AORN Virtual Town Hall and Special Membership Meeting: February 23, 2016

Clinical FAQs

AORN’s Clinical FAQs are an important clinical resource for the perioperative industry. They are one of the many tools and resources that further AORN’s mission of promoting safety and optimal outcomes for patients undergoing operative and other invasive procedures. Select a category to find the answers to your clinical questions.

All FAQs

Anesthetic Equipment

  • What is best practice regarding the processing and storage of laryngoscope blades?

    Laryngoscope blades should be processed according to manufacturers' instructions by either high-level disinfection or sterilization and protected from contamination until used. Processed blades should be stored in packages, appropriate for the processing method selected, to ensure the blade is protected from contamination. The storage of unpackaged laryngoscope blades is unreliable and often leads to questions regarding the safe use of the blades.

    Resources:

    • Recommended practices for cleaning, handling, and processing anesthesia equipment. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:451-458.
    • Burlingame, B. Storage of disinfected laryngoscope blades [Clinical Issues]. AORN J. 2010;92(1):107-108.

    Updated: January 28, 2013.

Surgical Attire

  • Are the AORN recommendations for surgical attire applicable to procedures performed in ambulatory surgery centers, endoscopy centers, and pain management clinics?

    The AORN “Guideline for surgical attire” is intended to represent what is believed to be an optimal level of practice. Policies and procedures will reflect variations in practice settings or clinical situations that determine the degree to which the guidelines can be implemented. AORN recognizes the many diverse settings in which perioperative nurses practice, and as such, these guidelines are adaptable to all areas where operative and other invasive procedures may be performed.

    Resources:

    Guideline for surgical attire. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

    Updated November 13, 2014.

  • What are the AORN recommendations for wearing cover apparel?

    The collective evidence does not support wearing cover apparel to protect scrub attire from contamination, and there is evidence that lab coats worn as cover apparel can be contaminated with large numbers of pathogenic microorganisms. Researchers have found that cover apparel is not always discarded after daily use or laundered on a frequent basis. Cover apparel (eg, lab coats) worn over scrub attire should be clean or single use. Reusable cover apparel should be laundered in a health care-accredited laundry facility after each daily use and when contaminated.

    Resources

    • Guideline for surgical attire. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.
    • Treakle AM, Thom KA, Furuno JP, Strauss SM, Harris AD, Perencevich EN. Bacterial contamination of health care workers’ white coats. Am J Infect Control. 2009;37(2):101-105.
    • Munoz-Price LS, Arheart KL, Lubarsky DA, Birnbach DJ. Differential laundering practices of white coats and scrubs among health care professionals. Am J Infect Control. 2013;41(6):565-567.
    • Munoz-Price LS, Arheart KL, Mills JP, et al. Associations between bacterial contamination of health care workers’ hands and contamination of white coats and scrubs. Am J Infect Control. 2012;40(9):e245-e248.
    • Butler DL, Major Y, Bearman G, Edmond MB. Transmission of nosocomial pathogens by white coats: an in-vitro model. J Hosp Infect. 2010;75(2):137-138.
    • Henderson J. The endangered white coat. Clin Infect Dis. 2010;50(7):1073-1074.

    Updated: November 13, 2014.

  • I wear eyeglasses during surgery. What are the AORN recommendations for cleaning them?

    Reusable eye protection devices worn with surgical masks, such as goggles, or personal glasses supplemented with solid side shields, should be cleaned according to the manufacturer’s instructions for use before and after the health care worker performs or assists with each new procedure. Reducing the number of microorganisms present on eye protection devices and glasses may protect patients from SSIs resulting from the transfer of microorganisms from the devices or hands of health care workers to patients or environmental surfaces.

    Resources:

    • Guideline for surgical attire. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

    Updated November 13, 2014.

  • What are the AORN recommendations for cell phones and other hand-held electronic equipment taken into the perioperative areas?

    Cell phones, tablets, and other personal communication or hand-held electronic equipment should be cleaned with a low-level disinfectant according to the manufacturer’s instructions for use before and after being brought into the perioperative setting. The collective evidence demonstrates that cell phones, tablets, and other personal hand-held devices are highly contaminated with microorganisms, some potentially pathogenic. Reducing the numbers of microorganisms present on the devices may protect patients from the risk of HAIs resulting from the transfer of microorganisms from the devices or hands of health care workers to patients.

    • Guideline for surgical attire. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.
    • Saxena S, Singh T, Agarwal H, Mehta G, Dutta R. Bacterial colonization of rings and cell phones carried by health-care providers: are these mobile bacterial zoos in the hospital? Trop Doct. 2011;41(2):116-118.
    • Kilic IH, Ozaslan M, Karagoz ID, Zer Y, Davutoglu V. The microbial colonisation of mobile phone used by healthcare staffs. Pak J Biol Sci. 2009;12(11):882-884.
    • Albrecht UV, von Jan U, Sedlacek L, Groos S, Suerbaum S, Vonberg RP. Standardized, app-based disinfection of iPads in a clinical and nonclinical setting: comparative analysis. J Med Internet Res. 2013;15(8):e176.
    • Al-Abdalall AH. Isolation and identification of microbes associated with mobile phones in Dammam in eastern Saudi Arabia. J Family Community Med. 2010;17(1):11-14.
    • Brady RR, Chitnis S, Stewart RW, Graham C, Yalamarthi S, Morris K. NHS connecting for health: healthcare professionals, mobile technology, and infection control. Telemed J E-Health. 2012;18(4):289-291.
    • Tekerekoglu MS, Duman Y, Serindag A, et al. Do mobile phones of patients, companions and visitors carry multidrug-resistant hospital pathogens? Am J Infect Control. 2011;39(5):379-381.
    • Sadat-Ali M, Al-Omran AK, Azam Q, et al. Bacterial flora on cell phones of health care providers in a teaching institution. Am J Infect Control. 2010;38(5):404-405.
    • Akinyemi KO, Atapu AD, Adetona OO, Coker AO. The potential role of mobile phones in the spread of bacterial infections. J Infect Dev Countries. 2009;3(8):628-632.
    • Basol R, Beckel J, Gilsdorf-Gracie J, et al. You missed a spot! Disinfecting shared mobile phones. Nurs Manage. 2013;44(7):16-18.
    • White S, Topping A, Humphreys P, Rout S, Williamson H. The cross-contamination potential of mobile telephones. J Res Nurs. 2012;17(6):582-595.
    • Ustun C, Cihangiroglu M. Health care workers’ mobile phones: a potential cause of microbial cross-contamination between hospitals and community. J Occup Environ Hyg. 2012;9(9):538-542.
    • Singh A, Purohit B. Mobile phones in hospital settings: a serious threat to infection. Occup Health Saf. 2012;81(3):42-44

    Updated November 6, 2014.

  • Should perioperative team members remove surgical head coverings when leaving the perioperative areas?

    Personnel wearing scrub attire should not remove the surgical head covering when leaving the perioperative area. The purpose of the head covering is to contain hair and minimize microbial dispersal. When the head covering is removed, hair and microbes may be shed onto the scrub attire.

    Head coverings commonly used in the perioperative setting (eg, bouffant caps) are worn for hair and skin containment and are not considered personal protective equipment (PPE). The Occupational Safety and Health Administration (OSHA) requires that PPE not permit blood, body fluids, or other potentially infectious materials to pass through or reach the employee’s clothing, skin, eyes, or other mucous membranes under normal conditions of use.

    Resources:

    • Guideline for surgical attire. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.
    • Occupational exposure to bloodborne pathogens. OSHA Final rule. Fed Regist. 1991;56(235):64004-64182.

    Updated November 6, 2014.

  • What are the AORN recommendations for wearing jewelry in the perioperative areas?

    Jewelry (eg, earrings, necklaces, bracelets, rings) that cannot be contained or confined within the scrub attire should not be worn in the semi-restricted or restricted areas. Wearing earrings, watches, and rings was found to increase bacterial counts on skin surfaces both when the jewelry is in place and after its removal. The collective evidence supports the removal of rings, the removal or containment of watches, and the complete covering of ear and nose piercings with a surgical mask or head covering in the surgical setting.

    • Guideline for surgical attire. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.
    • Saxena S, Singh T, Agarwal H, Mehta G, Dutta R. Bacterial colonization of rings and cell phones carried by health-care providers: are these mobile bacterial zoos in the hospital? Trop Doct. 2011;41(2):116-118.
    • Bartlett GE, Pollard TC, Bowker KE, Bannister GC. Effect of jewelry on surface bacterial counts of operating theatres. J Hosp Infect. 2002;52(1):68-70.
    • Field EA, McGowan P, Pearce PK, Martin MV. Rings and watches: should they be removed prior to operative dental procedures? J Dent. 1996;24(1-2):65-69.
    • Kelsall NKR, Griggs RKL, Bowker KE, Bannister GC. Should finger rings be removed prior to scrubbing for theatre? J Hosp Infect. 2006;62(4):450-452.
    • Jeans AR, Moore J, Nicol C, Bates C, Read RC. Wristwatch use and hospital-acquired infection. J Hosp Infect. 2010;74(1):16-21.
    • Salisbury DM, Hutfilz P, Treen LM, Bollin GE, Gautam S. The effect of rings on microbial load of health care workers’ hands. Am J Infect Control. 1997;25(1):24-27.
    • Khodavaisy S, Nabili M, Davari B, Vahedi M. Evaluation of bacterial and fungal contamination in the health care workers’ hands and rings in the intensive care unit. J Prev Med Hyg. 2011;52(4):215-218.

    Updated November 6, 2014.

  • Is it okay to wear home laundered cloth caps if they are covered by a disposable cap?

    “We have surgical team members in our facility that wear reusable cloth caps. The caps are not washed in a health care-accredited laundry. Our director has asked these team members to put a disposable cap over the cloth cap. Is this okay?”

    Yes. A reusable cloth cap that is contained within a disposable cap may be home laundered, just as other personal clothing (e.g.,T-shirts) contained within the scrub attire are home laundered.

    Resources:

    • Guideline for surgical attire. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

    Updated November 13, 2014.

  • What is the AORN recommendation for perioperative team members who may be allergic to the detergent being used by the health care-accredited laundry?

    Health care-accredited laundering may reduce the potential for allergies to laundry detergents or other chemical additives because the rinsing process leaves little to no soap residue in the fabric. Perioperative team members with potential allergies to chemical used for laundering scrub attire should work with their facility infection preventionist to determine the source of the specific allergen and eliminate exposure.

    Resources:

    • Guideline for surgical attire. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

    Updated November 13, 2014.

  • Should unscrubbed perioperative team members wear long-sleeved jackets when preparing and packaging items in the clean assembly section of the sterile processing area?

    The perioperative or sterile processing team member should wear scrub attire that covers the arms while preparing and packaging items in the clean assembly section of the sterile processing area. Wearing long-sleeved attire helps contain skin squames shed from bare arms. Not wearing a long-sleeved jacket while preparing and packaging items that will be used during operative or other invasive procedures may allow skin squames from the bare arm to drop onto the item that is being prepared or packaged and may increase the patient’s risk for SSI. This organic material may be subsequently transferred to the surgical wound or other areas of the body and may increase the patients risk of SSI or other postoperative complications.

    Resources:

    • Guideline for surgical attire. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.
    • Andersen BM, Solheim N. Occlusive scrub suits in operating theaters during cataract surgery: effect on airborne contamination. Infect Control Hosp Epidemiol. 2002;23(4):218-220.
    • Guideline for sterile technique. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

    Updated November 6, 2014.

  • Should unscrubbed perioperative team members wear long-sleeved jackets when performing preoperative patient skin antisepsis?

    Perioperative team members should wear scrub attire that covers the arms while performing preoperative patient skin antisepsis. Wearing long-sleeved attire helps contain skin squames shed from bare arms. Performing the preoperative skin antisepsis without wearing a long-sleeved jacket may allow skin squames from the perioperative team member’s bare arms to drop onto the area that is being prepped and may increase the patient’s risk for an SSI.

    Resources

    • Guideline for surgical attire. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.
    • Guideline for preoperative patient skin antisepsis. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.
    • Andersen BM, Solheim N. Occlusive scrub suits in operating theaters during cataract surgery: effect on airborne contamination. Infect Control Hosp Epidemiol. 2002;23(4):218-220.
    • Guideline for sterile technique. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

    Updated November 6, 2014.

  • Should unscrubbed perioperative team members wear long-sleeved jackets when opening sterile supplies?

    Perioperative team members should wear scrub attire that covers the arms when opening sterile supplies. Wearing long-sleeved attire helps contain skin squames shed from bare arms. Opening sterile supplies onto the sterile field without wearing a long-sleeved jacket may allow skin squames from the perioperative team member’s bare arms to drop onto the sterile field and may increase the patient’s risk for an SSI.

    Resources

    • Andersen BM, Solheim N. Occlusive scrub suits in operating theaters during cataract surgery: effect on airborne contamination. Infect Control Hosp Epidemiol. 2002;23(4):218-220.
    • Guideline for sterile technique. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

    Updated November 13, 2014.

  • Are masks with ear loops acceptable for use in the perioperative setting?

    Masks with ear loops may not have been designed and intended for use as surgical masks and may not provide a secure facial fit that prevents venting at the sides of the mask. The surgical mask should cover the mouth and nose and be secured in a manner that prevents venting at the sides of the mask. A mask that conforms to the perioperative team member’s face decreases the risk of the perioperative team member transmitting nasopharyngeal and respiratory microorganisms to the patient or the sterile field.

    • Guideline for surgical attire. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

    Updated November 6, 2014.

  • What are the AORN recommendations for perioperative team members wearing T-shirts or other personal clothing under scrub attire that are visible at the neck and sleeve?

    Personal clothing that cannot be contained within the scrub attire either should not be worn or should be laundered in a health care-accredited laundry facility after each daily use and when contaminated.

    Resources:

    • Guideline for surgical attire. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

    Updated November 13, 2015.

  • Does AORN recommend wearing scrub attire outside of the building?

    Health care personnel should change into street clothes whenever they go outside of the building. Surgical attire may become contaminated by contact with the external environment. Changing into clean surgical attire before entering the semi-restricted area(s) decreases the possibility of contamination with microorganisms present in the external environment.

    Resources:

    • Guideline for surgical attire. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

    Updated November 6, 2015.

  • Can patients wear their own clothes in the OR?

    Necessity for clothing worn into the semirestricted and restricted areas by patients should be determined on an individual basis and be in accordance with the health care organization's policy. If allowed, considerations should be made for required access during patient care (e.g., IV access, electrosurgical unit dispersive electrode), patient injury from attire (e.g., restrictive to respiratory or circulatory system, pressure injury, burn injury), soiling of garment, and traffic patterns in the semirestricted and restricted areas (i.e., cover patient attire with clean linen).

    • Burlingame B., Patients wearing personal clothing into the OR. [Clinical Issues]. AORN Journal. 2012;95(2):288-289.

    Updated November 6, 2014.

  • What are the AORN recommendations for briefcases and personal items taken into the perioperative areas?

    Briefcases, backpacks, and other personal items that are taken into the semi-restricted or restricted areas should be cleaned with a low-level disinfectant and should not be placed on the floor. Items brought into the OR, such as briefcases, backpacks, and other personal items, may be difficult to clean and may harbor pathogens, dust, and bacteria.

    Maintaining a clean perioperative environment helps decrease the patient’s risk of SSI. Cleaning these items may help to decrease the transmission of potentially pathogenic microorganisms from external surfaces to perioperative surfaces and from perioperative surfaces to external surfaces. Floors in the OR or procedure room are considered contaminated. Items placed on the floor could become vehicles for transferring microorganisms from the floor to other perioperative or external surfaces.

    Resources:

    • Guideline for surgical attire. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.<
    • Guideline for environmental cleaning. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

    Updated November 6, 2014.

  • What are the AORN recommendations for briefcases and other personal items made of material that cannot be cleaned with a low-level disinfectant before being brought into the perioperative areas?

    If the item is unable to be effectively cleaned, it should be contained within an impervious cover before being brought into the perioperative areas and should remain covered while in the perioperative areas.

