment is cleaned to prevent growth of microorganisms during storage and to prevent subsequent contamination of the surgical practice setting.?'
Recommended Practice V All areas and equipment in the surgical practice setting should be cleaned according to an established routine. Interpretive statement I : Areas and equipment to be cleaned should include 0 air conditioning grills andor filters, 0 cabinets, shelves, walls, ceilings, 0 offices, lounges, and 0 locker rooms. Rationale: A clean environment will minimize and control the number of pathogens present.26
Recommended Practice VI Policies and procedures for sanitation should be written, reviewed annually, and readily available within the practice setting; Discussion: These recommended practices should be used as guidelines for the development of policies and procedures within the practice setting. Policies and procedures establish authority, responsibility, and accountability and serve as operational guidelines. The AORN recommended practices that deal with sanitation should be consulted when developing those policies and procedures. Introduction and review of policies and procedures should be included in the orientation and ongoing education of personnel to assist in the development of knowledge, skills, and attitudes that affect patient care. Policies and procedures also assist i n the development of quality assessmenthmprovement activities.
DECEMBER 1991, VOL 54, NO 6
AORN JOURNAL
Recommended Practices Comment Form AORN recommended practices represent what is believed to be an achievable and optimal level of practice. Because of differences in practice settings, recommended practices are necessarily broad to meet the needs of the membership. Recommended practices are meant to serve as guidelines to develop policies and procs dures. The Recommended Practices Coordinating Committee highly values all comments from the AORN membership regarding these proposed recommended practices. Please complete this comment form and return it to AORN Headquarters at the address below by Jan 6,1992.
Please attach additional pages of comments and/or suggestions as needed. All comments will be considered. Proposed recommended practices: 1. What is your overall opinion of these recommended practices?
Excellent
Fair
Good
Poor
Explain: 2. Will these recommended practices be useful in your practice setting? Yes Explain:
No
~
3. Do these recommended practices address the major elements of this practice? Yes No Explain: 4. Please comment on particular areas of concern in these recommended practices and submit supporting documentation. 5. Is the format workable and easy to understand? Yes ~~
No
Explain:
~
6. What is your general impression of AORN Standards and Recommended Practicesfor Perioperative Nursing? 7. How could the Recommended Practices Coordinating Committee further assist you?
8. Please list suggestions for future recommended practices. Thank you for your assistance. Return to: Recommended Practices Coordinating Committee AORN, Inc 10170E Mississippi Ave, Denver, CO 80231 Am: Mary ONeale, RN, BS, CNOR Name (optional): Address: City: State:
Zip 1255
AORN JOURNAL
DECEMBER 1991, VOL 54, NO 6
Glossary Chemical germicide: A generic term for an Environmental Protection Agency (EPA)-registered agent that destroys microorganisms. The EPA classifies germicides as sporicides, general disinfectants, hospital disinfectants, sanitizers, and others. Confine and contain: A principle that recommends that patient microorganisms be restricted to an area of three feet around the patient. When patient microorganisms escape that limited area. they are confined in a leakproof or impervious container or destroyed. Procedures designed to implement this principle will prevent cross-contamination of patients and personnel. Contaminated: The presence of pathogenic microorganisms on or in an animate or inanimate object. Cross-infection: An infection spread from one source to another (eg, person to person). Detergent germicide: A detergent-disinfectant combination with an unregulated combination (ratio) of soap to chemical germicide that is registered with the EPA. Disinfection: A process that destroys most forms of microorganisms on inanimate surfaces. High-level disinfection: A process that destroys all microorganisms with the exception of high numbers of bacterial spores. Intermediate-level disinfection: A process that inactivates M y c o b a c t e r i u m tuberculosis, vegetative bacteria, most viruses, and most fungi, but does not necessarily kill bacterial spores. Low-level disinfection: A process that kills most bacteria, some viruses, and some fungi, but cannot be relied on to kill resistant microorganisms such as tubercle bacilli or bacterial spores. End-of-case cleaning: Cleaning that is performed at the end of one surgical procedure. Exogenous: From a source other than the patient (eg, personnel. equipment, the environment, instruments, supplies, dust).
