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Proposed Recommended Practices
AORN J O U R N A L
JULY 1990. VOL. 5 2 , NO I
Proposed Recommended Practices CLEANING AND PROCESSING ANESTHESIAEQUIPMENT
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 the 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, C O 80231 Attention: Mary O'Neale, RN, BS, CNOR
The deadline for comments is Aug 6, 1990. Purpose. Anesthesia apparatus has a potential to be a vector in the transmission of microorganisms. Proper cleaning, disinfection, and/or sterilization of this apparatus can reduce the risk of infection to the patient. These recommended practices provide information for the cleaning and processing of anesthesia equipment and instrumentation used during the administration of anesthetic agents. These recommended practices are meant to supply information and guidance for the institutions where the responsibility falls under the authority of the practice setting.
Recommended Practice I Portions of anesthesia equipment that are in contact with mucous membranes, blood, or body fluid should be terminally cleaned then processed by disinfection or sterilization between each patient use. Interpretive statement I: Reusable endotracheal tubes, stylets, masks, breathing tubes, connectors, self-inflating bags, airways, forceps, and laryngoscope blades should be cleaned and thoroughly dried before high-level disinfection or sterilization. Rationale: Organic material must be removed before disinfection or sterilization to reduce bioburden and to ensure proper exposure of equipment for disinfection/sterilization.' Interpretive statement 2: Single-use items such as suction catheters,
JULY 1990. VOL. 52. NO I
breathing circuits, or absorbers should be discarded appropriately after each use and should not be reprocessed or reused. Rationale: It is difficult to document that the devices can be reprocessed without residual toxicity and still function safely and effectively.2
AORN J O U R N A L
developed and approved by appropriate mechanisms and be consistent throughout the practice setting. Rationale: All patients are entitled to the same standard of care?
Recommended Practice IV Recommended Practice 11 Equipment (eg, anesthesia machine, blood pressure cuff, carts, and monitors) not in contact with mucous membranes, normally sterile areas of the body, or nonintact skin should be cleaned/decontaminated when contaminated or at the conclusion of the day. Interpretive statement I: Surfaces of equipment should be cleaned with an infection control committee approved or Environmental Protection Agency (EPA) registered hospital-grade detergent/disinfectant. Rationale: Sanitation in the operating room is essential to reduce the possibility of contamination of patients and health care per~onnel.~ Interpretive statement 2: Absorbers and valves should be cleaned with a hospital-grade detergent/germicide when the soda lime is changed paying particular attention to the valves. Rationale: Soda lime is not an effective bactericidal agent, and microbial growth can occur especially in valve area^.^ Interpretive statement 3: Anesthesia ventilator bellows should be cleaned followed by high-level disinfection or steriliiation according to an established routine. Rationale: Patient exposure causes microbial b u i l d ~ p . ~
Policies and procedures on cleaning and processing anesthesia equipment should be established. Discussion: The policies should establish authority, responsibility, and accountability for cleaning and processing anesthesia equipment within the practice setting. Procedures should include, but are not limited to cleaning schedule for reusables, disposal of single-use items, routine guidelines for equipment care, disinfection and/or sterilization techniques for all items in direct or indirect patient contact, and adherence to universal precautions as recommended by the Centers for Disease Control, Atlanta.
Glossary High-level disinfection: A process that uses an EPA registered agent that kills vegetative bacteria, tubercle bacilli, some spores, fungi, and lipid and nonlipid viruses given appropriate concentration, submersion, and contact time. Manufacturers’ recommendations may differ. Sterilization: The process of destroying all microorganisms on a substance by exposure to physical and chemical agents. Cleaning: A process using friction, detergent, and water to remove organic debris.
Recommended Practice 111 Anesthesia and respiratory therapy equipment should be processed in the same manner in all areas of the practice setting. Interpretive statement I: Guidelines for infection control should be
Notes 1. J S Garner, M S Favero, “Guideline for handwashing and hospital environmental control, 1985,” in Guidelinefor fhe Prevenlion and Conrrol of Nosocornid 1nfecfrion.s (Atlanta: Centers for Disease Control, 1985) 8; Centers for Disease Control, “Cleaning, disinfecting, and sterilizing patient-care 91
AORN J O U R N A L
J U L Y 1990. VOI.. 52. NO I
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 procedures. 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 Aug 6, 1990. 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
Good
Fair
Poor
Explain: 2. Will these recommended practices be useful in your practice setting? Yes - No Explain:
~
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.