    Resources:

    • Guideline for surgical attire. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.
    • Guideline for environmental cleaning. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

    Updated November 6, 2014.

  • Does AORN recommend wearing scrub dresses?

    Scrub dresses may be worn over scrub pants or leggings. The scrub dresses and pants or leggings should be laundered in a health care-accredited laundry facility after each daily use and when contaminated.

    Resources:

    • Guideline for surgical attire. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

    Updated November 6, 2014.

  • Why does AORN recommend that scrub attire be laundered in a health care accredited-laundry facility?

    AORN recommends that scrub attire, cover apparel (e.g., lab coats), reusable head coverings, and personal clothing not covered by the scrub attire be laundered in a health care-accredited laundry facility after each daily use and when contaminated.

    The benefit of health care-accredited laundering is that it may protect the patient from exposure to pathogens remaining on the attire after home laundering and may prevent transmission of pathogens from the attire worn in the health care facility into the home or community.



    Wright and colleagues reported three cases of postoperative Gordonia bronchialis sternal infections after coronary artery bypass grafting surgery. G bronchialis was isolated from the scrub attire, axilla, hands, and purse of a nurse anesthestist, and was implicated as the cause of the SSIs. Cultures taken from her roommate, who was also a nurse, showed the same microorganism. The authors concluded that the home washing machine was the likely bacterial reservoir. This report is the first to demonstrate a causal relationship between home laundering and human disease.



    Home laundering is not monitored for quality, consistency or safety. Home laundering may not reliably kill all pathogens and the pathogens may survive in the form of biofilms within the washing machine. Home washing machines may not have the adjustable parameters or controls required to achieve the necessary thermal measures (e.g., water temperature); mechanical measures (e.g., agitation); or chemical measures (e.g., capacity for additives to neutralize the alkalinity of the water, soap, or detergent) to reduce microbial levels in soiled surgical attire. Scrub attire that is home laundered may not be protected from contaminants in the environment during transport to the practice setting.

    Resources:

    • Wright SN, Gerry JS, Busowski MT, et al. Gordonia bronchialis sternal wound infection in 3 patients following open heart surgery: intraoperative transmission from a healthcare worker. Infect Control & Hosp Epidemiol. 2012;33(12): 1238-1241.

    Updated November 6, 2014.

  • What are the AORN recommendations for shoes worn in the perioperative areas?

    Perioperative personnel should wear clean shoes that are dedicated for use within the perioperative area. Shoes worn within the perioperative environment must have closed toes and backs, low heels, and nonskid soles and must meet Occupational Safety and Health Administration (OSHA) and the health care organization’s safety requirements. Shoe covers or boots must be worn in instances when gross contamination can reasonably be anticipated (e.g., orthopedic surgery).

    Resources:

    • Guideline for surgical attire. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.
    • Occupational exposure to bloodborne pathogens. OSHA Final rule. Fed Regist. 1991;56(235):64004-64182.

    Updated November 6, 2014.

  • Does AORN recommend wearing socks?

    AORN has no official position related to wearing socks in the perioperative areas. There is no evidence that wearing socks reduces surgical site infections. However, socks do absorb moisture and may help prevent the development of foot fungus. As the presence of bacteria, fungi, and viruses should be minimized in the perioperative areas, the preferred practice would be to wear some form of absorbent footwear.

    Updated December 11, 2014.

  • Are surgical masks required during cystoscopy or myringotomy procedures?

    Surgical masks in combination with eye protection devices, such as goggles, glasses with solid side shields, or chin-length face shields, must be worn whenever splashes, spray, spatter, or droplets of blood, body fluids, or other potentially infectious materials may be generated and eye, nose, or mouth contamination can be reasonably anticipated. Wearing surgical masks and face and eye protection is recommended by the Centers for Disease Control and Prevention (CDC) and is a regulatory requirement.

    Surgical masks worn in the perioperative setting serve two purposes - first, they help protect the patient and environment from microbial contamination by organisms carried in the provider’s mouth or nose and second they provide protection for the wearer from exposure to blood, body fluids, or other potentially infectious materials. The results of an observational, descriptive, nonexperimental study conducted by White et al. involving 8,500 surgical procedures showed that 26% of exposures to blood were to the heads and necks of scrubbed personnel, and 17% of blood exposures were to circulating personnel outside the sterile field. For additional information on surgical masks, refer to the AORN Guidelines for Sterile Technique and Prevention of Transmissible Infections in the Perioperative Practice Setting.

    Resources:

    • Occupational Safety and Health Administration. Toxic and Hazardous Substances: Blood-borne Pathogens, 29 CFR §1910.1030 (2012). Occupational Safety and Health Administration. Accessed November 10, 2014.
    • Guideline for surgical attire. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.
    • White MC, Lynch P. Blood contact and exposures among operating room personnel: a multicenter study. Am J Infect Control. 1993;21(5):243-248.
    • Guideline for sterile technique. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.
    • Guideline for prevention of transmissible infections in the perioperative practice setting. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

    Updated November 13, 2014.

Autologous Tissue

  • How should autologous bone autografts be stored?

    There are gaps in the literature related to best practices for storage of autologous bone and further research is warranted. The American Association of Tissue Banks and the AORN “Guideline for autologous tissue management” recommend that autologous bone autografts be stored at -4° F (-20° C) or colder for six months or less. Autologous bone may be stored at -40° F (-40° C) for up to five years; however, this is considered long-term storage and may require registering with the US Food and Drug Administration as a tissue establishment.

    Storage at -40° F (-40° C) or colder is preferred because tissue enzymes may be active at temperatures warmer than -40° F (-40° C) and may negatively affect tissue if it is stored for an extended time. Temperatures of -94° F (-70° C) or colder may prevent enzymatic destruction of tissue. Maintaining the storage temperature below -40° F (-40° C) may also be a “buffer” that provides additional time before critical temperatures are reached in the event of a freezer malfunction.

    Resources:

    • Standards for Tissue Banking. McLean, VA: American Association of Tissue Banks; 2012.
    • Guideline for autologous tissue management. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.
    • Sample Procedure: Handling Autologous Bone Skull Flaps. Version 14. McLean, VA: American Association of Tissue Banks; 2012.

    Updated November 6, 2014.

  • Can autologous bone be subjected to the steam sterilization process?

    Autologous bone should not be subjected to the steam sterilization process unless there is a clinical indication to do so. The steam sterilization process may denature bone protein, severely damage the bone structure, and increase the potential for bone resorption and infection; however, steam sterilization may also destroy and prevent recurrence of tumor cells.

    There are gaps in the literature related to best practices for management of autologous cranial bone flaps removed for treatment of brain tumors and subjected to steam or other sterilization processes. Further research is warranted. Subjecting the bone flap to the steam sterilization process is considered manufacturing and would require that the facility register with the FDA as a tissue bank.

    Resources:

    • Guideline for autologous tissue management. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc. 
    • Schultke E, Hampl JA, Jatzwauk L, Krex D, Schackert G. An easy and safe method to store and disinfect explanted skull bone. Acta Neurochir (Wien). 1999;141(5):525-528. 
    • Vanaclocha V, Saiz-Sapena N, Garcia-Casasola C, De Alava E. Cranioplasty with autogenous autoclaved calvarial bone flap in the cases of tumoural invasion. Acta Neurochir (Wien). 1997;139(10):970-976. 
    • Wester K. Cranioplasty with an autoclaved bone flap, with special reference to tumour infiltration of the flap. Acta Neurochir (Wien). 1994;131(3-4):223-225. 
    • §21 CFR 1271: Human cells, tissues, and cellular and tissue-based products. April;2013. US Food and Drug Administration. 
    • Current Good Tissue Practice (CGTP) and Additional Requirements for Manufacturers of Human Cells, Tissues, and Cellular and Tissue-Based Products (HCT/ Ps). Silver Spring, MD: US Food and Drug Administration; 2012.

    Updated November 6, 2014.

  • Can allografts and autografts be stored in the same refrigerator or freezer?

    Allografts and autografts may be stored in the same refrigerator or freezer if they are separated, packaged using appropriate materials, and prominently labeled, and if the correct storage conditions exist for all items in the refrigerator or freezer. Allografts can be separated from autografts in the same refrigerator or freezer by placing the tissue in separate storage bins and storing the allografts on the upper shelves and the autografts on the lower shelves to avoid accidental contamination of the allografts.

    Bins or shelves used for storing allografts and autografts should contain prominent, easily identifiable labels to help perioperative personal distinguish between the containers. Perioperative team members storing allografts and autografts in the same refrigerator or freezer should ensure the appropriate storage conditions are maintained.

    Resources:

    • Guideline for autologous tissue management. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

    Updated November 6, 2014.

  • What actions should be taken when an autograft intended for replantation or autotransplantation is contaminated or dropped on the OR floor?

    A multidisciplinary team should first conduct a risk assessment to consider the benefits and potential harms associated with replantation or autotransplantation of a contaminated autograft. If a decision is made to replant or autotransplant the contaminated autograft, the following steps should be taken:

    • Rinse the contaminated graft in sterile normal saline solution to remove surface debris and contaminants. Rinsing the dropped autograft in normal saline solution may be sufficient to remove surface debris and contaminants.
    • Use a separate sterile field for decontaminating the dropped graft and exercise care to prevent splashing onto the primary sterile field.
    • Implement corrective actions as necessary to maintain the sterility of the primary sterile field (eg, changing gowns and gloves after pulsatile lavage of the contaminated graft).
    • Change the wound classification to Class III, Contaminated. According to the Centers for Disease Control and Prevention surgical wound classification system, a surgical wound with a major break in sterile technique is classified as Class III, Contaminated.
    • Document the event in a variance report.
    • Conduct a debriefing session and a root cause analysis with members of the surgical team and other individuals who may be helpful in providing a critical analysis to help determine the factors that contributed to the event and methods to prevent its recurrence.

    Resources:

    • Guideline for autologous tissue management. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc. 
    • Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for Prevention of Surgical Site Infection, 1999. Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advisory Committee. Am J Infect Control. 1999;27(2):97-132; quiz 133-4; discussion 96.

    Updated November 6, 2014.

  • How should autologous human skin autografts be stored?

    There are gaps in the literature related to best practices for storage of autologous skin and further research is warranted. The American Association of Tissue Banks and the AORN “Guideline for autologous tissue management” recommend that autologous skin autografts be stored between 32° F to 50° F (0° C to 10° C) for no longer than 14 days. Refrigerated skin should be submerged in a storage medium, and the storage medium should be changed every 72 hours. Refrigeration retards autolysis and helps prevent bacterial proliferation, and keeping the skin submerged helps prevent dehydration of the tissue. Changing the storage medium every 72 hours may help prevent microbial growth and improve skin autograft viability.

    Resources:

    • Standards for Tissue Banking. McLean, VA: American Association of Tissue Banks 2012.
    • Guideline for autologous tissue management. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.
    • Robb EC, Bechmann N, Plessinger RT, Boyce ST, Warden GD, Kagan RJ. Storage media and temperature maintain normal anatomy of cadaveric human skin for transplantation to full-thickness skin wounds. J Burn Care Rehabil. 2001;22(6):393-396.
    • Titley OG, Cooper M, Thomas A, Hancock K. Stored skin—stored trouble? Br J Plast Surg. 1994;47(1):24-29.
    • Cram AE, Domayer MA. Short-term preservation of human autografts. J Trauma. 1983;23(10):872-873.

    Updated November 6, 2014.

  • How should autologous human vein autografts be stored?

    There are gaps in the literature related to best practices for storage of autologous veins and further research is warranted. The American Association of Tissue Banks and the AORN “Guideline for autologous tissue management” recommend that autologous vein autografts be stored between 32° F to 50° F (0° C to 10° C) for no longer than 14 days. Refrigerated veins should be submerged in a storage medium, and the storage medium should be changed every 72 hours. Refrigeration retards autolysis and helps prevent bacterial proliferation, and keeping the vein submerged helps prevent dehydration of the tissue. Changing the storage medium every 72 hours may help prevent microbial growth and improve vein autograft viability

    Resources:

    • Standards for Tissue Banking. McLean, VA: American Association of Tissue Banks; 2012.
    • Guideline for autologous tissue management. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc. 
    • Robb EC, Bechmann N, Plessinger RT, Boyce ST, Warden GD, Kagan RJ. Storage media and temperature maintain normal anatomy of cadaveric human skin for transplantation to full-thickness skin wounds. J Burn Care Rehabil. 2001;22(6):393-396. 
    • Titley OG, Cooper M, Thomas A, Hancock K. Stored skin—stored trouble? Br J Plast Surg. 1994;47(1):24-29. 
    • Cram AE, Domayer MA. Short-term preservation of human autografts. J Trauma. 1983;23(10):872-873.

    Updated November 6, 2014.

  • Does storing autologous tissue require registration with the US Food and Drug Administration as a tissue bank?

    Facilities that handle autologous tissue for delayed replantation or autotransplantation into the same patient and within the same facility are not required to register with the US Food and Drug Administration (FDA) as tissue banks. Facilities that handle autologous tissue are required to recover, process, package, label, store, track, and replant or autotransplant the tissue in a manner that minimizes microbial growth, prevents mix-ups, and reduces the risk of errors.

    Storing autologous tissue to be used in a subsequent replantation or autotransplantation procedure for the same patient in the same facility is exempt from registration because the FDA considers the two applications to be a single continuous procedure.

    Resources:

    • 21 CFR 1271: Human cells, tissues, and cellular and tissue-based products. April;2013. US Food and Drug Administration. 
    • Human ells, Tissues, and Cellular and Tissue- Based Products; Establishment Registration and Listing. Fed Regist. 2001;66(13):5447-5469.

    Updated November 6, 2014.

  • What are the AORN recommendations for temperature monitoring of refrigerators and freezers used to store autologous tissue?

    Freezers and refrigerators used for storage of autologous tissue should:

    • Provide continuous temperature monitoring and should be monitored regularly with daily temperature checks recorded;

    • Have an alert or alarm system that notifies personnel when the temperature is not within the acceptable range; and

    • Have an emergency power system.
    The alert or alarm should sound in an area where an individual is present at all times to initiate corrective action or notify personnel who are available to respond. Processes should be established for maintaining the temperature and integrity of stored autologous tissue in the event of a refrigerator or freezer malfunction and for responding to a malfunction of the refrigerator or freezer that occurs when the facility is closed or when the area where the tissue is stored is unoccupied.

    Resources:

    • Joint Commission. Transplant safety. In: Comprehensive Accreditation Manual for Hospitals E-dition. Washington, DC: The Joint Commission; March 2014. 

    • Joint Commission. Transplant safety. In: Comprehensive Accreditation Manual for Ambulatory Care E-dition. Washington, DC: The Joint Commission; March 2014.

    • Guideline for autologous tissue management. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc. 

    • Sample Procedure: Handling Autologous Bone Skull Flaps. Version 14. McLean, VA: American Association of Tissue Banks; 2012.

    • Standards for Tissue Banking. McLean, VA: American Association of Tissue Banks; 2012.

    Updated November 6, 2014.

Cleaning Endoscopes

  • What is the potential for endoscopic transmission of prions?

    The collective evidence shows there are concerns about the potential for endoscopic transmission of prions and other transmissible spongiform encephalopathies (TSEs), including Creutzfeld-Jakob disease (CJD), and variant Creutzfeld-Jakob disease, (vCJD). For an endoscope to act as a vehicle for transmission of prions, contact with infective tissue is required.

    In CJD, the prions accumulate in the central nervous system and are transmitted by exposure to infectious brain, pituitary, or eye tissue. Because flexible endoscopes do not come in contact with brain, pituitary, or eye tissue, endoscopic transmission of CJD or other TSEs is unlikely.

    In vCJD, the prions accumulate in both central nervous system and lymphoid tissue. Patients with vCJD have infectivity detectable in the appendix, spleen, tonsils, thymus, and lymph nodes. The prions responsible for vCJD are found in abundance in the Peyer patches located in the terminal ileum. Aggregates of lymphoid prions are also found in the large intestine and the stomach. Transmission of vCJD via a flexible gastrointestinal endoscope is therefore theoretically possible because of the lymphatic distribution of prions. The risk for transmission is greater during invasive interventional procedures (e.g., biopsy, polypectomy, mucosal resection, sphincterotomy) than during noninterventional procedures; however, there have been no reports of such transmission described in the literature.

