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Recommended Practices: Traffic Patterns In The Surgical Suite
MARCH 1993, VOL 57, NO 3
AORN JOURNAL
Recommended Practices TRMC PATERNSr~
T
he following recommended practices were developed by the AORN Recommended Practices Coordinating Committee and have been approved by the AORN Board of Directors. They were published as proposed recommended practices in the August 1992 AORN Journal for comment by 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. Purpose. Care of the patient during surgery requires movement of patients, personnel, and material within the surgical suite. Planning and controlling these movements assists in the containment of contamination. The design of the surgical suite often predetermines traffic patterns. Traffic patterns suggest movement into and out of the surgical suite as well as movement within the suite. Total implementation of the recommended practices may not be feasible 730
THE SURGICAL SUITE
within every facility because of the environmental design.
Recommended Practice I The practice setting should be designed to facilitate movement of patients and personnel through, into, and out of defined areas within the surgical suite. Signs should clearly indicate the appropriate environmental controls and surgical attire required. Interpretive statement 1: The surgical suite should be divided into three designated areas that are defined by the physical activities performed in each area. The unrestricted area includes a central control point that is established to monitor the entrance of patients, personnel, and materials. Communication takes place between personnel within the surgical suite and the entire health care facility, not excluding outside medical offices. Street clothes are permitted in this area, and traffic is not limited. The semirestricted area includes the most peripheral support areas of the surgical suite and has storage areas for clean and sterile supplies, work areas for storage and processing of instruments, and corridors to the restricted areas of the surgical suite. Traffic in this area is limited to authorized personnel and patients. Personnel are required to wear surgical attire and hats or hoods. Patients are required to wear gowns and hair covering. The restricted area is where surgical procedures are performed and unwrapped supplies
AORlri JOURNAL
are sterilized. It includes operating suites and clean core and scrub sink areas. Surgical attire. hats or hoods. and masks are required in this area at all times. Rationale: Environmental controls and surgical attire should increase as progression is made from unrestricted to restricted areas.' Interpretive statement 2: Movement of personnel from unrestricted areas to either semirestricted or restricted areas should be through the vestibular area. Rationale: Vestibular areas may serve as a transition zone where one can enter locker rooms, holding areas, and offices. Locker rooms serve as a transition zone between outside and inside of the surgical suite and may serve as a security point to monitor people admitted.? Interpretive statement 3: Patients entering the surgical suite should wear clean gowns, be covered with clean linens. and have their hair covered. Discussion: Clean gowns, linens, and hair coverings are worn to contain debris and dead cells shed by the patient.' Patients are not required to wear masks while in the surgical suite. While in the restricted area, the mask would hinder access to the face and airway and might increase the patient's anxiety. Keeping the sterile field away from the head of the surgical bed until the patient is draped will minimize the possibility of contamination.4
Recomnierzded Practice I I Movement of personnel should be kept to a minimum while surgery is in progress. Interpretive statement I : Careful asseesment and planning for patient care needs by each member of the surgical team can reduce the need for increased traffic in the operating room. Rationale: Greater amounts of airborne contamination can be expected with increased movement.-s lnterpretive statement 2: 732
MARCH 1993, VOL 57, NO 3
Doors to the operating rooms should be closed except during movement of personnel and equipment. Rationale: Keeping the doors closed decreases the mixing of operating room air with corridor air and thereby decreases the bacterial count. The air pressure within each operating room should be greater than in the semirestricted area.6 Interpretive statement 3: Movement, talking, and the number of people present s h o u l d b e m i n i m i z e d d u r i n g surgery. Rationale: Bacteria counts rise sharply as air travels through the operating room because air currents pick up contaminated particles shed from patients, personnel, a n d drapes. Shedding increases with activity.'
