- Email: [email protected]
Shoe covers in the OR; postanesthesia care unit staffing; energy-saving devices for OR ventilation systems
AUGUST 1989. VOL. 50, NO 2
AORN JOURNAL
Clinical Issues Shoe covers in the OR; postanesthesia care unit staffing; energy-saving devices for OR ventilation systems
Q
uestion: For the past two years I have heard controversial statements about the use of shoe covers in the OR. I know that AORN has recommended shoe covers in the past, but with the information from the Centers for Disease Control (CDC), Atlanta, saying that shoe covers are not necessary, I question whether I should continue to stock them in the OR. What is AORNs current position regarding shoe covers?
A
nswer: The AORN “Recommended practices for surgical attire” currently are being reviewed and revised by the Technical Practices Coordinating Committee, and a copy of the proposed revision appears in this issue. Comments from our readers are sought. In this revised draft, use of shoe covers is no longer included as a recommended practice. The revised statement states that “Shoe covers that are changed whenever they become torn, wet, or soiled, may be worn to facilitate good housekeeping.”’ The CDC information to which you refer states the following: “. . . in one study, no significant differences in floor contamination were seen when ordinary shoes, clean shoes, or shoe covers were worn.”2 The study was reported in 1979 in the Scandinavian Journal of Infeetiow Dkeases? The study was conducted in a microbiology laboratory where floor contamination was measured in relation to use of shoe covers, dedicated shoes, and ordinary shoes that were worn throughout the health care facility. In 1987, a study done at Stanford (Calif) University Hospital demonstrated that unprotected street shoes transfer comider-
able numbers of bacteria onto a stdy area in the OR, and. . . thk transfer can be significantly reduced by wearing OR restricted shoes or shoe covers. Moreover, of the two types of protective footwear, shoe covers appear to be the most effective . . . I Clinical studies relating the use of shoe covers to reduction or prevention of postoperative wound infections have not been done. Such studies would be both difficult and costly to conduct because of the multitude of independent variables, both controllable and uncontrollable. Although no longer s@ed as a recommended practice, AORN continues to encourage the use of shoe covers as optimum practice in promoting a clean and safe OR environment. Footwear may become soiled during the normal workday in the OR. Shoe covers can be easily removed, discarded, and replaced when soiled. This can be done as often as necessary to reduce tracking of blood, solutions, sutures, paper, or other debris throughout the OR. Frequent and adequate cleaning of uncovered shoes is difficult, at best. Shoe covers also can protect and prolong the life of the shoes. Shoe covers also are preferred aesthetically over street shoes or dedicated OR shoes because the shoe covers can be removed when surgeons leave the OR to meet with families immediately following the operative procedure or between subsequent cases. Removal of the shoe covers before this conference eliminates the unsightly evidence of a particularly bloody procedure.
Q
uestion: I am the director of surgical services in a small department that includes the OR, 437
AUGUST 1989. VOL. 50, NO 2
AORN JOURNAL
the postanesthesia care unit (PACU), and the ambulatory surgery unit. I would like to increase staffing in the PACU, but I am getting resistance from my nursing administrator. My administrator thinks that because the surgical intensive care unit is just down the hall from the PACU, it is all right to have only one nurse in the PACU during the lunch period. I am uncomfortable with this staffing because there are frequently two and sometimes three patients in the area during this time. Does AORN have any recommendations for staffing levels in the PACU?
A
nswer: AORN has not addressed staffing levels for the PACU, but the American Society of Post Anesthesia Nurses (ASPAN) has developed and published Standards of Nursing Pracrice in which your question is addressed. According to ASPAN, the patient/staff ratio will vary according to patient classifications.5 The ASPAN identifies three classifications: Class I-uncomplicated patients who are awake and stable, Class 11-uncomplicated pediatric patients, stable conscious patients who have undergone major surgery, or stable unconscious patients, and Class 111-patients requiring life-support care. According to the ASPAN Standards of Nursing Practice the following patiedstaff ratios are recommended: Class I-one nurse to three patients, Class 11-one nurse to two patients, and Class 111-one nurse to one patient. In addition, ASPAN recommends that two licensed staff nurses, one of whom is an RN, be present when a single patient is recovering from anesthesia.