    Resources:

    • Guideline for processing flexible endoscopes. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

    Updated December 11, 2015

  • Is it necessary to wear gloves when handling processed flexible endoscopes?

    Yes. Personnel should wear clean, low-protein, powder-free, natural rubber latex gloves or latex-free gloves when handling processed flexible endoscopes and when transporting them to and from the storage cabinet. Sterile gloves are not required for handling processed flexible endoscopes unless the endoscope is intended to be placed on a sterile field.

    Wearing clean gloves may lessen contamination of processed flexible endoscopes by the hands of personnel. Using low-protein, powder-free natural rubber latex gloves or latex-free gloves can minimize latex exposure and the risk of reactions in both health care workers and patients. Studies related to storage of flexible endoscopes have confirmed endoscope contamination from the hands of personnel and environmental surfaces.

    Resources:

    • Guideline for processing flexible endoscopes. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

    Updated December 11, 2015

  • Does AORN recommend manual processing of flexible endoscopes?

    No. After manual cleaning and when compatible with the endoscope manufacturer's instructions for use (IFU), flexible endoscopes and accessories should be either mechanically cleaned and mechanically processed by exposure to a high-level disinfectant or a liquid chemical sterilant or should be mechanically cleaned and sterilized.

    Mechanical processing includes mechanical cleaning, mechanical high-level disinfection or sterilization, and mechanical rinsing. The collective evidence shows that mechanical processing improves cleaning effectiveness, increases efficiency, minimizes personnel exposure to biohazardous materials, and can be more successfully monitored for quality and consistency.

    Resources:

    • Guideline for processing flexible endoscopes. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

    Updated December 11, 2015

  • Does AORN recommend using rapid cleaning verification tests when processing flexible endoscopes?

    Yes. Manual cleaning of flexible endoscopes should be verified using cleaning verification tests when new endoscopes are purchased and at established intervals (e.g., after each use, daily). Visual inspection alone, even with magnification, is not sufficient to determine cleanliness of complex devices such as flexible endoscopes. Residual soil may remain and prevent effective subsequent high-level disinfection (HLD) or sterilization.

    Cleaning verification tests include adenosine triphosphate (ATP) and chemical reagent tests for detecting clinically relevant soils (e.g., protein, carbohydrate). Periodic verification of cleaning effectiveness using rapid cleaning verification tests provides an objective method for verifying cleanliness and helps assure that insufficiently cleaned flexible endoscopes are recleaned before HLD or sterilization.

    Resources:

    • Guideline for processing flexible endoscopes. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

    Updated December 11, 2015

  • Where should processed flexible endoscopes be stored?

    Flexible endoscopes should be stored in a drying cabinet. The collective evidence shows that optimal storage of flexible endoscopes facilitates drying, decreases the potential for contamination, and provides protection from environmental contaminants. Drying cabinets include a drying system that circulates high-efficiency particulate air (HEPA)-filtered air through the cabinet while filtered air under pressure is forced through the endoscope channels. The internal and external surfaces of the endoscope are continuously dried, suppressing bacterial growth. Studies related to the efficacy of drying cabinets compared with other methods of storage have shown that drying cabinets effectively limit bacterial proliferation during storage.

    If a drying cabinet is not available, flexible endoscopes may be stored in a closed cabinet with HEPA-filtered air that provides positive pressure and allows air circulation around the flexible endoscopes. Ventilation promotes drying of the endoscope. Using HEPA-filtered air may help prevent bacterial growth in the endoscope. Positive pressure may help prevent contamination of stored endoscopes.

    Flexible endoscopes should not be stored in their original shipment cases. The cases are difficult to clean, may be contaminated, and are designed for shipping only.

    Resources:

    • Guideline for processing flexible endoscopes. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

    Updated December 11, 2015

  • How long can flexible endoscopes be stored before reprocessing is required?

    The collective evidence regarding the maximum safe storage time for processed endoscopes is inconclusive. Recommendations from professional organizations for maximum storage times for flexible endoscopes are not in agreement. Studies are also not in agreement and have shown that when correctly processed, flexible endoscopes may be safe to use for 48 hours to 56 days after processing. Safe storage times may be affected by factors unique to the facility including the type of endoscopes processed and stored, processing effectiveness (e.g., level of residual contamination), storage conditions (e.g., restricted access, drying cabinet, HEPA-filtered air), compliance with manufacturers' IFU (i.e., endoscope, mechanical processor, storage cabinet), frequency of use, and patient population. For these reasons, a multidisciplinary team that includes infection preventionists, endoscopy and perioperative RNs, endoscopy processing personnel, endoscopists, and other involved personnel should establish a policy to determine the maximum storage time that processed flexible endoscopes are considered safe to use without reprocessing.

    Resources:

    • Guideline for processing flexible endoscopes. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

    Updated December 11, 2015

  • Should flexible endoscopes be cultured?

    A multidisciplinary team that includes infection preventionists, endoscopists, endoscopy processing personnel, microbiologists, laboratory personnel, risk managers, and other involved individuals should evaluate the need to implement a program for regular microbiologic surveillance cultures of flexible endoscopes and mechanical processors. A program of regular microbiological surveillance culturing of flexible endoscopes and mechanical processors is advised in the processing guidelines of several international organizations; however, there are variances among the recommendations. Routine surveillance microbiological culturing is supported in the literature as an effective method for monitoring the effectiveness and quality of processing, reinforcing best practices, evaluating the effectiveness of corrective interventions, and detecting endoscopes requiring service. Routine microbiological surveillance may also help to identify the source of contamination and rectify processing methods to prevent transmission of infection.

    Notably, there are problems with microbiological culture surveillance of flexible endoscopes. The sensitivity of routine cultures may be unreliable for detecting the organisms associated with outbreaks. The use of surveillance cultures is confounded by the delay in feedback and the frequent isolation of nonpathogenic organisms resulting from environmental contamination. The need to quarantine flexible endoscopes until the culture results have been obtained may not allow for rapid reuse of the tested endoscope and could also lead to delays in patient care. Microbiological culturing is resource-intensive, and requires additional expenditures for microbiological testing and time for personnel to collect and process samples.

    Resources:

    • Guideline for processing flexible endoscopes. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

    Updated December 11, 2015

  • Should all flexible endoscopes be sterilized?

    According to the Spaulding classification, devices that enter sterile tissue or the vascular system are considered critical items that should be processed by sterilization. Items such as flexible endoscopes that come in contact with nonintact skin or mucous membranes, are considered to be semicritical, and should be processed by sterilization, or at a minimum, by high-level disinfection.

    At a meeting of the Gastroenterology-Urology Devices Panel convened by the FDA in May 2015 to seek expert scientific and clinical opinion related to reprocessing of duodenoscopes and other flexible endoscopes, Rutala proposed a modification of the Spaulding system wherein items that secondarily enter sterile tissue or the vascular system are considered to be critical items. Devices secondarily entering sterile tissue would include devices that enter sterile tissue by way of a mucous membrane, such as a bronchoscope, a cystoscope, or a duodenoscope. Requiring sterilization of items that secondarily enter sterile tissue or the vascular system may help prevent patient infection. A multidisciplinary team that includes infection preventionists, endoscopy and perioperative RNs, sterile processing personnel, endoscopists, and other involved personnel should conduct a risk assessment to determine whether items that secondarily enter sterile tissue or the vascular system (ie, via a mucous membrane) should be sterile.

    Resources:

    • Guideline for processing flexible endoscopes. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

    Updated December 11, 2015

  • Should flexible duodenoscopes be processed using enhanced methods?

    Enhanced methods for processing flexible duodenoscopes may include implementing high-level disinfection (HLD) followed by:

    • endoscope quarantine until the duodenoscope is culture-negative,
    • a liquid chemical sterilant processing system,
    • a second HLD,
    • ethylene oxide sterilization, or
    • FDA-cleared low-temperature sterilization.

    Initiating enhanced processing methods for duodenoscopes may decrease the potential for pathogenic microorganisms to remain on the endoscope after processing.

    Notably, performing HLD followed by HLD, liquid chemical sterilization, low-temperature sterilization, or ethylene oxide sterilization has not been validated by the endoscope, mechanical processor, or sterilizer manufacturers, and further research is warranted. A multidisciplinary team that includes infection preventionists, endoscopy and perioperative RNs, endoscopy processing personnel, endoscopists, and other involved personnel should conduct a risk assessment to determine the benefits compared with the potential harms of initiating one or more enhanced methods for processing duodenoscopes.

    Resources:

    • Guideline for processing flexible endoscopes. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

    Updated December 11, 2015

  • Should flexible endoscopes lumens be flushed with alcohol?

    A multidisciplinary team that includes infection preventionists, endoscopy and perioperative RNs, endoscopy processing personnel, endoscopists, and other involved personnel should conduct a risk assessment to determine whether endoscope lumens should be flushed with 70% to 90% ethyl or isopropyl alcohol.

    Many clinical practice guidelines and experts in the field recommend manual or mechanical flushing of endoscope lumens with alcohol because it facilitates drying of the endoscope lumens by binding with residual water and enhancing evaporation. Alcohol prevents colonization and transmission of waterborne bacteria. However, flushing endoscope lumens with alcohol may not be necessary if the endoscope is effectively dried. Because of the fixative properties of alcohol, this practice is not recommended in some countries.

    Resources:

    • Guideline for processing flexible endoscopes. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

    Updated December 11, 2015

Counts/Retained Surgical Items

  • When is an item considered to be retained?

    Reporting requirements for retained surgical items vary among quality organizations and accreditation bodies. Events that necessitate reopening a wound to retrieve a RSI should be reported in compliance with your policy, as well as local, state and federal regulatory agencies.

    Resources:

    • Guideline for Prevention of Retained Surgical Items. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

    Updated December 2, 2015.

  • Is the count incorrect if there are extra items?

    Yes, the initial count may have been miscounted and the count is not valid. Discrepancies can be a result of miscounts (e.g., incorrect baseline count, overcount, undercount), documentation errors (e.g., addition), or misplaced items (e.g., retained). The count should be reconciled according to the facility’s policy and procedure for resolving count discrepancies.

    Resources:

    • Guideline for Prevention of Retained Surgical Items. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

    Updated December 2, 2015

  • Does it matter which order we count items?

    The health care organization should establish the sequence in which the counts should be conducted (e.g., order of standardized count board or sheet, proximal to distal from the patient). The collective evidence supports using a standardized, consistent counting methodology.

    Resources:

    • Guideline for Prevention of Retained Surgical Items. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

    Updated December 2, 2015

  • Should we count sponges by 1-10 or 1-5?

    Packaged items should be counted according to the number that the item is packaged in. Counting to the number that items are packaged in allows perioperative team members to identify packaging errors and may serve as an indication of a miscount.

    Resources:

    • Guideline for Prevention of Retained Surgical Items. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

    Updated December 2, 2015

  • If we have multiple procedures for the same patient, should we count the items together or separately?

    For multiple procedures or sterile fields, all items should be counted together at the final count while sterile technique is maintained. Multiple procedures or sterile fields increase the risk of counted items moving between setups and creating confusion during counting, which may contribute to counting errors if items are missed. Counting items across all sterile fields, while maintaining sterile technique, accounts for all surgical items in the room and validates that the items have not been retained in the patient.

    Resources:

    • Guideline for Prevention of Retained Surgical Items. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

    Updated December 2, 2015

  • Is the count correct or incorrect when the patient leaves with packing?

    When radiopaque surgical soft goods are intentionally used as therapeutic packing and the patient leaves the OR with this packing in place, the number and types of items placed should be documented in the medical record as:

    • reconciled and confirmed by the surgeon when this information is known with certainty or
    • as incorrect if the number and type of sponges used for therapeutic packing is not known with certainty.

    Resources:

    • Guideline for Prevention of Retained Surgical Items. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

    Updated December 2, 2015

  • If a RN circulator and scrub person count an instrument tray prior to sterilization, can this count as a first instrument count?

    No, the initial count should still be performed when opening the set for use. If you are unable to count for an emergency procedure, then your facility should determine if this meets criteria for a "waived" count. If your facility decides to have the RN and tech count prior to sterilization as an additional prevention measure, you should still attempt to count the instruments in the room for the initial count if feasible. If you are not able to count due to the clinical situation, you should follow your facility's policy for waived counts and take any additional measures per policy.

    Resources:

    • Guideline for Prevention of Retained Surgical Items. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

    Updated December 2, 2015

  • Should prep sponges be radiopaque?

    If gauze sponges are used for vaginal antisepsis, the gauze sponges should be radiopaque and counted. For antisepsis other than in the vagina, non-radiopaque gauze sponges may be used, but should be isolated from counted radiopaque sponges to avoid confusion. For most procedures, foam sponges are used for antisepsis rather than gauze sponges, and there is no recommendation for these types of sponges to be radiopaque or counted.

    Resources:

    • Guideline for Prevention of Retained Surgical Items. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

    Updated December 2, 2015

  • Does AORN recommend performing the initial count before the patient enters the room?

    Yes, the initial count should be conducted before the patient enters the OR or procedure room, when possible. Performing the initial count before the patient enters the room will allow the perioperative team members to have the optimal benefit or reduced interruption from patent care distractions. When conducting the initial count before the patient enters the room is not possible, a second RN circulator may assist the primary RN circulator.

    Resources:

    • Guideline for Prevention of Retained Surgical Items. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

    Updated December 2, 2015

  • Do we have to recount if we are interrupted during the count?

    If the count is interrupted, the count for the type of item being counted during the interruption (e.g., laparotomy sponge) should be restarted. The surgical count is a critical phase of the procedure during which distractions, noise, and unnecessary interruptions should be minimized. The collective evidence recommends that minimizing distractions, noise, and interruptions in the OR creates a safer environment for patients and perioperative team members. During the count, a no-interruption zone should be created that prohibits nonessential conversation and activities, including rushing the count.

    Resources:

    • Guideline for Prevention of Retained Surgical Items. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

    Updated December 2, 2015

Disaster Response

  • What are appropriate steps to restoring OR operations after a power outage and flooding?
    1. Perform an environmental assessment by a multi-disciplinary team including:

      1. Infection Preventionist

      2. Facility Plant Engineer

      3. Nursing

      4. Sterile Processing Department Manager

      5. Management

    2. Assess environmental cleanliness:

      1. Condensation on surfaces (eg, walls, flooring)

        • Terminally clean room to remove condensation on walls or flooring.

      2. Condensation or any signs of water damage on sterile packaging

        • Reprocess or discard any sterile items with condensation or suspected water damage.

      3. Flooding or water damage

        • Collaborate with multi-disciplinary team on an infection control risk assessment (ICRA) and renovation plans.
        • Follow CDC recommendations for cleaning of floodwater.

    3. Assess power supply: Fully restored or on emergency generator?

      1. Operate essential equipment from emergency power outlets (red).

      2. If flooding occurred, work with facilities plant engineer to assess electrical safety and biomedical engineer to evaluate electrical equipment.

    4. Assess HVAC system:

      1. Air exchanges restored?

        • Do not resume elective procedures until minimum air exchanges met.

      2. Temperature within acceptable range?

        • Do not resume elective procedures until temperature within range

      3. Humidity less than 60%?

        • Do not resume elective procedures until humidity within range and assess for condensation.

      4. If flooding occurred, work with multi-disciplinary team to follow CDC recommendations for cleaning air ducts and vents prior to turning on HVAC system.

    5. Assess water supply.

      1. Water pressure and quality

        • Do not perform procedures until water is functioning or if water supply is contaminated.

      2. Steam supply lines

        • Do not perform procedures until steam is functioning.

    6. Perform quality check on steam sterilizers and automated cleaning equipment before returning to service.

    7. Terminally clean operating rooms.

      1. If flooding occurred, follow CDC recommendations for cleaning of floodwater.

    8. Inventory and record discarded damaged supplies for insurance claim purposes and to obtain replacements.

    Resources:

    • Lessons Learned from Hurricane Ike. AORN Journal. 2009;89(6):1073-1078.