Recommended Practice 111 The movement of clean and sterile supplies and equipment should be separated as much as possible from contaminated supplies, equipment, and waste by space, time, or traffic patterns. Interpretive statement 1 : Supplies prepared for surgical cases outside the surgical suite, such as in central service, should be transported to the operating room in closed or covered carts. Rationale: Supplies transported in open carts through unrestricted areas can be easily contaminated by contact and/or by airborne contaminants.R Interpretive statement 2 : Supplies and equipment should be removed from external shipping containers in the unrestricted area before transfer into the surgical suite. Rationale: External shipping containers m a y collect dust, microorganisms, and insects during shipment and may carry contaminants into the surgical suite.Y Interpretive statement 3: Soiled supplies, instruments, and equipment
MARCH 1993, VOL 57, NO 3
AORN JOURNAL
for reprocessing should be transported along a planned route that avoids restricted areas.
Rationale: Soiled materials should be separated from the movement of clean and sterile supplies and equipment by space, time, and traffic patterns to prevent cross-contamination.’”
Recommended Practice IV Policies and procedures for traffic patterns for patients, personnel, supplies, and equipment 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. Information on traffic patterns and methods of handling supplies and equipment should be included in the orientation and continuing education of personnel in the surgical practice setting. Traffic patterns may be affected during construction, renovation, and maintenance. Specific traffic plans for construction personnel and movement of supplies, equipment, and debris should be developed. Policies and procedures should establish guidelines for quality assessment and improvement activities to be used when monitoring traffic control patterns in the surgical practice setting.
Glossary Substerile area: Acts as a service area between two or more operating rooms and may be equipped with a flash sterilizer, warming cabinet, sterile supply storage, and small sink. Vestibular area: Area inside the entrance to the surgical suite separating the corridors of the surgical suite from those of the hospital. Notes 1 . H Laufman, “Internal configuration of the surgical suite.” in Hospital Sperial Care Facilities: Planning for User Needs, ed H Laufman (New York 734
City: Academic Press, 1981) 77; M A Pierson, “Design of the surgical suite,” in Alexander’s Care ofthe Patient in Surgery, ninth ed, M H Meeker, J C Rothrock, eds (St Louis: The C V Mosby Co, 1991) 37-38; J S Gamer, J K Schultz, “Absence of infection,” in Perioperative Patient Care: The Nursing Perspective, second ed, J A Kneedler, G H Dodge, eds (Boston: Blackwell Scientific Publications, Inc, 1987) 226. 2. L Groah, Operating Room Nursing: Perioperati\*e Practice, second ed (East Norwalk, Conn: Appleton & Lange, 1990) 23; Gamer, Schultz, “Absence of infection,” 226; J K Schultz, “Traffic and commerce in the surgical suite,” in Hospital Special Care Facilities: Planning far User-Needs, ed H Laufman (New York City: Academic Press, 1981) 235. 3. Gamer, Schultz, “Absence of infection,” 226227; Pierson, “Design of the surgical suite,” 38. 4. Gamer, Schultz, “Absence of infection,” 226227. 5. J Gamer, “Guidelines for prevention of surgical wound infections, 1985” in Guidelines for the Prevention and Control of Nosocomial infections (Atlanta: Centers for Disease Control, 1985) 6. 6. [bid; Gamer, Schultz, “Absence of infection,” 226; Groah, Operating Room Nursing: Perioperative Practice, 25. 7. Gamer, “Guidelines for prevention of surgical wound infections, 1985,” 6; R H Adams, D E Fry, “Surgical suite reconstruction,” AORN Journal 39 (April 1984) 870. 8. J K Schultz, “Covered case carts reduce contamination, instrument ‘borrowing,’” AORN Journal 33 (May 1981) 1042. 9. Groah, Operating Room Nursing: Perioperative Practice, 23; Pierson, “Design of the surgical suite,” 38. 10. W R Frieben, “Control of the aseptic processing environment,” American Journal of Hospital Pharmacy 40 (November 1983) 1928; Schultz, “Traffic and commerce in the surgical suite,” 236; Gamer, Schultz, “Absence of infection,” 227.