Q
uestion: We are remodeling our OR, and the question of O R ventilation and air exchanges has been discussed heatedly. The contractor is planning to install an energy-saving device that decreases the O R ventilation during the night when the O R is not in use. I am against this because I know the O R has to maintain a 438
certain number of air exchanges and a directional flow of air within the department. I have talked with members of the infection control department, but they d o not have any information to assist me. Does AORN have any information on this subject that I can use in my argument?
A
nswer: According to the Guidelines for Construction and Equipment of Hospital and Medical Facilities, the required minimum number of total air exchanges per hour in the O R is 15 with a minimum outside air replacement of three exchanges per hour? The pressure gradient should be such that air moves from the ORs out into the surrounding corridors. It is permissible for the number of air exchanges to be reduced when the area is not in use, but there must be a mechanism to reestablish the defined number of air exchanges any time the area is to be used. The energy-saving device must be such that the pressure gradient between the O h and surrounding corridors is maintained during the decreased ventilation period.’
Q
uestion: At a recent OR staff meeting, we discussed two methods for the surgical scrub. All staff members are using the timed scrub method, however, no one knew precisely how to do a counted stroke scrub. Would you please describe the counted stroke scrub method?
A
nswer: Whether using a timed scrub method or a counted stroke method, the surgical scrub should be preceded by a prewash to remove surface dirt and debris. The hands and arms should be moistened with water, washed with an antimicrobial soap, and then rinsed. Next, the nails and subungual areas should be cleaned. If a disposable file is used, it should be discarded following use. If a sterilized reusable file is used, it should be placed into the designated receptacle for reprocessing. For the counted stroke method, each surface of the fingers, hands, and arms is scrubbed for a specified number of strokes. The number of strokes may be specified by policy and may be based on manufacturer recommendations for contact time with the antimicrobial product being
AUGUST 1989. VOL. 50, NO 2
AORN JOURNAL
used. If policy does not specify the number of strokes, an acceptable formula is 30 strokes for the nails, and 20 strokes for all other surfaces.* After the nails have received 30 strokes, each finger is divided into four sides, and each side, including the webbed space between the fingers, receives 20 strokes. Next, the palm of the hand is scrubbed, followed by the back of the hand. Each surface receives 20 strokes. The arm is divided into thirds up to 2 inches above the elbow. The wrist and first third of the arm receive 20 strokes. This is followed by scrubbing the middle third of the arm and then the upper third including 2 inches above the elbow in the same manner. When completed, the process is repeated on the opposite hand and arm, and the brush is discarded. The hands and arms are rinsed with the hands held higher than the elbows so the water runs from the hands to the elbows. Regardless of whether the timed or counted stroke method of scrubbing is used, the hands and arms are rinsed in a similar fashion. The hands should remain above the elbows until the hands and arms have been dried and the surgical gown has been put on. The closed gloving method may be used for the first gloving before the hands have extended through the stockinet cuffs of the gown.
Q
uestion: Our hospital is expanding, and part of the expansion includes a new surgical suite. The current plan is to place the scrub sinks in the sterile core area. I am concerned about this because of the potential for sterile supplies to become wet and contaminated. I think it would be better to place the scrub sinks in the peripheral corridor. What does AORN recommend?