    • Mitchell, L.Flood water after a disaster or emergency. Centers for Disease Control and Prevention. http://emergency.cdc.gov/disasters/floods/cleanupwater.asp. Accessed November 19, 2012.

    Updated November 19, 2012

Documentation

  • How is the surgical wound classification determined?

    Surgical wound classification is determined using the wound classification scheme from the CDC described below. AORN has developed the Surgical Wound Classification Decision Tree to assist in decision making for surgical wound classification. Perioperative nurses can use the Surgical Wound Classification Decision Tree as a tool to assist in decision making for surgical wound classification. The wound classification is subject to change; therefore, the wound classification should be assigned in consultation with the surgeon at the end of the procedure and documented in the perioperative record.

    Resources:

    • Recommended practices for prevention of transmissible infections in the perioperative practice setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013;331-364.
    • Van Wicklin S. CDC surgical wound classification system/Surgical wound classification decision tree [Clinical Issues]. AORN J. 2012.
    • Mangram AJ , Horan TC , Pearson ML , Silver LC .Hospital Infection Control Practices Advisory Committee. Guidelines for prevention of surgical site infection, 1999. Infect Control Hosp Epidemiol. 1999;27(2):97-132.
    • Howard JM, Barker WF, Culbertson WR, et al. Postoperative wound infections: The influence of ultraviolet irradiation of the operating room and various other factors . Ann Surg. 1964;160(Suppl 2):1–192.
    • Simmons BP. Guideline for prevention of surgical wound infections. Infect Control. 1982;3:185-196.

    Updated January 28, 2013.

  • What is the purpose of documenting surgical wound classifications?

    The wound classification is a formula used for grading the extent of microbial contamination postoperatively, thereby indicating the likelihood that a patient will develop an infection at the surgical site. The classification also allows for comparison of wound infection rates associated with different surgical techniques, surgeons and facilities. The comparison may be useful for research and may also serve to alert infection prevention personnel to wounds at increased risk for infection, enabling appropriate surveillance and preventative measures to be taken

    Resources:

    • Recommended practices for prevention of transmissible infections in the perioperative practice setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013;331-364.
    • Van Wicklin S. CDC surgical wound classification system/Surgical wound classification decision tree [Clinical Issues]. AORN J. 2012.
    • Mangram AJ , Horan TC , Pearson ML , Silver LC .Hospital Infection Control Practices Advisory Committee. Guidelines for prevention of surgical site infection, 1999. Infect Control Hosp Epidemiol. 1999;27(2):97-132.
    • Howard JM, Barker WF, Culbertson WR, et al. Postoperative wound infections: The influence of ultraviolet irradiation of the operating room and various other factors . Ann Surg. 1964;160(Suppl 2):1–192.
    • Simmons BP. Guideline for prevention of surgical wound infections. Infect Control. 1982;3:185-196.

    Updated January 28, 2013.

  • What is the correct procedure for receiving verbal medication orders in the perioperative setting?

    The National Coordinating Council for Medication Error Reporting and Prevention recommends that all verbal orders be converted to written orders and signed by the individual receiving the order. Verbal orders should be documented in the patient's medical record and reviewed and countersigned by the prescriber as soon as possible. Record the order on either the regular physician's order form or perioperative record according to facility policy and procedure.

    The following steps can be taken to guide safe medication practices when taking verbal orders:
    • Develop a read-back system that includes verbalizing the read-back digit-by-digit (e.g., one-five, not fifteen).
    • Allow only licensed health care providers to receive verbal orders.
    • Consider using a visual tool to enhance communication (ie, dry erase board).
    • Limit distractions and interruptions.
    • Record the order on the patient medical record as soon as possible.
    • Question prescribers when there are any concerns or clarification is needed about verbal orders.

    Resources:

    • Recommended practices for medication safety. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013;255-294.
    • Recommendations to reduce medication errors associated with verbal medication orders and prescriptions, February 24, 2006. National Coordinating Council for Medication Error Reporting and Prevention. http://www.nccmerp.org/council/council2001-02-20.html. Accessed November 20, 2012.
    • Hendricksen T. Verbal medication orders in the OR. AORN J. 2007;86(4):626-629.
    • Record of care, treatment, and services. In: Comprehensive Accreditation Manual for Hospitals. Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations;2010:RC-1-RC-13.

    Updated January 28, 2013.

  • What are the surgical wound classifications?

    The Center for Disease Control and Prevention uses an adaptation of the American College of Surgeons wound classification schema, which divides surgical wounds into four classes:

    CLASS I/CLEAN WOUNDS: an uninfected surgical wound in which no inflammation is encountered and the respiratory, alimentary, genital, or urinary tracts are not entered. Clean wounds are primarily closed and, if necessary, drained with closed drainage. Surgical wound incisions that are made after nonpenetrating (ie, blunt) trauma should be included in this category if they meet the criteria.

    CLASS II/CLEAN-CONTAMINATED WOUNDS: a surgical wound in which the respiratory, alimentary, genital, or urinary tracts are entered under controlled conditions and without unusual contamination. Specifically included in this category are surgical procedures involving the biliary tract, appendix, vagina, and oropharynx, provided no evidence of infection is encountered and no major break in technique occurs.

    CLASS III/CONTAMINATED WOUNDS: open, fresh, accidental wounds. This typically involves surgical procedures in which a major break in sterile technique occurs (eg, emergency open cardiac massage) or when gross spillage from the gastrointestinal tract and incisions in which acute, nonpurulent inflammation is encountered.

    CLASS IV/DIRTY OR INFECTED WOUNDS: old traumatic wounds with retained or devitalized tissue, as well as wounds that involve existing clinical infection or perforated viscera. This definition suggests that the organisms causing postoperative infection were present in the wound before the surgical procedure.

    Resources:

    • Recommended practices for prevention of transmissible infections in the perioperative practice setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013;331-364.
    • Van Wicklin S. CDC surgical wound classification system/Surgical wound classification decision tree [Clinical Issues]. AORN J. 2012.
    • Mangram AJ , Horan TC , Pearson ML , Silver LC .Hospital Infection Control Practices Advisory Committee. Guidelines for prevention of surgical site infection, 1999. Infect Control Hosp Epidemiol. 1999;27(2):97-132.
    • Howard JM, Barker WF, Culbertson WR, et al. Postoperative wound infections: The influence of ultraviolet irradiation of the operating room and various other factors . Ann Surg. 1964;160(Suppl 2):1–192.
    • Simmons BP. Guideline for prevention of surgical wound infections. Infect Control. 1982;3:185-196.

    Updated January 28, 2013.

  • Who is authorized to receive and record verbal orders in the perioperative setting?

    Authorization is given according to facility policy and state and federal regulations such as the nurse practice act. The Joint Commission (JC) and Centers for Medicare and Medicaid Services (CMS) requirements state facility policy and state and federal regulations must be followed regarding who is authorized to receive and record verbal orders.

    Resources:

    • Recommended practices for medication safety. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013;255-294.
    • Recommendations to reduce medication errors associated with verbal medication orders and prescriptions, February 24, 2006. National Coordinating Council for Medication Error Reporting and Prevention. http://www.nccmerp.org/council/council2001-02-20.html. Accessed November 20, 2012.
    • Hendricksen T. Verbal medication orders in the OR. AORN J. 2007;86(4):626-629.
    • Record of care, treatment, and services. In: Comprehensive Accreditation Manual for Hospitals. Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations;2010:RC-1-RC-13.

    Updated January 28, 2013.

  • Does the count sheet need to be kept in the patient's record or retained for a set amount of time?

    AORN does not have a recommendation to include count sheets in the patient's record or to retain the sheet for a set amount of time. Count sheets are usually a tool used to facilitate the counting process and instrument inventory. If the health care organization develops a policy for retaining count sheets, the policies should comply with regulatory and accreditation requirements.

    Resources:

    • Denholm B. Count sheets. [Clinical Issues]. AORN J. 2013;98(1):88-89.

    Updated August 7, 2013.

Ebola

  • What precautions should the perioperative team take in the OR when caring for a patient with known or suspected Ebola?

    Perioperative team members should take standard, contact, droplet, and airborne precautions when caring for a patient with known or suspected Ebola in the OR. See Ebola: Perioperative Considerations for more information.

    Resources:

    • CDC’s Updated PPE Guidance 
    • CDC’s web-based Training for Putting on and Removing PPE 
    • CDC’s Information for Healthcare Workers and Settings 
    • AORN Journal Clinical Issue – Ebola: Perioperative Considerations
    • ANA’s Ebola Information 
    • AOHP’s Ebola Toolkit 
    • Preparing for Ebola: What U.S. Hospitals Can Learn From Emory Healthcare and Nebraska Medical Center

    Updated October 24, 2014.

  • What PPE should sterile processing team members wear when decontaminating instruments used on patients with known or suspected Ebola?
    • No exposed skin
    • Either a Surgical N95 Respirator or a PAPR: both should be NIOSH certified
    • Either a gown (fluid resistant, extends to mid-calf) or coveralls (fluid resistant, without integrated hood)
    • Boot covers (fluid resistant, extends to mid-calf)
    • Gloves (double, heavy duty, outer pair has extended cuff)
    • Apron (fluid resistant, extends to mid-calf)
    • Full face shield and surgical hood (If wearing PAPR, should be integrated)

    Resources:

    Updated November 18, 2014.

  • Why is the CDC recommendation for removal of gowns and gloves different from AORN’s recommendations?

    The CDC recommends that when removing Personal Protective Equipment (PPE), the contaminated gloves should be removed before the gown. This is contrary to long-standing perioperative practice related to sterile technique. When removing gown and gloves after participating in a sterile procedure, the gown is removed followed by the gloves. This is because the sterile gown has a Velcro seal at the back of the neck that can be released by the scrubbed person moving their shoulders forward. In this case, the surgical gown can be removed, and folded inside-out as it is removed, after which the gloves can be removed using a glove-to-glove then a skin-to-skin technique.

    The CDC recommends removing the gloves before the gown because the unsterile gowns used as PPE have a string tie at the back of the neck. This tie cannot be removed by the team member moving their shoulders forward. In this case, the gloves have to be removed first so that the team member can safely untie the back of the neck with ungloved hands. In this scenario, the team member would first remove the gloves using a glove-to-glove and skin-to-skin technique, untie the string tie at the back of the neck, and then remove the gown. Whenever gown and gloves are removed, hand hygiene should be performed immediately after.

    Resources:

    Updated October 24, 2014.

  • How should Ebola-contaminated instruments be handled?

    Updated November 17, 2014.

  • How should Ebola-contaminated laryngoscope equipment (ie, blades, handles) be handled?
  • Are there any Ebola precaution guidelines for performing cesarean section procedures?

    When performing a cesarean section procedure for a patient with known or suspected Ebola, perioperative team members should take standard, contact, droplet, and airborne precautions. See Ebola: Perioperative Considerations for more information. Guidance from the CDC specific to labor and delivery settings is in development.

    Resources:

    Updated October 24, 2014.

  • Is air travel to AORN events safe?

    Please refer to CDC guidance for the most current travel information.

    AORN is monitoring the status of travel recommendations related to Ebola. If there is any change in status that would impact AORN events or the safety of traveling attendees, we will provide updated information.

    Resources:

Environmental Cleaning

  • How should the floors in the operating room be cleaned during terminal cleaning?

    The entire floor should be mopped with an Environmental Protection Agency (EPA)-registered disinfectant after scheduled procedures are performed as part of terminal cleaning. The floor may be mopped with either a wet-vacuum or a single-use mop.

    Resources:

    • Guidelines for environmental infection control in health-care facilities. Centers for Disease Control and Prevention. 2003. http://www.cdc.gov/hicpac/pdf/guidelines/eic_in_HCF_03.pdf. Accessed November 14, 2012.

    Updated July 3, 2013.

  • Does the wet vacuum used for terminal cleaning need to be cleaned?

    Cleaning equipment (i.e. wet vacuum) should be disassembled, cleaned, and disinfected with an EPA-registered disinfectant, and dried before reuse and storage to prevent the growth of microorganisms and subsequent contamination of the perioperative area.

    Resources:

    • Recommended practices for environmental cleaning in the perioperative setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:243-254.
    • Blanchard J. Terminal cleaning [Clinical Issues]. AORN J. 2009;89(2):409-411.

    Updated January 28, 2012.

  • Are alcohol wipes appropriate for cleaning surfaces in the operating room?

    Alcohol should not be used for cleaning and disinfecting surfaces in the operating room because alcohol is not an adequate cleaning and disinfecting agent. When used as an ingredient in an EPA-registered disinfectant product, alcohol may be acceptable for disinfection in the OR pending product approval by a multidisciplinary team (eg, perioperative services, environmental services, infection prevention) and consideration of the product's flammability.

    Resources:

    • Recommended practices for environmental cleaning in the perioperative setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:243-254.
    • Blanchard, J. Use of alcohol wipes for perioperative cleaning and disinfection. [Clinical Issues]. AORN J. 2011;94(5):503-504

    Updated July 3, 2013.

Environment of Care

  • What are the appropriate temperature settings for blanket warming cabinets?

    The temperature range of blanket or linen warming cabinets should not exceed 130°F (54.4°C). Post the temperature parameters on the cabinet for ready reference. The temperature of the warming cabinet should be checked on regular intervals and documented on a log or electronically.

    Resources:

    • Recommended practices for a safe environment of care. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc;2013;217-242.
    • Hazard report: ECRI Institute revises its recommendation for temperature limits on blanket warmers. Health devices. 2009;38(7):230-231.

    Updated January 28, 2013.

  • What are the recommended temperature ranges for an operating room?

    The recommended temperature range in an operating room is between 68°F and 75°F. Collaborate with infection prevention, and facility engineers when determining temperature ranges. Each facility should determine acceptable ranges for temperature in accordance with regulatory and accrediting agencies.

    Resources:

    • Guideline for a safe environment of care, part 2. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

    Updated March 3, 2015.

  • What are the recommended humidity ranges for an operating room?

    The recommended humidity range in an operating room is 20% to 60% based upon addendum d to ANSI/ASHRAE/ASHE Standard 170-2008. Each facility should determine acceptable ranges for humidity in accordance with regulatory and accrediting agencies and local regulations. The center for Medicaid and Medicare systems has modified their requirements to allow for the 20% lower limit effective June 2013.

    Resources:

    • Guideline for sterilization. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2015:665-692.
    • ANSI/ASHRAE/ASHE Addendum d to Standard 170-2008: Ventilation of Health Care Facilities. 2010. www.ashrae.org/File%20Library/docLib/Public/20100714_ad170_2008_d.pdf. Accessed November 30, 2012.
    • Centers for Medicare & Medicaid Services. State Operations Manual Appendix A: Survey Protocol, Regulations and Interpretive Guidelines for Hospitals. Rev;84.2013;. http://cms.hhs.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_a_hospitals.pd. Accessed July 15, 2013.

    Updated July 18, 2013.

  • What is the temperature range for solution warming cabinets?

    The temperature range of solution warming cabinets should be in accordance with the solution manufacturer's specifications. Post the temperature parameters on the cabinet for ready reference. Be consistent within your facility. The temperature of the warming cabinet should be checked on regular intervals and documented on a log or electronically.

    Resources:

    • Recommended practices for a safe environment of care. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013;217-242.

    Updated January 28, 2013.

  • How long can fluids remain in the warmer?

    Contact the solution manufacturer for maximum temperature and length of time that the fluids may remain in the warming cabinet. The stability of the fluids will vary by the type of solution and the storage container. Post the temperature and length parameters on the cabinet for ready reference. Label and date the fluids with either the date into the warmer or the date the fluids should be removed, according to your institution policy.

    Resources:

    • Recommended practices for a safe environment of care. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013;217-242.

    Updated January 28, 2013.

  • Should the OR windows be covered when using a carbon dioxide (CO2) laser?

    The OR windows do not need to be covered when using the carbon dioxide (CO2) laser because the CO2 laser is the only laser that does not pass through windows. Doors should remain closed when the laser is in use, including the CO2 laser, to stop the transmission of the laser beam.