AORN JOURNAL
Recommended Practices TRMC PATERNSr~
T
he following recommended practices were developed by the AORN Recommended Practices Coordinating Committee and have been approved by the AORN Board of Directors. They were published as proposed recommended practices in the August 1992 AORN Journal for comment by 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. Purpose. Care of the patient during surgery requires movement of patients, personnel, and material within the surgical suite. Planning and controlling these movements assists in the containment of contamination. The design of the surgical suite often predetermines traffic patterns. Traffic patterns suggest movement into and out of the surgical suite as well as movement within the suite. Total implementation of the recommended practices may not be feasible 730
THE SURGICAL SUITE
within every facility because of the environmental design.
Recommended Practice I The practice setting should be designed to facilitate movement of patients and personnel through, into, and out of defined areas within the surgical suite. Signs should clearly indicate the appropriate environmental controls and surgical attire required. Interpretive statement 1: The surgical suite should be divided into three designated areas that are defined by the physical activities performed in each area. The unrestricted area includes a central control point that is established to monitor the entrance of patients, personnel, and materials. Communication takes place between personnel within the surgical suite and the entire health care facility, not excluding outside medical offices. Street clothes are permitted in this area, and traffic is not limited. The semirestricted area includes the most peripheral support areas of the surgical suite and has storage areas for clean and sterile supplies, work areas for storage and processing of instruments, and corridors to the restricted areas of the surgical suite. Traffic in this area is limited to authorized personnel and patients. Personnel are required to wear surgical attire and hats or hoods. Patients are required to wear gowns and hair covering. The restricted area is where surgical procedures are performed and unwrapped supplies
AORlri JOURNAL
are sterilized. It includes operating suites and clean core and scrub sink areas. Surgical attire. hats or hoods. and masks are required in this area at all times. Rationale: Environmental controls and surgical attire should increase as progression is made from unrestricted to restricted areas.' Interpretive statement 2: Movement of personnel from unrestricted areas to either semirestricted or restricted areas should be through the vestibular area. Rationale: Vestibular areas may serve as a transition zone where one can enter locker rooms, holding areas, and offices. Locker rooms serve as a transition zone between outside and inside of the surgical suite and may serve as a security point to monitor people admitted.? Interpretive statement 3: Patients entering the surgical suite should wear clean gowns, be covered with clean linens. and have their hair covered. Discussion: Clean gowns, linens, and hair coverings are worn to contain debris and dead cells shed by the patient.' Patients are not required to wear masks while in the surgical suite. While in the restricted area, the mask would hinder access to the face and airway and might increase the patient's anxiety. Keeping the sterile field away from the head of the surgical bed until the patient is draped will minimize the possibility of contamination.4
Recomnierzded Practice I I Movement of personnel should be kept to a minimum while surgery is in progress. Interpretive statement I : Careful asseesment and planning for patient care needs by each member of the surgical team can reduce the need for increased traffic in the operating room. Rationale: Greater amounts of airborne contamination can be expected with increased movement.-s lnterpretive statement 2: 732
MARCH 1993, VOL 57, NO 3
Doors to the operating rooms should be closed except during movement of personnel and equipment. Rationale: Keeping the doors closed decreases the mixing of operating room air with corridor air and thereby decreases the bacterial count. The air pressure within each operating room should be greater than in the semirestricted area.6 Interpretive statement 3: Movement, talking, and the number of people present s h o u l d b e m i n i m i z e d d u r i n g surgery. Rationale: Bacteria counts rise sharply as air travels through the operating room because air currents pick up contaminated particles shed from patients, personnel, a n d drapes. Shedding increases with activity.'
