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The gifts we bring
DECEMBER 1999, VOL 70, NO 6 P W E S I I)E N T ’ S M E S S A <; E
The gifls we bring
D
ecember is the traditional month for giving gifts. This spirit of generosity is reflected in our professional practice all year and can be seen in the many ways that we offer our knowledge and skill to patients and colleagues. These gifts may take the form of “translating” for patients who are unclear about what their impending surgery entails, sharing knowledge about surgical techniques with nurse colleagues, or educating sales representatives about the OR culture. One of the most valuable gifts we bring is our body of knowledge related to aseptic practice and infection control. Consider the problem of surgical site infections (SSIs, formerly known as surgical wound infections), which are the third most frequently reported nosocomial infection, accounting for 14% to 16%of all nosocomial infections among hospitalized patients.’ Of these SSIs, two-thirds are confined to the incision, and one-third involve organs or spaces that were involved in the surgical procedure. Not only do SSIs result in a prolonged postoperative stay and extra charges for patients, but they also produce considerable pain and suffering. Despite advances in infection control practices, SSIs represent a substantial cause of morbidity and mortality. Perioperative nurses play a vital role in creating and maintaining a safe environment to minimize the devastating consequences of SSIs. The Centers for Disease
Control and Prevention (CDC) recently published its “Guideline for Prevention of Surgical Site Infection, 1999.’”The CDC’s recommendations apply both to the “ambulatory” (eg, same day, outpatient) setting and the inpatient setting. In addition, although procedures (eg, endoscopic procedures, interventional radiology) performed outside the OR are not specifically addressed, the guideline states that
it is likely that many SSI prevention strategies also could be applied or adapted to reduce infectious complications associated with these procedures? Prevention measures applicable to open procedures such as cholecystectomies also are indicated for their laparoscopic counterparts, such as laparoscopic cholecystectomies. Many of the recommendations are directly related to perioperative nursing practice; AORN members should familiarize themselves with the guideline and use the recommendations as part of the scientific basis of our practice.
IMPLICATIONS FOR PfRlOPfRATlVf NURSES The guideline promotes a realistic approach by recognizing that the risk of SSI is influenced by characteristics of the patient, surgical procedure, health care personnel, and hospital. Each of these factors is important for peri972 AORN JOURNAL
operative nurses in identifying patients at risk, technical aspects of surgical interventions, staffing considerations related to skill mix and competency, and environmental variables. The guideline recommendations are based on existing scientific evidence (with 497 references) and are placed into four categories of scientific rigor. Category IA recommendations are strongly recommended for implementation and supported by well-designed experimental, clinical, or epidemiological studies. Category IB recommendations are strongly recommended for implementation and supported by some experimental, clinical, or epidemiological studies and strong theoretical rationale. Category 11 recommendations are suggested for implementation and supported by suggestive clinical or epidemiological studies or theoretical rationale. The fourth category is labeled “no recommendation; unresolved issue” and includes practices for which insufficient evidence or no consensus exists regarding efficacy (eg, wearing nail polish, disinfecting environmental surfaces or equipment between procedures in the absence of visible soiling). These four categories are employed in descending order of scientific evidence throughout the
,-.