    Resources:

    • Ogg, MJ. Safe use of carbon dioxide lasers. [Clinical Issues]. AORN Journal. 2011;94(4):411-412.

    Updated November 30, 2012.

  • What type of a fire extinguisher should be used in an operating room?

    In the AORN Recommended Practices for a Safe Environment of Care, the recommendation is made that “Fire extinguishers should be selected according to standards established by the National Fire Protection Association (NFPA) and the local authority with jurisdiction.” The local authority with jurisdiction is frequently the local fire marshall or may be a representative from the state government.

    According to the recommendations from the NFPA a water mist or carbon dioxide extinguisher may be used in the OR. This recommendation is based upon the rating of the extinguishers. Water mist extinguishers are rated Class 2A:C and carbon dioxide extinguishers are rated Class B and Class C, but also may be used for Class A fires. The rating is determined by the types of fuel that is being burned. The operating room frequently has Class A fuels which would be drapes, paper, and human tissue. There can also be Class B fuels present such as the flammable skin prep products. Class C fires involve electrical equipment which has electrical current flowing to it. When the equipment is unplugged the electrical current is removed and the fuel is then considered to be either a class A or B.

    Resources:

    • Recommended practices for a safe environment of care. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013;217-242.
    • National Fire Protection Association Technical Committee on Portable Fire Extinguishers. NFPA 10: Standard for Portable Fire Extinguishers. Quincy, MA: National Fire Protection Association; 2010.

    Updated July 18, 2013.

Hand Antisepsis

  • When should we wash our hands in the perioperative setting?

    Your hands should be washed:

    • Upon entering the perioperative setting
    • Before and after every patient contact (contact in this situation is interpreted as an exposure to a patient and not each time you touch a patient)
    • Before putting on or after removing gloves or other personal protective equipment
    • Any time there has been contact with blood or other potentially infectious materials
    • Before and after eating
    • Before and after using the restroom
    • Before leaving the health care facility
    • When hands are visibly soiled

    Resources:

    • Recommended practices for hand hygiene in the perioperative setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:63-74.

    Updated January 28, 2013.

  • Can nail polish be worn by personnel in the operating room?

    Nail polish that is unchipped may be worn by staff in the operating room. Studies have demonstrated that nail polish begins to harbor microorganisms when it is chipped or worn more than four days. In the event of a glove tear or perforation, the health care practitioner's chipped nail polish could potentially go into the surgical wound. Chipped nail polish should be removed to prevent contamination of the environment or the patient.

    Resources:

    Recommended practices for hand hygiene in the perioperative setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:63-74.

    Updated January 28, 2013

  • Can healthcare personnel wear gel or shellac nail polish in the perioperative setting?

    Gel and shellac nail polish should not be worn in the perioperative setting. Due to the lack of evidence on these types of nail polish, and their chemical similarities to artificial nail compounds, an abundance of caution should be taken until research evidence on gel and shellac nail polish is available and demonstrates their safety.

    Resources:

    Wood, A, & Van Wicklin, S. Ultraviolet (UV)-cured nail polish. [Clinical Issues]. AORN Journal. 2015;101(6):701-708.

    Updated July 10, 2015 

  • Can artificial nails be worn by personnel in the operating room?

    Artificial nails should not be worn in the perioperative environment. Any nail other than a natural nail is considered artificial. Artificial nails are defined as any fingernail enhancement, resin bonding, extensions, tips, gels, or acrylics. Studies have shown higher microbial counts under artificial nails than under natural nails before and after hand washing.

    Resources:

    Recommended practices for hand hygiene in the perioperative setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:63-74.

    Updated June 12, 2015

  • Does the first surgical hand scrub of the day have to be soap and water before using surgical hand rub products?

    A standardized surgical hand scrub with a soap (antimicrobial agent), nonabrasive sponge, and water does not have to be the first surgical hand scrub of the day before an alcohol-based surgical hand rub product is used, unless it is recommended in the manufacturer's instructions for use. The surgical hand scrub reduces the transient and resident flora of the hands, which also may reduce health care-associated infections. A standardized surgical hand scrub using an alcohol-based hand rub product will decrease transient and resident flora on the hands. Hand washing does however need to be performed before the first surgical hand scrub of the day.

    Resources:

    Ogg, MJ. First surgical hand scrub of the day. [Clinical Issues]. AORN Journal. 2011;93(3):397-398.

    Updated June 12, 2015

Hypothermia

  • Is it acceptable to warm a patient by using the hose of the force air warming machine without connecting it to a blanket?

    An air hose without a blanket attached should never be used to warm a patient. Dangerously high air temperatures flow through the hose and patients have suffered serious burns as a result of this unsafe practice. Always use warming equipment in accordance with the manufacturer's instructions for use.

    Resources:

    • Guideline for the prevention of unplanned patient hypothermia. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

    Updated November 17, 2015
  • Does AORN recommend a specific type of temperature measurement?
    The type of temperature measurement used is dependent upon the requirements of the procedure (eg, accessibility of the route, invasiveness of the route, anesthesia type, anesthesia delivery method). Temperature may be measured using core temperature sites (eg, tympanic membrane [via thermistor], distal esophagus, cutaneous [via zero-heat-flux thermometry], nasopharynx, pulmonary artery) or “near-core” sites (eg, mouth, axilla, bladder, rectum, skin, tympanic membrane [via infrared sensor]).

    Resources:
    • Guideline for the prevention of unplanned patient hypothermia. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.
    Updated November 17, 2015


  • May I change the temperature in the OR to go above or below the recommended temperature ranges?
    The temperature may be adjusted above or below the recommended temperature based upon the requirements of the patient. An example is increasing the temperature in the room for a burn or neonatal patient. After the procedure the temperature should be reset to be within the normal range.

    Resources:
    • Guideline for the prevention of unplanned patient hypothermia. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.
    • Guideline for a safe environment of care, part 2. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.
    Updated November 17, 2015
  • Which patients should have their temperature taken in the OR?
    All patients should have an intraoperative temperature taken. The AORN guidelines do not specify when it should be taken but states that a temperature should be taken in all phases of perioperative care.

    Resources:
    • Guideline for the prevention of unplanned patient hypothermia. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.
    Updated November 17, 2015
  • How often should the patient temperature be taken in the OR?

    AORN does not recommend a frequency therefore this needs to be determined by the organization.  An example is the temperature is taken every time the other vital signs are taken.

    Resources: 

    • Guideline for the prevention of unplanned patient hypothermia. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

    Updated November 17, 2015

  • Does AORN recommend a specific type of warming method?

    AORN does not recommend a specific type of warming method. The selection of warming method should be determined by the perioperative team after a collaborative discussion among the team members. The team should consider the planned procedure, patient positioning, IV access sites, and warming equipment constraints (eg, access to the surgical site, skin surface area contact) when selecting the best method for warming the patient. 

    Resources: 

    • Guideline for the prevention of unplanned patient hypothermia. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

    Updated November 17, 2015

  • How does AORN define hypothermia?

    A decrease in core body temperature below 36° C (96.8° F).

    Resources: 

    • Guideline for the prevention of unplanned patient hypothermia. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

    Updated November 17, 2015

Informatics

  • What is nursing informatics?

    Nursing Informatics is not about nursing the computer. The computer is the tool for the nurse informaticist and the perioperative clinical nurse, similar to the stethoscope being the tool for the bedside nurse. In 1989, Graves and Corcoran defined “the core of the science of nursing informatics is the commodities that computers process (data, information, knowledge) and not the computer itself.”¹ Prior to that time, nursing informatics definitions were more technology oriented and “underemphasized the need for the informatics nurse specialist to support the cognitive interaction between the nurse, the nursing process, nursing data, patients and the technology”². In the 1990s Graves and Corcoran asserted that nursing informatics combines nursing science, information science and computer science to manage and process nursing data. In 2008, the American Nurses Association defined Nursing Informatics in the Scope and Standards of Practice as:

    “a specialty that integrates nursing science to manage and communicate data, information, knowledge and wisdom in nursing practice. Nursing Informatics supports patients, nurses and other providers in their decision-making in all roles and settings. This support is accomplished through the use of information technology and information structures, which organize data, information and knowledge for processing by computers.”³

    The nursing informatics specialty involves understanding and working to improve the interaction between the nurse and patient using technology. The goal of nursing informatics is to have technology enhance nursing care for patients and their families by providing up-to-date, accurate information for each step of the nursing process which is the power behind high quality, safe patient centered care.

    Resources:

    • Graves, JR, Corcoran S. The study of nursing informatics. Image: J Nurs Scholarship. 1989; 21(4) 227-231.
    • Staggers N, Thompson CB. The evolution of definitions for nursing informatics: a critical analysis and revised definition. J Am Med Inform Assoc. 2002;9(3):257. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=344585 . Accessed October 20, 2009.
    • Nursing Informatics. Scope and Standards of Practice. Silver Spring, MD: American Nurses Association (ANA); 2008:1, 177.

    Updated September 2013.


  • What are some nursing informatics organizations?
    The Alliance for Nursing Informatics (ANI)
    ANI is a collaboration of organizations that represent a unified voice for nursing informatics. ANI provides the synergy and structure needed to advance the efforts of nursing informatics professionals in improving the delivery of patient care. ANI advances nursing informatics leadership, practice, education, policy and research through a unified voice of nursing informatics organizations.

    American Nursing Informatics Association (ANIA)
    ANIA is an association of professional nurses and associates who are committed to their specialty that integrates nursing science, computer science and information science to manage and communicate data, information, knowledge and wisdom in nursing and informatics practice. ANIA members identify informatics practice as a specialty that is essential to the delivery of high quality, and cost-effective health care and are committed to their professional development and seek to actively engage in a community of like-minded professionals. ANIAs mission is to advance the field of nursing informatics through communication, education, research and professional activities.

    Technology Informatics Guiding Educational Reform (TIGER)
    TIGER enables nurses and interprofessional colleagues to use informatics and emerging technologies to make healthcare safer, more effective, efficient, patient-centered, timely and equitable by interweaving evidence and technology seamlessly into practice, education and research fostering a learning healthcare system. The TIGER Initiative Foundation goal is to implement and integrate TIGER recommendations across the continuum of care by:

    • Dissemination of recommendations of nine collaboratives and completion of collaborative reports developed in TIGER Phase II
    • Developing funding for, pilots and implementation of a Virtual Learning Environment (VLE) to enhance the adoption of informatics and technology (e.g., competencies, national QSEN competencies, competency examinations)
    • Exploring the application and integration of TIGER Phases I and II with nursing, interdisciplinary and allied health stakeholders through an interdisciplinary invitational symposium
    • Addressing TIGER-related implications relevant to future workforce issues with specific emphasis for bridging the digital divide with minority, rural populations and consumers
    • Longer term implications of use of EHRs and PHRs in future Best Practices Decision-Support such as: Comparative Effectiveness Research and Personalized Medicine
    • Planting seeds for TIGER International roll-out
     
    Health Information Management Systems Society (HIMSS)
    HIMSS is a global, cause-based, not-for-profit organization focused on better health through information technology (IT). HIMSS leads efforts to optimize health engagements and care outcomes using information technology. HIMSS produces health IT thought leadership, education, events, market research and media services around the world.

    HIMSS encompasses more than 52,000 individuals, of which more than two-thirds work as a healthcare provider, or in governmental and not-for-profit organizations across the globe, plus over 600 corporations and 250 not-for-profit partner organizations share this cause. Stakeholder groups help HIMSS establish strategic direction and official positions on issues pertaining to the best use of IT and management systems for the betterment of healthcare.

    HIMSS provides a unique forum for its members to collaborate on programs and initiatives that contribute to the common good. They fund activities which enable individuals and groups to gain consensus on best/common practices, equip stakeholders with tools and resources to transform healthcare within a care setting, learn from each other and create positions. Examples include Integrating the Healthcare Enterprise (IHE), the Alliance for Nursing Informatics, senior IT executive community, the Annual Conference & Exhibition and the Latino Initiative.

    American Medical Informatics Association (AMIA)
    AMIA is the professional home of leading informaticians: clinicians, scientists, researchers, educators, students, and other informatics professionals who rely on data to connect people, information, and technology. It is the center of action for more than 4,000 health care professionals,informatics researchers, and thought-leaders in biomedicine, health care and science. AMIA is an unbiased, authoritative source within the informatics community and the health care industry. AMIA and its members are transforming healthcare through trusted science, education, and practice in biomedical and health informatics. AMIA supports Translational Bioinformatics, Clinical Research Informatics, Clinical Informatics, Consumer Health Informatics, and Public Health Informatics.

    Interagency Council on Information Resources in Nursing (ICIRN)
    ICIRN is a voluntary group made up of agencies and organizations concerned with providing library and informational resources for nursing and improving access to library services for all nurses. Each member organization appoints a representative and an alternate, usually a nurse or librarian, to serve on the Council. ICIRNs mission is to establish an effective system of information resources in nursing to advance the profession through the promotion and use of its literature.

    Updated September 2013.

  • How do I get a nursing informatics certification?

    The American Nurses Credentialing Center (ANCC)

    The largest and most prestigious nurse credentialing organization in the United States and a subsidiary of the ANA. They are trusted and committed to quality, nationally accredited and a true gauge of a nurse’s ability as an expert in their specialty. Once you have taken the exam and successfully passed, you are awarded the credentials: Registered Nurse-Board Certified (RN-BC). ANCC offers a variety of specialty certifications, but currently only one focused on nursing informatics.

    Eligibility Criteria:

    • Hold a current, active RN license within a state or territory of the United States
    • BSN or BS in “related field”
    • Practiced two (2) years full-time as an RN
    • Completed 30 continuing education hours in Informatics within the last three years
    • Meet one of the following practice hour requirements:
      • Practiced a minimum of 2,000 hours in informatics within the last 3 years
      • Practiced a minimum of 1,000 hours in informatics nursing in the last 3 years and completed a minimum of 12 semester hours of academic credit in informatics courses that are part of a graduate-level informatics nursing program
      • Completed a graduate program in informatics nursing containing a minimum of 200 hrs of faculty-supervised practicum in informatics nursing

    American Nurses’ Association Credentialing Center Board Certification in Nursing Informatics website.

    Healthcare Information and Management Systems Society (HIMSS) 

    A global, not-for-profit organization focused on better health through information technology (IT). HIMSS leads efforts to optimize health engagements and care outcomes using information technology. They equip stakeholders with the education, knowledge, tools and resources they need to transform healthcare where they work and live. HIMSS offer two health IT certification exams.

    The Certified Associate in Healthcare Information & Management (CAHIMS)

    A new HIMSS health IT certification designed for emerging professionals facilitating entry-level careers in health IT and management systems. It is designed to be a career pathway to the CPHIMS credential.

    Eligibility Criteria: 
    • Five (5) years or less work experience in health IT
    • Individuals looking to work in the healthcare setting or mid-level professional seeking change
    • Non-IT professional working in other departments, who work as an extension of the IT department
    • Those who want to learn more about health IT, including clinicians
    • Those enrolled in an academic program at the undergraduate or graduate level
    • Veterans returning to active duty
    Healthcare Information and Management Systems Society Heath IT Certifications

    The Certified Professional in Healthcare Information & Management Systems (CPHIMS)

    A professional certification program for healthcare professionals with proven expertise in healthcare information and management systems.

    Eligibility Criteria: 

    • BS plus five (5) years information and management system experience, three (3) of those years in healthcare
    • Graduate Degree plus three (3) years of associated information and management systems experience, two (2) of those years in healthcare

    Updated September 2013.

Instrument Cleaning

  • Should the scrub person wipe instruments with sterile water during the surgical procedure?

    During the procedure, the scrub person should remove gross soil from instruments by wiping the surfaces with a sterile surgical sponge moistened with sterile water. Saline should not be used to wipe instrument surfaces. Blood, organic material, debris, and saline are highly corrosive to instrument surfaces and can cause corrosion, rusting, and pitting when allowed to dry on surgical instruments. These materials can be difficult to remove from all surfaces during the cleaning and decontamination process, reducing the efficacy of the subsequent sterilization process.