A
nswer: The surgical scrub area should not be within the sterile core or in the peripheral corridor. Ideally, the scrub area should be an alcove or room that can be accessed from the peripheral corridor but is not located in the corridor itself? The scrub area should be adjacent to the operating room, with a single scrub area located between two operating rooms so it can service both rooms. Usually two or three sinks are sufficient. Teaching hospitals or those
with surgical teams made up of many members may require additional sinks. The scrub area should contain a window into each OR served so the activities in the room can be observed while scrubbing. A separate door should be planned for access from the scrub area directly into the OR without returning to the corridor.I0 DOROTHY M. FOGG,RN, BSN ASSISTANT DIRECTOR OF EDUCATION/ CONSULTATION Notes 1. “Proposed recommended practices for surgical attire,” AORN Journal 50 (August 1989) pages 409415. 2. J S Garner, “Guideline for prevention of surgical wound infections, 1985,” in Guidelines for the
Prevention and Control of Nosocomial Infections (Atlanta: Centers for Disease Control, 1985) 6. 3. A Hambraeus, A S Malmborg, “The influence of different footwear on floor contamination,’’ Scandinavian Journal of Infectious Diseases 11 no 3
(1979) 243-246. 4. G Copp et al, “Footwear practices and operating room contamination,” Nursing Research 36 (November/December 1987) 366-369. 5. The American Society of Post Anesthesia Nurses, “Part IV: ASPAN standards of nursing practice: Management standards,” in Standarcis of Nursing Practice (Richmond Va: The American Society of Post Anesthesia Nurses, 1986) 18. 6. The American Institute of Architects Committee on Architecture for Health with assistance from US Department of Health and Human Services, Guidelines for Constructionand Equipment of Hospital and Medical Facilities (Washington, DC: American Institute of Architects Press, 1987) 50. 7. Ibid. 8. C Spry, Essentials of Perioperative Nursing: A Self-Learning Guide (Rockville, Md: Aspen Publishers
Inc, 1988) 113-114. 9. H Lau fman, ed, Hospital Special Care Facilities: Planning for User Nee& (New York City: Academic Press, 1981) 101. 10. Ibid. If you have questions you would like addressed in the “Clinical Issues” column of the AORN Journal, please send them to the AORN Consultation Division, 10170 E Mississippi Ave, Denver, C 5 80231. AN quesrions will be consideredfor inclusion in this column,
AORN JOURNAL
Clinical Issues Shoe covers in the OR; postanesthesia care unit staffing; energy-saving devices for OR ventilation systems
Q
uestion: For the past two years I have heard controversial statements about the use of shoe covers in the OR. I know that AORN has recommended shoe covers in the past, but with the information from the Centers for Disease Control (CDC), Atlanta, saying that shoe covers are not necessary, I question whether I should continue to stock them in the OR. What is AORNs current position regarding shoe covers?
A
nswer: The AORN “Recommended practices for surgical attire” currently are being reviewed and revised by the Technical Practices Coordinating Committee, and a copy of the proposed revision appears in this issue. Comments from our readers are sought. In this revised draft, use of shoe covers is no longer included as a recommended practice. The revised statement states that “Shoe covers that are changed whenever they become torn, wet, or soiled, may be worn to facilitate good housekeeping.”’ The CDC information to which you refer states the following: “. . . in one study, no significant differences in floor contamination were seen when ordinary shoes, clean shoes, or shoe covers were worn.”2 The study was reported in 1979 in the Scandinavian Journal of Infeetiow Dkeases? The study was conducted in a microbiology laboratory where floor contamination was measured in relation to use of shoe covers, dedicated shoes, and ordinary shoes that were worn throughout the health care facility. In 1987, a study done at Stanford (Calif) University Hospital demonstrated that unprotected street shoes transfer comider-
able numbers of bacteria onto a stdy area in the OR, and. . . thk transfer can be significantly reduced by wearing OR restricted shoes or shoe covers. Moreover, of the two types of protective footwear, shoe covers appear to be the most effective . . . I Clinical studies relating the use of shoe covers to reduction or prevention of postoperative wound infections have not been done. Such studies would be both difficult and costly to conduct because of the multitude of independent variables, both controllable and uncontrollable. Although no longer s@ed as a recommended practice, AORN continues to encourage the use of shoe covers as optimum practice in promoting a clean and safe OR environment. Footwear may become soiled during the normal workday in the OR. Shoe covers can be easily removed, discarded, and replaced when soiled. This can be done as often as necessary to reduce tracking of blood, solutions, sutures, paper, or other debris throughout the OR. Frequent and adequate cleaning of uncovered shoes is difficult, at best. Shoe covers also can protect and prolong the life of the shoes. Shoe covers also are preferred aesthetically over street shoes or dedicated OR shoes because the shoe covers can be removed when surgeons leave the OR to meet with families immediately following the operative procedure or between subsequent cases. Removal of the shoe covers before this conference eliminates the unsightly evidence of a particularly bloody procedure.