Hospital-grade chemical germicide: A chemical germicide labeled as effective against S a l m o n e l l a , S t a p h y l o c o c c u s aureus, o r Pseudoinonas aeruginosa that performs low- or intermediate-level disinfection. Infectious waste: Waste that is capable of producing an infectious disease. Five factors must be present simultaneously for an infection to o c c u r . T h e s e f a c t o r s a r e : p r e s e n c e of a pathogen, sufficient virulence and quantity of the pathogen, a portal of entry, and a susceptible host.” No-touch technique: The use of an extension (eg, sponge forcep) rather than hands to handle or touch contaminated or sterile items. Organic debris: Blood and tissue. Personal protective equipment: Specialized equipment or clothing used by individuals to protect themselves from direct exposure to blood or other potentially infectious materials. Personal protective equipment includes gloves; gowns; fluid-resistant aprons; head and foot coverings; laboratory coats; f a c e shields, masks, and eye protection; and ventilation devices (eg, mouth pieces, resuscitation bags, pocket masks). Terminal cleaning: Cleaning that is performed at the completion of the day’s surgical schedule. Notes 1 . W A Altemeier et al, eds, Manual on Control of In,fection in Surgical Patients, second ed (Philadelphia: J B Lippincott Co, 1984) 11 ; M H Meeker, J C Rothrock, Alexander’s Care of the Patient in Surgery, ninth ed (St Louis: Mosby Year
Book, Inc, 1991) 101. 2. P Wells, ‘‘ ‘Confine and contain’ approach to OR cleanup,” AORN Journal 25 (January 1977) 6162. 3 . Altemeier et al, Manual on Control of Injection in Surgical Patients, 28 1. 4. U S Department of Health and Human Services, Guidelines for Prevention of Transmission qf Human Immunodeficiency Virus and Hepatitis B Virus to Health-Care and Public-Safety Workers
(Atlanta: Centers for Disease Control, February 1989) 40,4 1 ; US Department of Labor Occupational Safety and Health Administration, Compliance Assistance Guideline f o r the February 27, 1990, OSHA Instruction, C P L 2-2.44B Enforcement
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Procedures for Occupational Exposure to Hepatitis B Virus and Human Immunodeficiency Virus, (Washington, DC: US Government Printing Office, 1991) 5, 8. 5. US Department of Health and Human Services, Guidelines for Prevention of Transmission of Human Intinunodeficiency Virus and Hepatitis B Virus to Health-Care and Public-Safety Workers, 40. 6. US Department of Labor Occupational Safety and Health Administration, Compliance Assistance Guideline f o r the February 27, 1990 OSHA Instruction CPL 2-2.44B Enforcement Procedures for Occupational Exposure to Hepatitis B Virus and Human Immunodeficiency Virus, 7. 7. Ibid, 6; US Department of Health and Human Services, Guidelines for Prevention of Transmission of Human Immunodeficiency Virus and Hepatitis B Virus to Health-Care and Public-Safety Workers, 31, 32. 8. US Department of Health and Human Services, Guidelines for Prevention of Transmission of Human Immunodeficiency Virus and Hepatitis B Virus to Health-Care and Public-Safety Workers, 37. 9. US Department of Labor Occupational Safety and Health Administration, Compliance Assistance Guideline f o r the February 27, 1990 OSHA Instruction CPL 2-244B Enforcement Proceduresfor Occupational Exposure to Hepatitis B Virus and Human Immunodeficiency Virus, 7 10. L J Atkinson, M L Kohn, eds, Berry and Kohn ’s Introduction to Operating Room Technique, sixth ed (New York City: McGraw-Hill, 1986) 183. 11. J S Garner, M S Favero, “Guideline for handwashing and hospital environmental control, 1985,” (Washington, DC: US Government Printing Office, 1985) 18. 12. US Department of Labor Occupational Safety and Health Administration, Compliance Assistance Guideline f o r the February 27, 1990 OSHA Instruction CPL 2-2.44B Enforcement Procedures for Occupational Exposure to Hepatitis B Virus and Human Immunodeficiency Virus, 9. 13. Ibid, 7; US Department of Health and Human Services, Guidelines for Prevention of Transmission of Human Immunodeficiency Virus and Hepatitis B Virus to Health-Care and Public-Safety Workers, 3 1, 37. 14. US. Department of Labor Occupational Safety and Health Administration, Compliance Assistance Guideline f o r the February 27, I990 OSHA Instruction CPL 2-2.448 Enforcement Procedures for Occupational Exposure to Hepatitis B Virus and Human Immunodeficiency Virus, 5,6. 15. L K Groah, Operating Room Nursing: Perioperative Practice (Norwalk, Conn: Appleton & Lange, 1990) 162; US Department of Health and Human Services, Guidelines f o r Prevention of
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Transmission of Human Immunodeficiency Virus and Hepatitis B Virus to Health-Care and PublicSafety Workers, 3 1. 16. US Department of Health and Human Services, Guidelines for Prevention of Transmission of Human Immunodeficiency Virus and Hepatitis B Virus to Health-Care and Public-Safety Workers, 31. 17. E R Hedrick, “Infectious waste managementWill science prevail?’ Infection Control Hospital Epidemiology 9 (November 1988) 489. 18. Groah, Operating Room Nursing: Perioperative Practice, 170; R E Condon, E J Quebbeman, “Preparing the operating room,” in Care of the Surgical Patient, vol2, ed D W Wilmore, et a1 (New York City: Scientific American, Inc, 1988) 6. 19. Atkinson, Kohn, Berry and Kohn’s Introduction to Operating Room Technique, 186. 20. Groah, Operating Room Nursing: Perioperalive Practice, 172. 21. Altemeier et al, ed, Manual on Control of Infection in Surgical Patients, 112; Groah, Operating Room Nursing: Perioperative Practice, 161. 22. Groah, Operating Room Nursing: Perioperative Practice, 170; Altemeier et al, Manual on Control of Infection in Surgical Patients, 114. 23. Altemeier et al, Manual on Control of Infection in Surgical Patients, 281; Meeker, Rothrock, Alexander’s Care of the Patient in Surgery, 101. 24. Garner, Favero, “Guidelines for handwashing and hospital environmental control, 1985,” 8. 25. Groah, Operating Room Nursing: Perioperative Practice, 172. 26. Altemeier et al, Manual on Control of Infection in Surgical Patients, 281. 27. WA Rutala, RL Odette, G P Samsa, “Management of infectious waste by U S hospitals,” Journal of the American Medical Association 262 (Sept 22-29, 1989) 1639.
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