DECEMBER 1999, VOL 70, NO 6
CDC recommendations, which are divided into the preoperative, intraoperative, and postoperative periods. Preoperative. The preoperative section addresses four areas: rn preparation of the patient, m hand/forearm antisepsis for surgical team members, rn management of infected or colonized surgical personnel, and m antimicrobial prophylaxis. I would like to focus on the Category IA recommendations (ie, those supported by the strongest data) that exist and that involve interventions appropriate to perioperative nursing practice. All three of the Category IA recommendations that address patient preparation involve nursing activities. The first recommendation refers to identifying and treating infections remote to the surgical site before elective procedures and postponing elective procedures until the infection has resolved. Although nurses might not “treat” an infection, they can identify existing infections as part of their preoperative assessment by reviewing laboratory data, questioning the patient, and observing the patient’s skin. When there is evidence of an infection, the nurse plays a pivotal role by communicating this information to the surgeon and the other members of the surgical team. The second and third recommendations relate to patient preparation and refer to preoperative hair removal. Hair removal by depilatory (versus razor shave) is associated with a decreased SSI risk. Shaving or clipping hair immediately before the procedure (versus shaving or clipping within 24 hours preoperatively) also is associated with decreased risk of SSI. It is important for nurses to be aware of the research supporting the timing and method of hair removal because evidenced-based practice is one of the best ways to
advocate for patients. Activities related to hand/forearm antisepsis for surgical team members and management of infected or colonized surgical personnel are strongly recommended and are supported by strong theoretical rationale and some research (eg, Category IB). Among the recommendations for antiseptic practices are keeping nails short, not wearing artificial nails, and performing a preoperative surgical scrub for at least two to five minutes. Activities related to management of infected personnel include educating and encouraging staff members to report infectious conditions, developing policies related to patient care responsibilities of potentially infected personnel, and excluding from duty personnel with draining skin lesions. Clinicians and managers have significant roles in implementing these practices. The fourth recommendation refers to antimicrobial prophylaxis, and considerable research supports the listed recommendations. Nursing interventions are aimed at ensuring that the timing of administration of the antimicrobial agent allows the bactericidal concentration to be established in serum and tissues when the incision is made. Confirming that the antibiotic is available and that it has been timed to start before the time of incision is an important part of the nurse’s responsibility. Intraoperative. Pertinent intraoperative factors include rn ventilation, cleaning and disinfection of environmental surfaces, sterilization of surgical instruments, surgical attire and drapes, and asepsis and surgical technique. A strong scientific basis exists for adhering to principles of asepsis when placing intravascular devices such as central venous catheters or when administering 974 AORN JOURNAL
IV medications. This has important implications for the growing number of minimally invasive surgical (MIS) procedures. Related research jointly performed by physicians and nurses on the subject of sterile barriers (eg, drapes) for central venous catheter insertion has shown that maximal barrier draping reduces the risk of catheter infection.“ Although this study did not specifically address MIS procedures, it would not be unrealistic for nurses to transfer these research findings to patients undergoing MIS procedures. The other intraoperative factors are supported by considerable research that reinforces many of the structure/administrative standards familiar to perioperative nurses.‘ Of special interest to nurses involved in the design of surgical suites are the recommendations related to positive pressure ventilation, air changes, and air filters. Cleaning and disinfection practices include cleaning visibly soiled or contaminated surfaces or equipment before the next procedure, avoiding tacky mats at the entrance of the OR, and not performing special cleaning or closing of ORs after contaminated or dirty procedures. Sterilization of surgical instruments should be performed according to published guidelines, and the CDC guideline lists AORN’s Standards, Recommended Practices, and Guidelines among the references supporting this recommendation? Practices related to surgical attire and drapes include covering the mouth and nose with masks when a procedure is about to begin or is already in progress or if sterile instruments are exposed. Covering hair on the head and face, wearing sterile gloves when part of the scrubbed surgical team, and using gowns and drapes that are effective barriers when wet are
DECEMBER 1999, VOL 70,NO 6
additional stated recommendations. One value of these recommendations is that they provide a strong rationale for use by perioperative nurses whose pleas for fully covering hair go unheeded. Recommended surgical techniques that promote gentle tissue handling, effective hemostasis, and minimal foreign bodies (ie, sutures, charred tissue, necrotic debris) are pertinent to RN first assistants as well as to surgeons. These practices support the need for clinicians with appropriate education and clinical experience. Postoperative. Two main issues are addressed under this section: incision care and m discharge planning. Two recommendations fall into Category IB (no IA practices are listed), and these refer to protecting an incision closed primarily with a sterile dressing for 24 to 48 hours and washing hands before and after dressing changes. Hand washing remains one of the most important practices to reduce the
risk of SSI. (Interestingly, the use of sterile technique for incisional dressing changes is a Category I1 recommendation.) Practices related to patiendfamily education include providing information about proper incision care, symptoms of SSI, and the need to report such symptoms (also Category I1 recommendations). Patient education becomes increasingly valuable in the current environment when patients are discharged soon after their procedure. According to the CDC guideline, optimum teaching protocols do not exist; therefore, discharge instructions must be individualized, and this requires nursing assessment skills to identify the patient’s unique needs.