Q
uestion: I am the director of surgical services in a small department that includes the OR, 437
AUGUST 1989. VOL. 50, NO 2
AORN JOURNAL
the postanesthesia care unit (PACU), and the ambulatory surgery unit. I would like to increase staffing in the PACU, but I am getting resistance from my nursing administrator. My administrator thinks that because the surgical intensive care unit is just down the hall from the PACU, it is all right to have only one nurse in the PACU during the lunch period. I am uncomfortable with this staffing because there are frequently two and sometimes three patients in the area during this time. Does AORN have any recommendations for staffing levels in the PACU?
A
nswer: AORN has not addressed staffing levels for the PACU, but the American Society of Post Anesthesia Nurses (ASPAN) has developed and published Standards of Nursing Pracrice in which your question is addressed. According to ASPAN, the patient/staff ratio will vary according to patient classifications.5 The ASPAN identifies three classifications: Class I-uncomplicated patients who are awake and stable, Class 11-uncomplicated pediatric patients, stable conscious patients who have undergone major surgery, or stable unconscious patients, and Class 111-patients requiring life-support care. According to the ASPAN Standards of Nursing Practice the following patiedstaff ratios are recommended: Class I-one nurse to three patients, Class 11-one nurse to two patients, and Class 111-one nurse to one patient. In addition, ASPAN recommends that two licensed staff nurses, one of whom is an RN, be present when a single patient is recovering from anesthesia.
Q
uestion: We are remodeling our OR, and the question of O R ventilation and air exchanges has been discussed heatedly. The contractor is planning to install an energy-saving device that decreases the O R ventilation during the night when the O R is not in use. I am against this because I know the O R has to maintain a 438
certain number of air exchanges and a directional flow of air within the department. I have talked with members of the infection control department, but they d o not have any information to assist me. Does AORN have any information on this subject that I can use in my argument?
A
nswer: According to the Guidelines for Construction and Equipment of Hospital and Medical Facilities, the required minimum number of total air exchanges per hour in the O R is 15 with a minimum outside air replacement of three exchanges per hour? The pressure gradient should be such that air moves from the ORs out into the surrounding corridors. It is permissible for the number of air exchanges to be reduced when the area is not in use, but there must be a mechanism to reestablish the defined number of air exchanges any time the area is to be used. The energy-saving device must be such that the pressure gradient between the O h and surrounding corridors is maintained during the decreased ventilation period.’
Q
uestion: At a recent OR staff meeting, we discussed two methods for the surgical scrub. All staff members are using the timed scrub method, however, no one knew precisely how to do a counted stroke scrub. Would you please describe the counted stroke scrub method?