Recommended Practice 111 The movement of clean and sterile supplies and equipment should be separated as much as possible from contaminated supplies, equipment, and waste by space, time, or traffic patterns. Interpretive statement 1 : Supplies prepared for surgical cases outside the surgical suite, such as in central service, should be transported to the operating room in closed or covered carts. Rationale: Supplies transported in open carts through unrestricted areas can be easily contaminated by contact and/or by airborne contaminants.R Interpretive statement 2 : Supplies and equipment should be removed from external shipping containers in the unrestricted area before transfer into the surgical suite. Rationale: External shipping containers m a y collect dust, microorganisms, and insects during shipment and may carry contaminants into the surgical suite.Y Interpretive statement 3: Soiled supplies, instruments, and equipment
MARCH 1993, VOL 57, NO 3
AORN JOURNAL
for reprocessing should be transported along a planned route that avoids restricted areas.
Rationale: Soiled materials should be separated from the movement of clean and sterile supplies and equipment by space, time, and traffic patterns to prevent cross-contamination.’”
Recommended Practice IV Policies and procedures for traffic patterns for patients, personnel, supplies, and equipment 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. Information on traffic patterns and methods of handling supplies and equipment should be included in the orientation and continuing education of personnel in the surgical practice setting. Traffic patterns may be affected during construction, renovation, and maintenance. Specific traffic plans for construction personnel and movement of supplies, equipment, and debris should be developed. Policies and procedures should establish guidelines for quality assessment and improvement activities to be used when monitoring traffic control patterns in the surgical practice setting.
Glossary Substerile area: Acts as a service area between two or more operating rooms and may be equipped with a flash sterilizer, warming cabinet, sterile supply storage, and small sink. Vestibular area: Area inside the entrance to the surgical suite separating the corridors of the surgical suite from those of the hospital. Notes 1 . H Laufman, “Internal configuration of the surgical suite.” in Hospital Sperial Care Facilities: Planning for User Needs, ed H Laufman (New York 734
City: Academic Press, 1981) 77; M A Pierson, “Design of the surgical suite,” in Alexander’s Care ofthe Patient in Surgery, ninth ed, M H Meeker, J C Rothrock, eds (St Louis: The C V Mosby Co, 1991) 37-38; J S Gamer, J K Schultz, “Absence of infection,” in Perioperative Patient Care: The Nursing Perspective, second ed, J A Kneedler, G H Dodge, eds (Boston: Blackwell Scientific Publications, Inc, 1987) 226. 2. L Groah, Operating Room Nursing: Perioperati\*e Practice, second ed (East Norwalk, Conn: Appleton & Lange, 1990) 23; Gamer, Schultz, “Absence of infection,” 226; J K Schultz, “Traffic and commerce in the surgical suite,” in Hospital Special Care Facilities: Planning far User-Needs, ed H Laufman (New York City: Academic Press, 1981) 235. 3. Gamer, Schultz, “Absence of infection,” 226227; Pierson, “Design of the surgical suite,” 38. 4. Gamer, Schultz, “Absence of infection,” 226227. 5. J Gamer, “Guidelines for prevention of surgical wound infections, 1985” in Guidelines for the Prevention and Control of Nosocomial infections (Atlanta: Centers for Disease Control, 1985) 6. 6. [bid; Gamer, Schultz, “Absence of infection,” 226; Groah, Operating Room Nursing: Perioperative Practice, 25. 7. Gamer, “Guidelines for prevention of surgical wound infections, 1985,” 6; R H Adams, D E Fry, “Surgical suite reconstruction,” AORN Journal 39 (April 1984) 870. 8. J K Schultz, “Covered case carts reduce contamination, instrument ‘borrowing,’” AORN Journal 33 (May 1981) 1042. 9. Groah, Operating Room Nursing: Perioperative Practice, 23; Pierson, “Design of the surgical suite,” 38. 10. W R Frieben, “Control of the aseptic processing environment,” American Journal of Hospital Pharmacy 40 (November 1983) 1928; Schultz, “Traffic and commerce in the surgical suite,” 236; Gamer, Schultz, “Absence of infection,” 227.