WHAT’S THE BIG DEAL? Many of the recommendations found in the CDC guideline are familiar to perioperative nurses, and you may be saying, “So what? What’s the big deal?” The big deal is that many of the practices that we often take for
NOTES 1. Hospital Infection Control Practices Advisory
Committee, Centers for Disease Control and Prevention, “Guideline for Prevention of Surgical Site Infection, 1999,”American Journal of Infection Control 27 (April 1999) 97- 132. Also available from http://www.cdc.gov/ ncidodhip. 2. Ihid. 3. Ihid. 100.
granted are supported by rigorous research cited by the CDC, one of the most authoritative sources on the subject of infection control practices. It is imperative that we take the opportunity to identify which interventions are scientifically grounded and which are not. Perioperative nurses can take considerable pride in the fact that many of the CDC recommendations reflect interventions for which we are especially educated and experienced to implement. Let us enter the next millennium bearing those gifts that not only have made us welcome in the hearts and minds of patients, but also will continue to confirm our value to the health care community and society. PATRICIA C. SEIFERT RN, MSN, CNOR, CRNFA PRESIDENT President Seifert can be contacted by telephone at (800)755-2676 x 311, by e-mail at [email protected],or by fmat (703)237-1259.
4. I I Raad et al, “Prevention of central venous catheter related infections by using maximal sterile banier precautions during insertion,” Infection Control and Hospital Epidemiology 15 no 4 (1994) 231-238. 5. Association of Operating Room Nurses, Inc, Standards, Recommended Practices, and Guidelines (Denver: Association of Operating Room Nurses, Inc,
1999). 6. h i d .
Guideline for Prevention of Surgical Site Infection Available The U S Centers for Disease Control and Prevention (CDC) “Guideline for Prevention of Surgical Site Infection” was published in the April 1999 issues of Infection Control and Hospital Epidemiology, American Journal of Infection Control, and Journal qf Surgical Outcomes. The
complete document also is available-along with a continuing education testk-on the CDC web site at www.cdc.gov/ncidod/hip. Copies of the publication also can be obtained by calling the AORN library at (800) 755-2676 x 3 14. The fee for AORN members is $6 per copy.
975 AORN JOURNAL
The gifls we bring
D
ecember is the traditional month for giving gifts. This spirit of generosity is reflected in our professional practice all year and can be seen in the many ways that we offer our knowledge and skill to patients and colleagues. These gifts may take the form of “translating” for patients who are unclear about what their impending surgery entails, sharing knowledge about surgical techniques with nurse colleagues, or educating sales representatives about the OR culture. One of the most valuable gifts we bring is our body of knowledge related to aseptic practice and infection control. Consider the problem of surgical site infections (SSIs, formerly known as surgical wound infections), which are the third most frequently reported nosocomial infection, accounting for 14% to 16%of all nosocomial infections among hospitalized patients.’ Of these SSIs, two-thirds are confined to the incision, and one-third involve organs or spaces that were involved in the surgical procedure. Not only do SSIs result in a prolonged postoperative stay and extra charges for patients, but they also produce considerable pain and suffering. Despite advances in infection control practices, SSIs represent a substantial cause of morbidity and mortality. Perioperative nurses play a vital role in creating and maintaining a safe environment to minimize the devastating consequences of SSIs. The Centers for Disease
Control and Prevention (CDC) recently published its “Guideline for Prevention of Surgical Site Infection, 1999.’”The CDC’s recommendations apply both to the “ambulatory” (eg, same day, outpatient) setting and the inpatient setting. In addition, although procedures (eg, endoscopic procedures, interventional radiology) performed outside the OR are not specifically addressed, the guideline states that
it is likely that many SSI prevention strategies also could be applied or adapted to reduce infectious complications associated with these procedures? Prevention measures applicable to open procedures such as cholecystectomies also are indicated for their laparoscopic counterparts, such as laparoscopic cholecystectomies. Many of the recommendations are directly related to perioperative nursing practice; AORN members should familiarize themselves with the guideline and use the recommendations as part of the scientific basis of our practice.