5. Is the format workable and easy to understand'? Yes - No
~
Explain:
6. What is your general impression of AORN Standarh and Recommended Practices for 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 10170 E Mississippi Ave, Denver, C O 80231 Attn: Mary O'Neale, RN, BS. CNOR Name (optional): Address: City: State:
Zip:
93
AORN JOURNAL
equipment,” Morbidity and Mortality Week@ Report 37 (June 24, 1988) 10-12; W W Bond, “Questions and answers,” Journal of the American Medical Association 257 (Feb 13, 1987) 843; L J Atkinson, M L Kohn, Berry and Kohn S Introduction to Operating Room Technique, sixth ed (New York City: McGrawHill Book Co, 1986) 253; A J Berry, “Practice advisory: Prevention of blood-borne infections (hepatitis B and AIDS),” American Society of Anesthesiologists Newsletter 53 (April 1989). 2. Garner, Favero, “Guideline for handwashing and hospital environmental control, 1985,” 12; M H Radany, S Perry, D McCallum, “Is it safe to reuse disposables?”American JournalojNursing 87 (January 1987) 36; Atkinson, Kohn, Berry and Kohn’s Introduction to Operating Room Technique, 253. 3. C Spry, Essentialsof PerioperativeNursing: A SelfLearning Guide (Rockville, Md: Aspen Publishers, Inc, 1988) 102. 4. L K Groah, Operating Room Nursing: The Perioperative Role (Reston, Va: Reston Publishing Company, Inc, 1983) 246; 0 J Viegas et al, “A case for using disposable anesthesia circuitry,” (Letter) Anesthesiology 60 (February 1984) 169. 5. J A Kneedler, G H Dodge, Perioperative Patient Care: The Nursing Perspective, second ed (Boston: Blackwell Scientific Publications, Inc, 1987) 214; Groah, Operating Room Nursing: The Perioperative Role, 246; Atkinson, Kohn, Berry and Kohn’s Introduction to Operating Room Technique,254. 6. Joint Commission on the Accreditation of Healthcare Organizations, AMH/90 Accreditation Manual for Hospitals (Chicago: Joint Commission on the Accreditation of Healthcare Organizations, 1989) 266, 267; Atkinson, Kohn, Berry and Kohn’s Introduction to Operating Room Technique,253. Suggested reading
du Moulin, G C; Hedley-Whyte, J . “Bacterial interactions between anesthesiologists,their patients, and equipment.”Anesthesiology 57 (July 1982) 3741. “Guidelines for prevention of nosocomial pneumonia and guideline ranking scheme.” In Guidelines for Prevention and Control of Nosocomial Infections. Atlanta: Centers for Disease Control, September 1982. Rutala, W A. “APIC guideline for selection and use of disinfectants.” American Journal of Infection Control 18 (April 1990) 99- 1 17. “Sterilization.” In Recommended Practice for Central Service. Chicago: American Society for Healthcare Central Service Personnel of the American Hospital Association, October 1989, section 6.
94
J U L Y 1990, VOL. S2. NO I
Metamedicine Techniques Reduce Surgery Fears The use of metamedicine techniques can increase patient satisfaction and reduce return visits, according to a report of a book, Metamedicine: Power and Medicine the Twenty-First Century Way, in the February 1990 issue of Same-Day Surgery. The book authors, Vida Baron and Norman Baron, of the Imperial Valley Surgery Center in Brawley, Calif, said metamedicine is used to control stress by working with the three aspects of the human personality complex: belief, emotion as an energy system, and thought. The process starts with patients learning to look forward to surgery. They learn exactly what will happen during surgery and are encouraged to talk, not only about surgery, but about any topic that comes to mind. This builds trust. Relaxation routines associated with deep breathing neutralize patients’ concerns. The authors found that the color red is especially useful in promoting deep breathing and muscle relaxation. Next, the patients visualize their anger and anxiety as an animal they especially dislike. With the help of individuals they trust, the patients destroy the animal in their imagination. The authors found that most patients are usually very relaxed at this point. The next step is called future pacing. Patients learn to look past the surgery to the time they will go home. Patients also reflect on surgery as a pleasant experience. Patients who have undergone this process emerge from anesthesia extremely relaxed and spend a minimum amount of time in the recovery room. Besides easing the trauma of surgery, the metamedicine techniques can speed up the evaluation process because the interviewer is speaking the patient’s language. The authors also found an unexpected benefit of the procedure. Patients are so pleased that the technique has turned into an effective marketing tool for the center.