    Periodically during the procedure, the scrub person should use sterile water to irrigate instruments with lumens. Irrigating instrument lumens periodically throughout a procedure removes gross soil and may reduce the risk of biofilm formation. Biofilm can form on many surfaces but is particularly problematic when it forms in lumens because it is difficult to see and remove.

    Resources:

    Guideline for cleaning and care of surgical instruments and powered equipment. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.
    AAMI TIR12: 2010 Designing, Testing, and Labeling Reusable Medical Devices for Reprocessing in Health Care Facilities: a Guide for Medical Device Manufacturers. Arlington, VA: Association for the Advancement of Medical Instrumentation; 2010.
    ANSI/AAMI ST79: Comprehensive Guide to Steam Sterilization and Sterility Assurance In Health Care Facilities. Arlington, VA: Association for the Advancement of Medical Instrumentation; 2013.
    Spry CC, Brooks Tighe SM. Care and handling of surgical instruments. In: Brooks Tighe S, ed. Instrumentation for the Operating Room: a Photographic Manual. 8th ed. St Louis, MO: Elsevier/Mosby; 2012:1-2.
    Root CW, Kaiser N, Antonucci C. What, how and why: enzymatic instrument cleaning products in healthcare environments. Healthc Purchasing News. 2008;32(11):50.

    Updated November 6, 2014

  • If an instrument is opened onto the sterile field, but not used, is it necessary to clean it in the same manner as instruments that have been used?

    All instruments opened onto the sterile field in the operating or procedure room should be cleaned and decontaminated whether or not they have been used. Airborne microorganisms may come in contact with instruments that have not been used. Scrubbed persons may touch and contaminate instruments without being aware of it. Instruments that were used may come in contact with unused items. Contamination of unused instruments on the sterile field can occur without the occurrence being noticed.

    Resources:

    Guideline for cleaning and care of surgical instruments and powered equipment. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.
    ANSI/AAMI ST79: Comprehensive Guide to Steam Sterilization and Sterility Assurance In Health Care Facilities. Arlington, VA: Association for the Advancement of Medical Instrumentation; 2013.
    Spry CC. Care and handling of basic surgical instruments. AORN J. 2007;86(Suppl 1):S77-S81.
    Spry CC, Brooks Tighe SM. Care and handling of surgical instruments. In: Brooks Tighe S, ed. Instrumentation for the Operating Room: a Photographic Manual. 8th ed. St Louis, MO: Elsevier/Mosby; 2012:1-2.

    Updated November 6, 2014

  • Does AORN have specific recommendations about the quality of water that should be used to clean and decontaminate surgical instruments?

    AORN recommends that the final rinse should be performed with treated (eg, distilled, reverse osmosis, filtered) water of a quality that will not stain or cause damage to instruments or contribute to recontamination of the instrument. Untreated water can contain contaminants, including endotoxins, which can be deposited on instruments during the final rinse. Rinsing with treated water can prevent deposits of impurities or contaminants on instruments. Endotoxins are heat stable and may not be destroyed by subsequent steam sterilization. Tissue contaminated with endotoxins can cause severe inflammation. Treated water can prevent spotting, stains, deposits, and corrosion on the surfaces of instruments.

    Resources:

    Guideline for cleaning and care of surgical instruments and powered equipment. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.
    ANSI/AAMI ST79: Comprehensive Guide to Steam Sterilization and Sterility Assurance In Health Care Facilities. Arlington, VA: Association for the Advancement of Medical Instrumentation; 2013.
    Alfa MJ, Olson N, Al-Fadhaly A. Cleaning efficacy of medical device washers in North American healthcare facilities. J Hosp Infect. 2010;74(2):168-177.
    AAMI TIR34:2007: Water for the Reprocessing of Medical Devices. Arlington, VA: Association for the Advancement of Medical Instrumentation; 2007.
    Proper Maintenance of Instruments. 8th ed. Morfelden-Walldorf, Germany: Arbeitskreis Instrumenten- Aufbereitung [Instrument Working Group]; 2004.

    Updated November 6, 2014

  • Does AORN have specific recommendations about the processes that should be used to clean ophthalmic instruments?

    Special precautions should be taken when processing intraocular ophthalmic instruments. Toxic anterior segment syndrome (TASS) is a complication of ophthalmic surgery involving a severe, noninfectious inflammation of the anterior segment of the eye, that requires thorough cleaning and rinsing of intraocular instruments and strict adherence to the manufacturer’s written IFU and to professional guidelines. Most instances of TASS appear to be related to errors in instrument processing. Adequate time, an adequate number of personnel, and sufficient instrument inventory should be provided to permit thorough instrument cleaning and sterilization in order to prevent TASS. For information on specific processes for cleaning ophthalmic instruments, the reader should refer to the AORN Guideline for cleaning and care of surgical instruments and powered equipment.

    Resources:

    Guideline for care and cleaning of surgical instruments and powered equipment. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.
    American Society of Cataract and Refractive Surgery, American Society of Ophthalmic Registered Nurses. Recommended practices for cleaning and sterilizing intraocular surgical instruments. J Cataract Refract Surg. 2007;33(6):1095-1100.
    Shunmugam M, Hugkulstone CE, Wong R, Williamson TH. Consecutive toxic anterior segment syndrome in combined phaco-vitrectomy. Int Ophthalmol. 2013;33(3):289-290.
    Tamashiro NS, Souza RQ, Goncalves CR, et al. Cytotoxicity of cannulas for ophthalmic surgery after cleaning and sterilization: evaluation of the use of enzymatic detergent to remove residual ophthalmic viscosurgical device material. J Cataract Refract Surg. 2013;39(6):937-941.
    Ozcelik ND, Eltutar K, Bilgin B. Toxic anterior segment syndrome after uncomplicated cataract surgery. Eur J Ophthalmol. 2010;20(1):106-114.
    Cutler Peck CM, Brubaker J, Clouser S, Danford C, Edelhauser HE, Mamalis N. Toxic anterior segment syndrome: common causes. J Cataract Refract Surg. 2010;36(7):1073-1080.
    Mamalis N. Toxic anterior segment syndrome update. J Cataract Refract Surg. 2010;36(7):1067-1068.
    Bodnar Z, Clouser S, Mamalis N. Toxic anterior segment syndrome: update on the most common causes. J Cataract Refract Surg. 2012;38(11):1902-1910.
    Mamalis N, Edelhauser HF, Dawson DG, Chew J, LeBoyer RM, Werner L. Toxic anterior segment syndrome. J Cataract Refract Surg. 2006;32(2):324-333.
    McCormick PJ, Kaiser JJ, Schoene MJ, et al. Ophthalmic viscoelastic devices as a cleaning challenge. Biomed Instrum Technol. 2013;47(4):347-355.
    Maier P, Birnbaum F, Bohringer D, Reinhard T. Toxic anterior segment syndrome following penetrating keratoplasty. Arch Ophthalmol. 2008;126(12):1677-1681.
    Mathys KC, Cohen KL, Bagnell CR. Identification of unknown intraocular material after cataract surgery: evaluation of a potential cause of toxic anterior segment syndrome. J Cataract Refract Surg. 2008;34(3):465-469.
    ANSI/AAMI ST79: Comprehensive Guide to Steam Sterilization and Sterility Assurance In Health Care Facilities. Arlington, VA: Association for the Advancement of Medical Instrumentation; 2013.

    Updated November 6, 2014

  • Does AORN have specific recommendations about the processes that should be used for cleaning and care of laryngoscope handles and blades?

    Laryngoscope blades are considered semicritical items (ie, items that contact mucus membranes or nonintact skin). They should be cleaned and high-level disinfected or sterilized after each use according to the manufacturer’s written IFU.

    The laryngoscope handle by itself is considered a noncritical device that contacts only intact skin and requires only low-level disinfection; however, the laryngoscope consists of two parts that are handled concurrently. When the laryngoscope blade is folded closed, the tip of the blade is in contact with the handle. Laryngoscope handles have a knurled surface that can accumulate bioburden. For this reason, laryngoscope handles should be cleaned and low-level disinfected after each use and may be high-level disinfected or sterilized according to the manufacturer’s written IFU.

    Cleaned and disinfected laryngoscope blades and handles should be packaged and stored in a manner that prevents contamination. Laryngoscope blades should be stored in individual packages.

    Resources:

    Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008. Atlanta, GA: Centers for Disease Control and Prevention; 2008.
    Tablan OC, Anderson LJ, Besser R, et al. Guidelines for preventing health-care–associated pneumonia, 2003: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR Recomm Rep. 2004;53(RR-3):1-36.
    Guideline for cleaning and care of surgical instruments and powered equipment. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.
    Negri de Sousa AC, Levy CE, Freitas MI. Laryngoscope blades and handles as sources of cross-infection: an integrative review. J Hosp Infect. 2013;83(4):269-275.
    Williams D, Dingley J, Jones C, Berry N. Contamination of laryngoscope handles. J Hosp Infect. 2010;74(2):123-128.
    Standards FAQs details: laryngoscopes — blades and handles — how to clean, disinfect and store these devices. The Joint Commission. Accessed October 27, 2014.

    Updated November 6, 2014

  • Does AORN have specific recommendations about the processes that should be used for cleaning and sterilizing instruments potentially contaminated with prions?

    Special precautions should be taken to minimize the risk of transmission of prion diseases from contaminated instruments. A multidisciplinary team should establish, document, and implement evidence-based policies and procedures to minimize the risk of prion disease transmission. Special precautions that may minimize the risk of transmission of prion diseases from contaminated instruments include:

    Using single-use surgical drapes, gowns, and supplies whenever possible and discarding them after use;

    Using single-use instruments, or if single-use instruments are not available

    Limiting the use of reusable instruments to those that are easy to clean and able to tolerate exposure to an extended steam sterilization cycle;

    Keeping the number of instruments used to a minimum;

    Decontaminating instruments in a mechanical washer as soon as possible after use;

    Using cleaning chemicals that have evidence of prionicidal activity and that are compatible with the instruments to be cleaned;

    Note: Some cleaning formulas have demonstrated an ability to remove and inactivate prions; however, it has also been shown that some cleaning agents may increase the resistance of prions to subsequent steam sterilization.
     
    Using one of the following three methods to steam sterilize instruments after decontamination

    Prevacuum sterilizer: 273o F (134o C) for 18 minutes,
    Gravity displacement sterilizer: 270o F (132o C) for 60 minutes, or
    Immerse in 1 N NaOH (sodium hydroxide [lye]) for 60 minutes, then remove, rinse in water, and sterilize using one of the cycles noted above; and
     
    Cleaning environmental surfaces and then spot decontaminating with a 1:5 or 1:10 dilution of sodium hypochlorite (bleach) or sodium hydroxide for a contact time of 15 minutes.

    For information on specific processes for cleaning instruments potentially contaminated with prions, the reader should refer to the AORN “Guideline for cleaning and care of surgical instruments and powered equipment.”

    Resources:

    Guideline for cleaning and care of surgical instruments and powered equipment. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.
    McDonnell G. Prion disease transmission: can we apply standard precautions to prevent or reduce risks? J Perioper Pract. 2008;18(7):98-304.
    Rutala WA, Weber DJ. Guideline for disinfection and sterilization of prion-contaminated medical instruments. Infect Control Hosp Epidemiol. 2010;31(2):107- 117.
    McDonnell G, Dehen C, Perrin A, et al. Cleaning, disinfection and sterilization of surface prion contamination. J Hosp Infect. 2013;85(4):268-273.
    Fichet G, Comoy E, Duval C, et al. Novel methods for disinfection of prion-contaminated medical devices. Lancet. 2004;364(9433):521-526.
    Lehmann S, Pastore M, Rogez-Kreuz C, et al. New hospital disinfection processes for both conventional and prion infectious agents compatible with thermosensitive medical equipment. J Hosp Infect. 2009;72(4):342-350.

    Updated November 6, 2014

Medication Management

  • How should medications on the sterile field be labeled?

    The medication label should state (at a minimum) the following, in accordance with the health care organization's policy:

    Medication name,
    Strength, and
    Concentration

    Resources:

    Recommended practices for medication safety. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:255-294.
    2013 National Patient Safety Goals. The Joint Commission. http://www.jointcommission.org/patientsafety/nationalpatientsafetygoals/. Accessed December 7, 2012.

    Updated January 28, 2013

  • Does a medication that is immediately administered to a patient (eg, pain medication) require labeling?

    No. An immediately administered medication that is prepared or obtained, taken directly to a patient, and administered to a patient without any break in the process by the same person does not require labeling.

    Resources:

    Recommended practices for medication safety. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:255-294.
    2013 National Patient Safety Goals. The Joint Commission. http://www.jointcommission.org/patientsafety/nationalpatientsafetygoals/. Accessed December 7, 2012.

    Updated January 28, 2013

  • Has propofol been classified as a controlled substance?

    Presently, propofol has not been classified as a controlled substance despite concerns regarding drug diversion and supply shortages. The American Society of Anesthesiologists (ASA) sent a letter to the Drug Enforcement Agency (DEA) in December 2010 supporting the scheduling of propofol as schedule IV. As of December 2012, propofol is not scheduled under the Controlled Substances Act, although it is listed as "Drugs and Chemicals of Concern".

    Resources:

    ASA submits letter to DEA supporting the scheduling of Propofol. American Society of Anesthesiologists (ASA). December 23, 2010. http://www.asahq.org/For-Members/Advocacy/Washington-Alerts/ASA-Submits-to-DEA-Supporting-the-Scheduling-of-Propofol.aspx. Accessed December 7, 2012.
    Drugs and Chemicals of Concern: Propofol (Diprivan). Drug Enforcement Agency (DEA). January 2010. http://www.deadiversion.usdoj.gov/drugs_concern/propofol.htm. Accessed December 7, 2012.

    Updated January 28, 2013

  • Who should fill pain pumps: the pharmacist or scrub personnel at the sterile field?

    Pain pump reservoirs should be filled by a pharmacist with exception of urgent situations.Personnel filling a pain pump with medication should follow the manufacturer’s instructions for use, local, state, and federal regulations, and United States Pharmacopeia (USP) chapter <797>. The reservoir should be filled in a sterile environment such as under a laminar airflow hood.

    Resources:

    Van Wicklin, SA. Filling pain pump reservoirs. [Clinical Issues]. AORN Journal.2012;96(5):547-549.

    Updated January 28, 2013

Moderate Sedation

  • May the RN circulate while administering medications and monitoring the patient receiving moderate sedation/analgesia?
    No, the perioperative RN may not circulate and provide moderate sedation/analgesia simultaneously. At a minimum two perioperative RNs should care for the patient who is receiving moderate sedation/analgesia provided by the perioperative RN. The responsibilities of one RN is to monitor the patient, administer the sedation and analgesia medications, and continuously care for the patient throughout the procedure. The second RN is the circulator.

    Resource:

    • Guideline for care of the patient receiving moderate sedation/analgesia. In: Guidelines for perioperative practice. Denver, CO: AORN.
    Updated December 8, 2015
  • What parameters need to be monitored and documented intraoperatively when the patient is receiving moderate sedation/analgesia??

    Intraoperative patient monitoring and documentation should include 

    • cardiac rate and rhythm, 
    • blood pressure, 
    • respiratory rate, 
    • SpO2 by pulse oximetry, 
    • end-tidal CO2 by capnography, 
    • depth of sedation assessment,
    • pain level, 
    • anxiety level, and 
    • level of consciousness.
    Resource:
    • Guideline for care of the patient receiving moderate sedation/analgesia. In: Guidelines for perioperative practice. Denver, CO: AORN.
    Updated December 8, 2015
  • When caring for the patient receiving moderate sedation/analgesia, is capnography necessary if SpO2 is monitored with pulse oximetry?
    Yes, the perioperative RN should monitor exhaled CO2 (ie, end-tidal CO2 [EtCO2]) by capnography in addition to SpO2 by pulse oximetry during moderate sedation/analgesia procedures. Also, the perioperative RN should continuously observe the adequacy of the patient’s ventilation. Monitoring the patient’s EtCO2, SpO2, and performing visual assessments completes the cycle of respiratory monitoring of oxygenation and ventilation of patients undergoing moderate sedation/analgesia.