IMPLICATIONS FOR PfRlOPfRATlVf NURSES The guideline promotes a realistic approach by recognizing that the risk of SSI is influenced by characteristics of the patient, surgical procedure, health care personnel, and hospital. Each of these factors is important for peri972 AORN JOURNAL
operative nurses in identifying patients at risk, technical aspects of surgical interventions, staffing considerations related to skill mix and competency, and environmental variables. The guideline recommendations are based on existing scientific evidence (with 497 references) and are placed into four categories of scientific rigor. Category IA recommendations are strongly recommended for implementation and supported by well-designed experimental, clinical, or epidemiological studies. Category IB recommendations are strongly recommended for implementation and supported by some experimental, clinical, or epidemiological studies and strong theoretical rationale. Category 11 recommendations are suggested for implementation and supported by suggestive clinical or epidemiological studies or theoretical rationale. The fourth category is labeled “no recommendation; unresolved issue” and includes practices for which insufficient evidence or no consensus exists regarding efficacy (eg, wearing nail polish, disinfecting environmental surfaces or equipment between procedures in the absence of visible soiling). These four categories are employed in descending order of scientific evidence throughout the
,-.
DECEMBER 1999, VOL 70, NO 6
CDC recommendations, which are divided into the preoperative, intraoperative, and postoperative periods. Preoperative. The preoperative section addresses four areas: rn preparation of the patient, m hand/forearm antisepsis for surgical team members, rn management of infected or colonized surgical personnel, and m antimicrobial prophylaxis. I would like to focus on the Category IA recommendations (ie, those supported by the strongest data) that exist and that involve interventions appropriate to perioperative nursing practice. All three of the Category IA recommendations that address patient preparation involve nursing activities. The first recommendation refers to identifying and treating infections remote to the surgical site before elective procedures and postponing elective procedures until the infection has resolved. Although nurses might not “treat” an infection, they can identify existing infections as part of their preoperative assessment by reviewing laboratory data, questioning the patient, and observing the patient’s skin. When there is evidence of an infection, the nurse plays a pivotal role by communicating this information to the surgeon and the other members of the surgical team. The second and third recommendations relate to patient preparation and refer to preoperative hair removal. Hair removal by depilatory (versus razor shave) is associated with a decreased SSI risk. Shaving or clipping hair immediately before the procedure (versus shaving or clipping within 24 hours preoperatively) also is associated with decreased risk of SSI. It is important for nurses to be aware of the research supporting the timing and method of hair removal because evidenced-based practice is one of the best ways to
advocate for patients. Activities related to hand/forearm antisepsis for surgical team members and management of infected or colonized surgical personnel are strongly recommended and are supported by strong theoretical rationale and some research (eg, Category IB). Among the recommendations for antiseptic practices are keeping nails short, not wearing artificial nails, and performing a preoperative surgical scrub for at least two to five minutes. Activities related to management of infected personnel include educating and encouraging staff members to report infectious conditions, developing policies related to patient care responsibilities of potentially infected personnel, and excluding from duty personnel with draining skin lesions. Clinicians and managers have significant roles in implementing these practices. The fourth recommendation refers to antimicrobial prophylaxis, and considerable research supports the listed recommendations. Nursing interventions are aimed at ensuring that the timing of administration of the antimicrobial agent allows the bactericidal concentration to be established in serum and tissues when the incision is made. Confirming that the antibiotic is available and that it has been timed to start before the time of incision is an important part of the nurse’s responsibility. Intraoperative. Pertinent intraoperative factors include rn ventilation, cleaning and disinfection of environmental surfaces, sterilization of surgical instruments, surgical attire and drapes, and asepsis and surgical technique. A strong scientific basis exists for adhering to principles of asepsis when placing intravascular devices such as central venous catheters or when administering 974 AORN JOURNAL