JULY 1990. VOL. 5 2 , NO I
Proposed Recommended Practices CLEANING AND PROCESSING ANESTHESIAEQUIPMENT
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 the 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, C O 80231 Attention: Mary O'Neale, RN, BS, CNOR
The deadline for comments is Aug 6, 1990. Purpose. Anesthesia apparatus has a potential to be a vector in the transmission of microorganisms. Proper cleaning, disinfection, and/or sterilization of this apparatus can reduce the risk of infection to the patient. These recommended practices provide information for the cleaning and processing of anesthesia equipment and instrumentation used during the administration of anesthetic agents. These recommended practices are meant to supply information and guidance for the institutions where the responsibility falls under the authority of the practice setting.
Recommended Practice I Portions of anesthesia equipment that are in contact with mucous membranes, blood, or body fluid should be terminally cleaned then processed by disinfection or sterilization between each patient use. Interpretive statement I: Reusable endotracheal tubes, stylets, masks, breathing tubes, connectors, self-inflating bags, airways, forceps, and laryngoscope blades should be cleaned and thoroughly dried before high-level disinfection or sterilization. Rationale: Organic material must be removed before disinfection or sterilization to reduce bioburden and to ensure proper exposure of equipment for disinfection/sterilization.' Interpretive statement 2: Single-use items such as suction catheters,
JULY 1990. VOL. 52. NO I
breathing circuits, or absorbers should be discarded appropriately after each use and should not be reprocessed or reused. Rationale: It is difficult to document that the devices can be reprocessed without residual toxicity and still function safely and effectively.2
AORN J O U R N A L
developed and approved by appropriate mechanisms and be consistent throughout the practice setting. Rationale: All patients are entitled to the same standard of care?
Recommended Practice IV Recommended Practice 11 Equipment (eg, anesthesia machine, blood pressure cuff, carts, and monitors) not in contact with mucous membranes, normally sterile areas of the body, or nonintact skin should be cleaned/decontaminated when contaminated or at the conclusion of the day. Interpretive statement I: Surfaces of equipment should be cleaned with an infection control committee approved or Environmental Protection Agency (EPA) registered hospital-grade detergent/disinfectant. Rationale: Sanitation in the operating room is essential to reduce the possibility of contamination of patients and health care per~onnel.~ Interpretive statement 2: Absorbers and valves should be cleaned with a hospital-grade detergent/germicide when the soda lime is changed paying particular attention to the valves. Rationale: Soda lime is not an effective bactericidal agent, and microbial growth can occur especially in valve area^.^ Interpretive statement 3: Anesthesia ventilator bellows should be cleaned followed by high-level disinfection or steriliiation according to an established routine. Rationale: Patient exposure causes microbial b u i l d ~ p . ~
Policies and procedures on cleaning and processing anesthesia equipment should be established. Discussion: The policies should establish authority, responsibility, and accountability for cleaning and processing anesthesia equipment within the practice setting. Procedures should include, but are not limited to cleaning schedule for reusables, disposal of single-use items, routine guidelines for equipment care, disinfection and/or sterilization techniques for all items in direct or indirect patient contact, and adherence to universal precautions as recommended by the Centers for Disease Control, Atlanta.
Glossary High-level disinfection: A process that uses an EPA registered agent that kills vegetative bacteria, tubercle bacilli, some spores, fungi, and lipid and nonlipid viruses given appropriate concentration, submersion, and contact time. Manufacturers’ recommendations may differ. Sterilization: The process of destroying all microorganisms on a substance by exposure to physical and chemical agents. Cleaning: A process using friction, detergent, and water to remove organic debris.
Recommended Practice 111 Anesthesia and respiratory therapy equipment should be processed in the same manner in all areas of the practice setting. Interpretive statement I: Guidelines for infection control should be
Notes 1. J S Garner, M S Favero, “Guideline for handwashing and hospital environmental control, 1985,” in Guidelinefor fhe Prevenlion and Conrrol of Nosocornid 1nfecfrion.s (Atlanta: Centers for Disease Control, 1985) 8; Centers for Disease Control, “Cleaning, disinfecting, and sterilizing patient-care 91
AORN J O U R N A L
J U L Y 1990. VOI.. 52. NO I
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 procedures. 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 Aug 6, 1990. 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
Good
Fair
Poor
Explain: 2. Will these recommended practices be useful in your practice setting? Yes - No Explain:
~
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.