    Resources:

    • Guideline for care of the patient receiving moderate sedation/analgesia. In: Guidelines for perioperative practice. Denver, CO: AORN.
    • Standards for basic anesthetic monitoring. In: ASA’s Standards, Guidelines, and Statements. Park Ridge, IL: American Society of Anesthesiologists; 2015. http://www.asahq.org/quality-and-practice-management/standards-and-guidelines. Accessed December 7, 2015.
    • Cacho G, Perez-Calle JL, Barbado A, Lledo JL, Ojea R, Fernandez-Rodriguez CM. Capnography is superior to pulse oximetry for the detection of respiratory depression during colonoscopy. Rev Esp Enferm Dig. 2010;102(2): 86-89.
    Updated December 8, 2015
  • Does AORN recommend screening patients for obstructive sleep apnea if they are scheduled to have a procedure with moderate sedation?
    Yes, the perioperative RN administering moderate sedation/analgesia should assess the patient’s airway preoperatively for the risk of obstructive sleep apnea (OSA). The undiagnosed range of moderate to severe OSA is estimated at 82% for men and 92% for women. Surgical patients have a reported higher incidence than the general population. The number of patients with OSA is likely to increase as the population ages and becomes more obese.

    Resources:
    • Guideline for care of the patient receiving moderate sedation/analgesia. In: Guidelines for perioperative practice. Denver, CO: AORN.
    • Gross JB, Bachenberg KL, Benumof JL, et al. Practice guidelines for the perioperative management of patients with obstructive sleep apnea: a report by the American Society of Anesthesiologists Task Force on Perioperative Management of patients with obstructive sleep apnea. Anesthesiology. 2006; 104(5): 1081-93; quiz 1117-8. 
    • Joshi GP, Ankichetty SP, Gan TJ, Chung F. Society for Ambulatory Anesthesia consensus statement on preoperative selection of adult patients with obstructive sleep apnea scheduled for ambulatory surgery. Anesthesia & Analgesia. 2012; 115(5): 1060-1068. 
    • Chung F, Elsaid H. Screening for obstructive sleep apnea before surgery: why is it important? CURR OPIN ANESTHESIOL. 2009; 22(3): 405-411.
    Updated December 8, 2015
  • How should the patient be assessed and screened for obstructive sleep apnea?
    The perioperative RN should use a screening tool to assess the patient for obstructive sleep apnea (OSA). Obstructive sleep apnea screening tools are useful to classify patients based on clinical symptoms and risk factors to determine high-risk patients who may need a referral to a higher level of care (eg, an anesthesia professional) or additional diagnostic testing (ie, polysomnography). Typical questions in the screening tools include body mass index, neck size, age, sex, hypertension, loud snoring, apnea during sleep, and tiredness during the day.

    Resources:

    • Guideline for care of the patient receiving moderate sedation/analgesia. In: Guidelines for perioperative practice. Denver, CO: AORN.
    • Abrishami A, Khajehdehi A, Chung F. A systematic review of screening questionnaires for obstructive sleep apnea. Canadian Journal of Anaesthesia. 2010; 57(5): 423-438. 
    Updated December 8, 2015
  • Why is it necessary to know if a patient has obstructive sleep apnea?
    Preoperative awareness of a patient with obstructive sleep apnea (OSA) is important as the patient may experience complications associated with their OSA during perioperative care. Complications include cardiac dysrhythmias (eg, bradycardia, atrial fibrillation, premature ventricular contractions), myocardial infarction, severe oxygen desaturation, episodic hypoxemia, hypercapnia, respiratory arrest, airway obstruction, hypoventilation, unplanned intensive care unit admission, impaired arousal from sedation, and sudden death. Moderate sedation medications that affect the central nervous system may interfere with the normal respiratory compensatory mechanisms of hypoxemia and hypercarbia, and depressant medications may facilitate pharyngeal collapse in patients with OSA.

    Resources:

    • Guideline for care of the patient receiving moderate sedation/analgesia. In: Guidelines for perioperative practice. Denver, CO: AORN.
    • Abrishami A, Khajehdehi A, Chung F. A systematic review of screening questionnaires for obstructive sleep apnea. Canadian Journal of Anaesthesia. 2010; 57(5): 423-438. 

    Updated December 8, 2015
  • What is a brief, interruptible task?
    Examples of brief interruptible tasks are tying a sterile gown and opening supplies (eg, suture packet, lap sponges) that are within the room when the circulator is unavailable. The perioperative RN providing moderate sedation/analgesia may perform these ancillary, brief, interruptible, patient related tasks to assist the perioperative team while remaining inside the room. If the patient is receiving propofol for moderate sedation/analgesia, the RN providing the moderate sedation/analgesia should not perform short, interruptible tasks.

    Resource:
    • Guideline for care of the patient receiving moderate sedation/analgesia. In: Guidelines for perioperative practice. Denver, CO: AORN.
    Updated December 8, 2015
  • May the RN monitoring the patient receiving moderate sedation/analgesia leave the room at any time?
    The perioperative RN providing moderate sedation/analgesia should not leave the room. The RN should be in constant attendance with unrestricted immediate visual and physical access to the patient.

    Resource:

    • Guideline for care of the patient receiving moderate sedation/analgesia. In: Guidelines for perioperative practice. Denver, CO: AORN.
    Updated December 8, 2015

Patient Skin Antisepsis

  • Which antiseptic should be used for vaginal antisepsis?

    The collective evidence indicates that povidone-iodine is commonly used for vaginal antisepsis in gynecological procedures.

    Resources:

    Guideline for preoperative patient skin antisepsis. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

    Updated November 6, 2014

  • Should Chlorhexidine (CHG)-impregnated cloths be used for preoperative bathing?

    There is a growing body of evidence supporting the use of 2% CHG-impregnated cloth products for preoperative bathing. CHG-impregnated cloths may increase the amount of CHG on the skin at the surgical site, which could enhance the activity and residual effect of CHG. Based on the collective evidence, this practice remains an unresolved issue and warrants additional generalizable, high-quality research to confirm the benefit of CHG-impregnated cloths for prevention of surgical site infection.

    Resources:

    Guideline for preoperative patient skin antisepsis. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

    Updated November 6, 2014

  • Our organization’s protocol for preoperative skin antisepsis is to use an alcohol-based antiseptic, but the dry time for the antiseptic in hair is 60 minutes which is not feasible. This conflicts with our protocol not to remove hair at the surgical site. Should we use an alcohol-based antiseptic or remove the hair at the surgical site?

    When using an alcohol-based skin antiseptic for procedures involving an ignition source (eg, electrosurgery, laser), hair at the surgical site should be clipped before application of the antiseptic. Hair removal at the surgical site should be performed only in select clinical situations, such as when the presence of hair may contraindicate the use of flammable antiseptics (eg, alcohol-based) according to manufacturer's instructions for use.

    There was no evidence found that describes the length or amount of hair that constitutes a fire risk when using alcohol-based skin antiseptics. When hair removal is necessary, clipping the hair may be associated with a lower risk of developing an SSI than hair removal with a razor

    Resources:

    Guideline for preoperative patient skin antisepsis. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

    Updated November 6, 2014

  • Should sterile gloves be worn when performing preoperative patient skin antisepsis?

    Sterile gloves should be worn when performing preoperative patient skin antisepsis. Nonsterile gloves may be worn if the antiseptic applicator is of sufficient length to prevent contact of the gloved hand with the antiseptic solution and the patient’s skin.

    Resources:

    Guideline for preoperative patient skin antisepsis. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

    Updated November 6, 2014

  • What protective measures should I take to prevent prolonged patient contact with skin antiseptics?

    Sheets, padding, positioning equipment, and adhesive tape should be protected from the dripping or pooling of skin antiseptics beneath and around the patient.

    Electrodes (eg, electrocardiogram [ECG], electrosurgical unit [ESU] dispersive electrode) and tourniquets should be protected from contact with skin antiseptics.

    A fluid-resistant pad should be placed under the patient's buttocks during preoperative patient skin antisepsis for patients in the lithotomy position. The pad should be removed after the antiseptic is dry and before sterile drapes are applied.

    Any material near the patient that is in contact with the skin antiseptic solution, including electrodes (eg, ECG, ESU) and tourniquet materials (ie, cuff, padding) should be removed and replaced, as necessary.

    Resources:

    Guideline for preoperative patient skin antisepsis. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

    Updated November 6, 2014

  • Is it necessary to wear long sleeves when performing preoperative patient skin antisepsis?

    Yes, the arms should be covered by surgical attire when performing preoperative patient skin antisepsis. The recommendation for nonscrubbed perioperative personnel to wear long-sleeves has been a part of the AORN “Recommended practices for surgical attire” since 1994. Wearing long-sleeved attire helps contain skin squames shed from bare arms. If the RN circulator performs the preoperative skin antisepsis without wearing a long-sleeved jacket, skin squames from his or her bare arms may drop onto the area that is being prepped and may increase the patient’s risk for a surgical site infection.

    Resources:

    Guideline for preoperative patient skin antisepsis. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

    Updated November 6, 2014

  • Is it necessary to remove nail polish or artificial nails when performing preoperative patient skin antisepsis on a patient having hand or foot surgery?

    Nails on the operative extremity should be clean and natural without artificial nail surfaces or polish. The evidence review for this recommended practices document found no cases of patient incision-site contamination related to wearing artificial nails or nail polish on the operative hand and foot. In two separate studies, researchers found that the amount of potentially pathogenic bacteria cultured from the fingertips of health care personnel wearing artificial nails was greater than for those with natural nails, both before and after hand washing. Artificial nail surfaces or polish may harbor microorganisms, which could contaminate the surgical site or reduce the effectiveness of preoperative patient skin antisepsis.

    Resources:

    Guideline for preoperative patient skin antisepsis. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc

    Updated November 6, 2014

  • Is it acceptable to dilute the skin antiseptic solution when performing preoperative patient skin antisepsis?

    In a drug safety communication, the FDA recommended that health care professionals do not dilute antiseptic products after opening them to reduce the possibility of these products becoming contaminated. Skin antiseptics should be applied according to the manufacturer’s instructions for use. Antiseptic manufacturers’ instructions for use convey important safety and efficacy instructions to the user.

    Skin antiseptics are designed and tested by the manufacturer to provide the safest and most effective reduction of skin microbes at specific concentrations. Diluting antiseptic solutions and failing to adhere to the manufacturer’s instructions for use may result in patient harm or ineffectiveness of preoperative patient skin antisepsis.

    Resources:

    Guideline for preoperative patient skin antisepsis. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.
    Over-the-counter topical antiseptic products: drug safety communication—FDA requests label changes and single-use packaging to decrease risk of infection. FDA.gov

    Updated November 6, 2014

  • Is it acceptable to use multi-use containers of skin antiseptic solution when performing preoperative patient skin antisepsis?

    In November 2013, the FDA issued a Drug Safety Communication requesting that manufacturers’ package antiseptics indicated for preoperative skin preparation in single-use containers to reduce the risk of infection from improper antiseptic use and contamination of products during use. In several case reports and non-experimental studies, contaminated skin antiseptics have been linked to patient infections. Skin antiseptics should be purchased in single-use containers, discarded after use (one patient, one time), and not refilled.

    Resources:

    Guideline for preoperative patient skin antisepsis. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.
    Over-the-counter topical antiseptic products: drug safety communication—FDA requests label changes and single-use packaging to decrease risk of infection. FDA.gov

    Updated November 6, 2014

  • Are there special methods that should be used when performing preoperative patient skin antisepsis of the hand or foot?

    When performing preoperative patient skin antisepsis of the hand or foot, perioperative team members should take care to apply the antiseptic to all surfaces between fingers or toes. Antisepsis may be difficult in the areas between the fingers and toes due to reaching all surfaces of the skin.

    In a randomized controlled trial of 50 patients undergoing foot surgery, researchers reported a significant reduction in bacterial recolonization of the foot with additional cleaning of the area between the toes. International studies from England, Australia, and New Zealand describe a novel technique for skin antisepsis of the hand or foot that involves using a sterile bag. Researchers have found the bag technique to be effective in reducing bacterial counts and application time. One researcher reported reducing musculoskeletal injury as an additional benefit of the bag technique.

    Resources:

    Guideline for preoperative patient skin antisepsis. In: Guidelines for Perioperative Practice, Denver, CO: AORN, Inc.

    Updated November 6, 2014

  • Why do we remove cosmetics before the preoperative skin prep?

    Cosmetics may contribute to increased soil and contamination and impede the effectiveness of the antiseptic agent. The removal of facial cosmetics also may be indicated to prevent debris from irritating the eyes, to facilitate securing the endotracheal tube, or for other reasons identified by the surgical team.

    Resources:

    Guideline for preoperative patient skin antisepsis. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

    Updated November 6, 2014

  • What precautions should providers take when removing hair at the surgical site?

    If the presence of hair will interfere with the surgical procedure and removal is in the best interest of the patient, the provider should take the following precautions:

    Hair removal should be performed the day of the surgery, in a location outside the operating or procedure room.

    Only hair interfering with the surgical procedure should be removed.

    Hair should be clipped using a single-use electric or battery-operated clipper.

    Resources:

    Guideline for preoperative patient skin antisepsis. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

    Updated November 6, 2014

  • How can I minimize the fire risk when using flammable patient skin antiseptic products?

    Because the potential for a fire exists in the presence of the triad of oxygen; energy sources (eg, electrosurgical units, lasers, light cords); and alcohol, it is critical that perioperative personnel receive education on the flammability of certain antiseptic products. In addition, the following interventions relating to the use of prep antiseptic products can minimize the fire risk in the OR:

    Allow sufficient drying time, including time for the vapors to dissipate, before applying surgical drapes, using a potential ignition source.

    Flammable skin antiseptics should be prevented from pooling or soaking into linens or the patient’s hair.

    Communicate use of flammable skin antiseptics as part of the fire risk assessment involving the entire perioperative team before beginning a surgical procedure.

    Resources:

    Guideline for preoperative patient skin antisepsis. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.
    Guideline for a safe environment of care. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.
    AORN Fire Safety Tool Kit. AORN, Inc.

    Updated November 6, 2014

  • Which patient skin antiseptic products are flammable?

    Alcohol-based antiseptics are rated as flammable patient antiseptic products. It is important to note, however, that chlorhexidine gluconate and providone-iodine without alcohol are not flammable but may be combustible. The National Fire Protection Association (NFPA) defines flammable as having a flash point below 100 degrees Fahrenheit. Those products with a flash point above 100°F are considered to be combustible. The flash point for all manufactured products can be found on the SDS sheets.

    Resources:

    Guideline for preoperative patient skin antisepsis. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.
    Guideline for a safe environment of care. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.
    National Fire Protection Association. NFPA 30: Flammable and Combustable Liquids Code. 2008 ed. Quincy, MA: National Fire Protection Association; 2008.
    AORN Fire Safety Tool Kit. AORN, Inc.
    Surgical fire prevention. ERCI Institute.

    Updated November 6, 2014

  • For a procedure that involves the genitalia, should a urinary catheter be inserted before or after preoperative patient skin antisepsis?

    When the surgical area involves the genitalia and the patient requires a urinary catheter, the nurse should insert the catheter after performing the preoperative patient skin antisepsis.

    Resources:

    Burlingame, BB. Perineal preps and urinary catheter insertion. [Clinical Issues]. AORN Journal. 2011;94(1):100.

    Updated November 6, 2014

Radiologic X-ray Exposure

  • Are there standard regulations regarding radiation dose monitoring (i.e. wearing radiation badges or dosimeters)?

    Answer:

    Federal regulations as stated below should be followed unless the state regulations are more restrictive. Current federal regulations states monitors must be worn by people who meet the following criteria:

    1.Adults likely to receive, in 1 year from sources external to the body, a dose in excess of 10 percent of the limits in § 20.1201(a), 
    2.Minors likely to receive, in 1 year, from radiation sources external to the body, a deep dose equivalent in excess of 0.1 rem (1 mSv), a lens dose equivalent in excess of 0.15 rem (1.5 mSv), or a shallow dose equivalent to the skin or to the extremities in excess of 0.5 rem (5 mSv); 
    3.Declared pregnant women likely to receive during the entire pregnancy, from radiation sources external to the body, a deep dose equivalent in excess of 0.1 rem (1 mSv); and 
    4.Individuals entering a high or very high radiation area.229 (p359-360)  


    Resources:

    •10 CFR 30.41 Transfer of byproduct material. CFR. 2013;10. 
    •Guideline for Radiation Safety. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc. 