IV medications. This has important implications for the growing number of minimally invasive surgical (MIS) procedures. Related research jointly performed by physicians and nurses on the subject of sterile barriers (eg, drapes) for central venous catheter insertion has shown that maximal barrier draping reduces the risk of catheter infection.“ Although this study did not specifically address MIS procedures, it would not be unrealistic for nurses to transfer these research findings to patients undergoing MIS procedures. The other intraoperative factors are supported by considerable research that reinforces many of the structure/administrative standards familiar to perioperative nurses.‘ Of special interest to nurses involved in the design of surgical suites are the recommendations related to positive pressure ventilation, air changes, and air filters. Cleaning and disinfection practices include cleaning visibly soiled or contaminated surfaces or equipment before the next procedure, avoiding tacky mats at the entrance of the OR, and not performing special cleaning or closing of ORs after contaminated or dirty procedures. Sterilization of surgical instruments should be performed according to published guidelines, and the CDC guideline lists AORN’s Standards, Recommended Practices, and Guidelines among the references supporting this recommendation? Practices related to surgical attire and drapes include covering the mouth and nose with masks when a procedure is about to begin or is already in progress or if sterile instruments are exposed. Covering hair on the head and face, wearing sterile gloves when part of the scrubbed surgical team, and using gowns and drapes that are effective barriers when wet are
DECEMBER 1999, VOL 70,NO 6
additional stated recommendations. One value of these recommendations is that they provide a strong rationale for use by perioperative nurses whose pleas for fully covering hair go unheeded. Recommended surgical techniques that promote gentle tissue handling, effective hemostasis, and minimal foreign bodies (ie, sutures, charred tissue, necrotic debris) are pertinent to RN first assistants as well as to surgeons. These practices support the need for clinicians with appropriate education and clinical experience. Postoperative. Two main issues are addressed under this section: incision care and m discharge planning. Two recommendations fall into Category IB (no IA practices are listed), and these refer to protecting an incision closed primarily with a sterile dressing for 24 to 48 hours and washing hands before and after dressing changes. Hand washing remains one of the most important practices to reduce the
risk of SSI. (Interestingly, the use of sterile technique for incisional dressing changes is a Category I1 recommendation.) Practices related to patiendfamily education include providing information about proper incision care, symptoms of SSI, and the need to report such symptoms (also Category I1 recommendations). Patient education becomes increasingly valuable in the current environment when patients are discharged soon after their procedure. According to the CDC guideline, optimum teaching protocols do not exist; therefore, discharge instructions must be individualized, and this requires nursing assessment skills to identify the patient’s unique needs.
WHAT’S THE BIG DEAL? Many of the recommendations found in the CDC guideline are familiar to perioperative nurses, and you may be saying, “So what? What’s the big deal?” The big deal is that many of the practices that we often take for
NOTES 1. Hospital Infection Control Practices Advisory
Committee, Centers for Disease Control and Prevention, “Guideline for Prevention of Surgical Site Infection, 1999,”American Journal of Infection Control 27 (April 1999) 97- 132. Also available from http://www.cdc.gov/ ncidodhip. 2. Ihid. 3. Ihid. 100.
granted are supported by rigorous research cited by the CDC, one of the most authoritative sources on the subject of infection control practices. It is imperative that we take the opportunity to identify which interventions are scientifically grounded and which are not. Perioperative nurses can take considerable pride in the fact that many of the CDC recommendations reflect interventions for which we are especially educated and experienced to implement. Let us enter the next millennium bearing those gifts that not only have made us welcome in the hearts and minds of patients, but also will continue to confirm our value to the health care community and society. PATRICIA C. SEIFERT RN, MSN, CNOR, CRNFA PRESIDENT President Seifert can be contacted by telephone at (800)755-2676 x 311, by e-mail at [email protected],or by fmat (703)237-1259.
4. I I Raad et al, “Prevention of central venous catheter related infections by using maximal sterile banier precautions during insertion,” Infection Control and Hospital Epidemiology 15 no 4 (1994) 231-238. 5. Association of Operating Room Nurses, Inc, Standards, Recommended Practices, and Guidelines (Denver: Association of Operating Room Nurses, Inc,
1999). 6. h i d .
Guideline for Prevention of Surgical Site Infection Available The U S Centers for Disease Control and Prevention (CDC) “Guideline for Prevention of Surgical Site Infection” was published in the April 1999 issues of Infection Control and Hospital Epidemiology, American Journal of Infection Control, and Journal qf Surgical Outcomes. The
complete document also is available-along with a continuing education testk-on the CDC web site at www.cdc.gov/ncidod/hip. Copies of the publication also can be obtained by calling the AORN library at (800) 755-2676 x 3 14. The fee for AORN members is $6 per copy.
975 AORN JOURNAL