5. Is the format workable and easy to understand'? Yes - No
~
Explain:
6. What is your general impression of AORN Standarh and Recommended Practices for 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 10170 E Mississippi Ave, Denver, C O 80231 Attn: Mary O'Neale, RN, BS. CNOR Name (optional): Address: City: State:
Zip:
93
AORN JOURNAL
equipment,” Morbidity and Mortality Week@ Report 37 (June 24, 1988) 10-12; W W Bond, “Questions and answers,” Journal of the American Medical Association 257 (Feb 13, 1987) 843; L J Atkinson, M L Kohn, Berry and Kohn S Introduction to Operating Room Technique, sixth ed (New York City: McGrawHill Book Co, 1986) 253; A J Berry, “Practice advisory: Prevention of blood-borne infections (hepatitis B and AIDS),” American Society of Anesthesiologists Newsletter 53 (April 1989). 2. Garner, Favero, “Guideline for handwashing and hospital environmental control, 1985,” 12; M H Radany, S Perry, D McCallum, “Is it safe to reuse disposables?”American JournalojNursing 87 (January 1987) 36; Atkinson, Kohn, Berry and Kohn’s Introduction to Operating Room Technique, 253. 3. C Spry, Essentialsof PerioperativeNursing: A SelfLearning Guide (Rockville, Md: Aspen Publishers, Inc, 1988) 102. 4. L K Groah, Operating Room Nursing: The Perioperative Role (Reston, Va: Reston Publishing Company, Inc, 1983) 246; 0 J Viegas et al, “A case for using disposable anesthesia circuitry,” (Letter) Anesthesiology 60 (February 1984) 169. 5. J A Kneedler, G H Dodge, Perioperative Patient Care: The Nursing Perspective, second ed (Boston: Blackwell Scientific Publications, Inc, 1987) 214; Groah, Operating Room Nursing: The Perioperative Role, 246; Atkinson, Kohn, Berry and Kohn’s Introduction to Operating Room Technique,254. 6. Joint Commission on the Accreditation of Healthcare Organizations, AMH/90 Accreditation Manual for Hospitals (Chicago: Joint Commission on the Accreditation of Healthcare Organizations, 1989) 266, 267; Atkinson, Kohn, Berry and Kohn’s Introduction to Operating Room Technique,253. Suggested reading
du Moulin, G C; Hedley-Whyte, J . “Bacterial interactions between anesthesiologists,their patients, and equipment.”Anesthesiology 57 (July 1982) 3741. “Guidelines for prevention of nosocomial pneumonia and guideline ranking scheme.” In Guidelines for Prevention and Control of Nosocomial Infections. Atlanta: Centers for Disease Control, September 1982. Rutala, W A. “APIC guideline for selection and use of disinfectants.” American Journal of Infection Control 18 (April 1990) 99- 1 17. “Sterilization.” In Recommended Practice for Central Service. Chicago: American Society for Healthcare Central Service Personnel of the American Hospital Association, October 1989, section 6.
94
J U L Y 1990, VOL. S2. NO I
Metamedicine Techniques Reduce Surgery Fears The use of metamedicine techniques can increase patient satisfaction and reduce return visits, according to a report of a book, Metamedicine: Power and Medicine the Twenty-First Century Way, in the February 1990 issue of Same-Day Surgery. The book authors, Vida Baron and Norman Baron, of the Imperial Valley Surgery Center in Brawley, Calif, said metamedicine is used to control stress by working with the three aspects of the human personality complex: belief, emotion as an energy system, and thought. The process starts with patients learning to look forward to surgery. They learn exactly what will happen during surgery and are encouraged to talk, not only about surgery, but about any topic that comes to mind. This builds trust. Relaxation routines associated with deep breathing neutralize patients’ concerns. The authors found that the color red is especially useful in promoting deep breathing and muscle relaxation. Next, the patients visualize their anger and anxiety as an animal they especially dislike. With the help of individuals they trust, the patients destroy the animal in their imagination. The authors found that most patients are usually very relaxed at this point. The next step is called future pacing. Patients learn to look past the surgery to the time they will go home. Patients also reflect on surgery as a pleasant experience. Patients who have undergone this process emerge from anesthesia extremely relaxed and spend a minimum amount of time in the recovery room. Besides easing the trauma of surgery, the metamedicine techniques can speed up the evaluation process because the interviewer is speaking the patient’s language. The authors also found an unexpected benefit of the procedure. Patients are so pleased that the technique has turned into an effective marketing tool for the center.