A
nswer: Whether using a timed scrub method or a counted stroke method, the surgical scrub should be preceded by a prewash to remove surface dirt and debris. The hands and arms should be moistened with water, washed with an antimicrobial soap, and then rinsed. Next, the nails and subungual areas should be cleaned. If a disposable file is used, it should be discarded following use. If a sterilized reusable file is used, it should be placed into the designated receptacle for reprocessing. For the counted stroke method, each surface of the fingers, hands, and arms is scrubbed for a specified number of strokes. The number of strokes may be specified by policy and may be based on manufacturer recommendations for contact time with the antimicrobial product being
AUGUST 1989. VOL. 50, NO 2
AORN JOURNAL
used. If policy does not specify the number of strokes, an acceptable formula is 30 strokes for the nails, and 20 strokes for all other surfaces.* After the nails have received 30 strokes, each finger is divided into four sides, and each side, including the webbed space between the fingers, receives 20 strokes. Next, the palm of the hand is scrubbed, followed by the back of the hand. Each surface receives 20 strokes. The arm is divided into thirds up to 2 inches above the elbow. The wrist and first third of the arm receive 20 strokes. This is followed by scrubbing the middle third of the arm and then the upper third including 2 inches above the elbow in the same manner. When completed, the process is repeated on the opposite hand and arm, and the brush is discarded. The hands and arms are rinsed with the hands held higher than the elbows so the water runs from the hands to the elbows. Regardless of whether the timed or counted stroke method of scrubbing is used, the hands and arms are rinsed in a similar fashion. The hands should remain above the elbows until the hands and arms have been dried and the surgical gown has been put on. The closed gloving method may be used for the first gloving before the hands have extended through the stockinet cuffs of the gown.
Q
uestion: Our hospital is expanding, and part of the expansion includes a new surgical suite. The current plan is to place the scrub sinks in the sterile core area. I am concerned about this because of the potential for sterile supplies to become wet and contaminated. I think it would be better to place the scrub sinks in the peripheral corridor. What does AORN recommend?
A
nswer: The surgical scrub area should not be within the sterile core or in the peripheral corridor. Ideally, the scrub area should be an alcove or room that can be accessed from the peripheral corridor but is not located in the corridor itself? The scrub area should be adjacent to the operating room, with a single scrub area located between two operating rooms so it can service both rooms. Usually two or three sinks are sufficient. Teaching hospitals or those
with surgical teams made up of many members may require additional sinks. The scrub area should contain a window into each OR served so the activities in the room can be observed while scrubbing. A separate door should be planned for access from the scrub area directly into the OR without returning to the corridor.I0 DOROTHY M. FOGG,RN, BSN ASSISTANT DIRECTOR OF EDUCATION/ CONSULTATION Notes 1. “Proposed recommended practices for surgical attire,” AORN Journal 50 (August 1989) pages 409415. 2. J S Garner, “Guideline for prevention of surgical wound infections, 1985,” in Guidelines for the
Prevention and Control of Nosocomial Infections (Atlanta: Centers for Disease Control, 1985) 6. 3. A Hambraeus, A S Malmborg, “The influence of different footwear on floor contamination,’’ Scandinavian Journal of Infectious Diseases 11 no 3
(1979) 243-246. 4. G Copp et al, “Footwear practices and operating room contamination,” Nursing Research 36 (November/December 1987) 366-369. 5. The American Society of Post Anesthesia Nurses, “Part IV: ASPAN standards of nursing practice: Management standards,” in Standarcis of Nursing Practice (Richmond Va: The American Society of Post Anesthesia Nurses, 1986) 18. 6. The American Institute of Architects Committee on Architecture for Health with assistance from US Department of Health and Human Services, Guidelines for Constructionand Equipment of Hospital and Medical Facilities (Washington, DC: American Institute of Architects Press, 1987) 50. 7. Ibid. 8. C Spry, Essentials of Perioperative Nursing: A Self-Learning Guide (Rockville, Md: Aspen Publishers
Inc, 1988) 113-114. 9. H Lau fman, ed, Hospital Special Care Facilities: Planning for User Nee& (New York City: Academic Press, 1981) 101. 10. Ibid. If you have questions you would like addressed in the “Clinical Issues” column of the AORN Journal, please send them to the AORN Consultation Division, 10170 E Mississippi Ave, Denver, C 5 80231. AN quesrions will be consideredfor inclusion in this column,