    Updated April 20, 2015

  • What precautions should a pregnant female take when working with radiation?

    Answer:

    The pregnant female should follow all the standard radiation safety precautions including maintaining the greatest distance between her and the radiation source possible (eg, at least 6 feet), use of protective shielding and decreasing the amount of time spent near the source to the lowest amount possible. She should also wear an apron that is large enough to cover the entire abdominal area and preferably a wraparound apron to ensure coverage of the back in case she turns away from the radiation source. The pregnant female may safely perform procedures which involve radiation if these precautions are followed.

    Resource:

    Guideline for Radiation Safety. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.


  • If I am pregnant do I need to report it to my employer?

    Answer:

    Reporting is not required by the law, but it enables the employer to assist the pregnant person in determining the dose of radiation received during the pregnancy. The pregnant female may report her condition to the person in charge of radiation safety such as the radiation safety officer or the designated equivalent to this person.

    Resources:

    10 CFR 20 Standards for Protection Against Radiation. Code of Federal Regulations. 2013;10. 
    Guideline for Radiation Safety. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.


  • Do I need to wear leaded eye glasses?

    Answer:

    Some form of eye protection (ie, leaded eyeglasses with wraparound side shields, ceiling-suspended shields, clear mobile shields that are taller than the person using them) should be used if the person is near the source of the radiation beam.

    Resource:

    Guideline for Radiation Safety. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.


Sharps Safety

  • Why should health care practitioners double-glove during invasive procedures?

    Answer:

    Recommendation IV.1. of the AORN Recommended Practices for Prevention of Transmissible Infections in the Perioperative Practice Setting states: Health care practitioners should wear two pairs of gloves, one over the other, during invasive procedures. A systematic review of 18 clinical trials of gloving practices clearly demonstrates that double-gloving minimizes the risk of exposure of health care works to blood during invasive procedures. Meta-analyses of nine of these studies demonstrate the following:

    •Perforation rates of the glove closest to the skin are significantly less when wearing double gloves compared to single gloves (P<0.00001).

    •Perforation rates are no different when wearing single gloves compared to the outer glove when two pairs of gloves are worn (P = 0.3).

    •More glove perforations are detected when using a colored under-glove indicator system when compared to two pairs of standard latex gloves (P = 0.002).

    Resources:

    Recommended Practices for Prevention of Transmissible Infections in the Perioperative Practice Setting, 2011 Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2011: 293. For references, refer to the original text. 

    Updated July 7, 2011

  • When I double-glove, I lose dexterity, what can I do?

    Answer:

    Ensure that your double gloves are fitted properly. Acquiring dexterity may be a matter of getting used to the sensation of having two gloves on.

    Resources:

    Ramon Berguer, MD, FACS

    Updated March 17, 2014 

  • How can we convince our scrub persons to use the neutral or hands-free zone when passing sharps?

    Answer:

    Education is the key to success for compliance with the use of a neutral zone. Experienced scrub persons can have a false sense of security regarding sharps handling. They may be more comfortable handling the sharp than using a neutral zone. Encouraging them to use basins, mats, or an identified place on the mayo may help ease their anxiety about using a neutral zone.

    Resources:

    Ramon Berguer, MD, FACS

    Updated March 17, 2014 

  • How can we get our scrub persons to use blade removal devices?

    Answer:

    It will help to provide documentation and education on the blade removal system in use at your facility, and have the device on hand for the surgical technologists to practice with prior to use in the OR. Once they get the feel for the device they will most likely feel more comfortable using it.

    Resources:

    Sheri Alexander, CST

    Updated March 17, 2014


  • How do we convince our scrub persons to double-glove?

    Answer:

    Provide documentation and education on the safety of double gloving. Often people new to double gloving will attempt to use two of the same sized pairs of gloves and in most cases this will not work. Encourage scrubbed personnel to try several combinations of glove sizes until they find the combination that feels the most natural.

    Resources:

    Sheri Alexander, CST

    Updated March 17, 2014 



  • How can we get our surgeons to use the neutral or hands-free zone when passing sharps?

    Answer:

    An OR sharps safety policy and procedure should be developed, implemented, and enforced to protect the safety of OR staff members and surgeons. The neutral or hands-free zone is an integral part of sharps safety. Including surgeons in the education about and implementation of its use is important. This technique takes time to develop and adapt to each institution and procedure. A few implementation tips include using a long basin that accommodates long needle holders; placing only one sharp in the basin at a time; using a separate basin for the local anesthesia medication syringe. The policy should identify the cases where it cannot be used or where a partial technique (eg, direct handoff to surgeon, instrument returns to neutral zone) must be

    Resources:

    Ramon Berguer, MD, FACS 

    Updated March 17, 2014  

  • How can we convince our surgeons to try the newer safety scalpels and sheathed scalpels?

    Answer:

    Using newer-generation scalpels that are better designed and more naturally weighted on a trial basis to determine which will work best for your facility may help. An OR sharps safety policy and procedure should be developed, implemented, and enforced to protect the safety of OR staff members and surgeons based on the Occupational Safety and Health Administration (OSHA) requirements. The OSHA's bloodborne pathogens standard requires that employers use engineering and work practice controls to eliminate occupational exposure or reduce it to the lowest feasible extent. One type of engineering control is using a sharp with engineered sharps injury protection (SESIP) (eg, sheathed scalpel). Where feasible, hospitals must implement.

    Resources:

    Ramon Berguer, MD, FACS

    Updated March 17, 2014 

  • How can you convince surgeons to try blunt suture needles for closing fascia?

    Answer:

    Provide a selection of #0 and #1 sutures in blunt needle sizes that are comparable to previously used sharp needle suture for fascial closure. Update preference cards and list blunt needles first on every card. Your suture company representative can assist with advice and provide charts listing comparable needle sizes. Use blunt suture needles only for fascial closure, and allow surgeons to use the suture needle of choice for procedures where the patients fascia is thickened form repeat surgeries. Identify a surgeon at your facility who uses blunt needles and who can champion the cause. An OR sharps safety policy and procedure should be developed, implemented, and enforced to protect the safety of the OR staff members and surgeons based on OSHA requirements.

    Resources:

    Ramon Berguer, MD, FACS

    Updated March 17, 2014 

  • How do you create a neutral zone on ophthalmology and microsurgery procedures?

    Answer:

    Ophthalmology and microsurgery procedures present unique challenges to creating a neutral zone because the surgeon must view the surgical site through a microscope. A partial technique (eg, direct handoff to surgeon, instrument returns to neutral zone) can be used on microsurgery procedures. Using this technique, the scrub nurse can place the instrument in the surgeon’s hand and alert him or her verbally as the sharp is being passed. A neutral zone can be established on the surgical field or Mayo stand for the surgeon to deposit the used sharp.

    Resources:

    Ramon Berguer, MD, FACS

    Updated March 17, 2014 

  • Do you always need a specially purchased container to establish a hands free zone?

    Answer:

    A specially purchased device is not needed to establish hands-free zone. Magnetic mats, basins, or a designated area on the Mayo stand are examples of ways to create a hands free or “neutral zone.” Use of a towel may be an acceptable hands-free technique if it can be placed on a flat surface. The neutral zone should be easily accessible to the involved team members and an area that assures that a sharp item does not slide off the sterile field.

    Resources:

    Ramon Berguer, MD, FACS

    Updated March 17, 2014 

  • How do you obtain a comfortable fit when you double-glove?

    Answer:

    Experiment with different combinations and sizes of gloves to find a comfortable fit. One method does not work for everyone. Possible double-gloving combinations are wearing a half-size larger glove as the underglove and the user’s usual size as the outer glove, wearing two similarly sized gloves, and wearing an outer glove that is a half size larger.

    Resources:

    Ramon Berguer, MD, FACS

    Updated March 17, 2014

  • Do you have to use an indicator under glove when you double-glove?

    Answer:

    An indicator underglove is not required when double gloving. Studies have shown, however, that punctures are detected more often with an indicator under glove. When wearing a perforation indicator system, 77% of punctures were detected compared to 21% when wearing standard double gloves.1 Punctures are more apparent in the outer glove, which allows team members to see the indication of a punctured glove and replace it in a timely manner.

    Resources:

    Ramon Berguer, MD, FACS
     
    Tanner J, Parkinson H. Double gloving to reduce surgical cross-infection. Cochrane Database Syst Rev. 2009;3:CD003087

    Updated March 17, 2014 

  • When I double glove my fingers fall asleep, what can I do to prevent that?

    Answer:

    This may be happening because you are wearing an underglove that is too tight. Try varying combinations of under and outer glove sizes such as wearing a larger size as the underglove and a glove that is your actual glove size as the outer glove.

    Resources:

    Ramon Berguer, MD, FACS

    Updated March 17, 2014 

Specimens

  • How is the disposition of surgical specimens determined? Is there a listing of specimens that do not require examination by a pathologist?

    Answer:

    Policies for the disposition of surgical specimens should be established by a multidisciplinary team including representatives of the pathology laboratory, facility or health care organization physicians, and perioperative registered nurses in accordance with local, state, and federal regulations. The College of American Pathologists (CAP) recommends that each facility or health care organization develop a written policy that lists which specimens are exempt from pathology examination, and which specimens should be submitted for gross examination but are exempt from microscopic examination. The CAP suggests that certain specimens may be exempt from submission to the pathologist for examination, provided there is a procedure for documenting their removal and disposition and that certain specimens be submitted for gross examination only, with exceptions at the pathologist’s discretion.

    Resources:

    •Policy on surgical specimens to be submitted to pathology for examination. Appendix M. 2007. College of American Pathologists. Accessed October 27, 2014.
    •Royal College of Pathologists. Histopathology and Cytopathology of Limited or No Clinical Value. 2nd ed. London, England: Royal College of Pathologists; 2005.
    •Guideline for specimen management. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.


    Updated November 6, 2014

  • Does AORN have specific recommendations for managing breast cancer specimens?

    Answer:

    The AORN “Guideline for specimen management” has two recommendations related to managing breast cancer specimens.

    •The first recommendation is that the time of excision, and the time of fixation should be documented.

    •The second recommendation is that the time from excision to fixation should be less than one hour.

    Long delays between excision and fixation of the specimen may result in a decreased ability to detect breast biomarkers in samples. Accurate recording of times can be helpful for verification that the testing was performed during a period of time when the biomarkers were stable.


    Resources:

    •Guideline for specimen management. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.
    •Hammond ME, Hayes DF, Dowsett M, et al. American Society of Clinical Oncology/College of American Pathologists guideline recommendations for immunohistochemical testing of estrogen and progesterone receptors in breast cancer. J Clin Oncol. 2010; 28(16):2784-2795.
    •Wolff AC, Hammond ME, Schwartz JN, et al. American Society of Clinical Oncology/College of American Pathologists guideline recommendations for human epidermal growth factor receptor 2 testing in breast cancer. Arch Pathol Lab Med. 2007;131(1):18-43. 
    •Wolff AC, Hammond ME, Hicks DG, et al. Recommendations for human epidermal growth factor receptor 2 testing in breast cancer: American Society of Clinical Oncology/College of American Pathologists clinical practice guideline update. Arch Pathol Lab Med. 2014;138(2):241-256. 
    •Yaziji H, Taylor CR, Goldstein NS, et al. Consensus recommendations on estrogen receptor testing in breast cancer by immunohistochemistry. Appl Immunohistochem Mol Morphol. 2008;16(6):513-520. 
    •Hewitt SM, Lewis FA, Cao Y, et al. Tissue handling and specimen preparation in surgical pathology: issues concerning the recovery of nucleic acids from formalin-fixed, paraffin-embedded tissue. Arch Pathol Lab Med. 2008;132(12):1929-1935.
    •Hicks DG, Boyce BF. The challenge and importance of standardizing pre-analytical variables in surgical pathology specimens for clinical care and translational research. Biotechnic Histochem. 2012;87(1):14-17.


    Updated November 6, 2014

  • Does AORN have specific recommendations for preoperative management of amputated digits and limbs?

    Answer:

    Amputated digits and limbs to be reimplanted should be collected and handled in a manner to protect and preserve the integrity of the specimen and the potential for replantation survival. Amputated digits and limbs should be cooled to help to preserve the tissue and increase the chance of replantation survival. The digit or limb should be handled gently to avoid crushing tissue. It should be wrapped in sponges moistened with saline, placed in a plastic bag, and then placed in another bag or chest filled with ice. This allows for cooling of the digit or limb, prevents direct contact with ice, and helps minimize cell damage that may hinder successful replantation.

    Resources:

    •Guideline for specimen management. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc. 
    •Li J, Guo Z, Zhu Q, et al. Fingertip replantation: determinants of survival. Plast Reconstr Surg. 2008;122(3):833- 839. 
    •Partlin MM, Chen J, Holdgate A. The preoperative preservation of amputated digits: an assessment of proposed methods. J Trauma. 2008;65(1):127-131. 
    •Allen DM, Levin LS. Digital replantation including postoperative care. Tech Hand Up Extrem Surg. 2002; 6(4):171-177. 
    •Lloyd MS, Teo TC, Pickford MA, Arnstein PM. Preoperative management of the amputated limb. Emerg Med J. 2005;22(7):478-480.


    Updated November 6, 2014 


  • How should explanted medical device specimens be handled?

    Answer:

    Explanted medical devices should be collected and handled according to the health care organization’s policies and procedures; manufacturers’ instructions; and local, state, and federal regulations. Hospitals and other health care facilities that implant medical devices are considered final distributors. Final distributors are subject to medical device tracking requirements and are responsible for providing information to the manufacturer about explanted devices.

    Explanted medical devices that are subject to medical device tracking regulation must be reported to the manufacturer. Serious injury related to an implanted medical device must be reported to the device manufacturer. Deaths related to an implanted medical device must be reported to both the manufacturer and the US Food and Drug Administration (FDA).


    Resources:

    •Guideline for specimen management. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.
    •21 CFR 821. Medical Device Tracking Requirements. 2013. US Food and Drug Administration. Accessed October 27, 2014.
    •Medical device tracking; guidance for industry and FDA staff. US Food and Drug Administration. Accessed October 27, 2014. 
    •21 CFR 803 Subpart C. User Facility Reporting Requirements. 2013. US Food and Drug Administration. Accessed October 27, 2014. 
    •Medical device reporting. US Food and Drug Administration. Accessed October 27, 2014.


    Updated November 6, 2014


  • How should explanted orthopedic hardware being returned to the patient be handled?

    Answer:

    Explanted orthopedic hardware to be returned to the patient should be collected, handled, decontaminated, labeled, packaged, and documented according to the facility or health care organization policies and procedures. Before returning the explanted hardware to the patient, facility or health care organization personnel should verify that the explanted hardware has not been recalled and does not need to be returned to the manufacturer. Return of the explanted hardware to the patient should be documented in the patient’s health record, including the patient’s request for return of the explanted hardware and identification of personnel returning the explanted hardware to the patient.

    Explanted orthopedic hardware may be excluded from submission to the pathologist for examination, provided there is an alternative policy in place for documentation of surgical removal. Explanted orthopedic hardware that is not submitted to the pathologist, returned to the manufacturer, or returned to the patient should be disposed of according to the facility or health care organization policies and procedures.

    Resources:

    •Guideline for specimen management. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc. 
    •Policy on surgical specimens to be submitted to pathology for examination. Appendix M. 2007. College of American Pathologists. Accessed October 27, 2014.


    Updated November 6, 2014


  • Can formalin be stored in the OR or procedure room?

    Answer:

    Formalin should be dispensed and stored in an area other than the OR or procedure room unless ignition sources are not used and the regulatory requirements for locations where formalin is used and stored are met.

    Formalin is a combustible liquid. Storage and use of formalin is regulated by the Occupational Safety and Health Administration and other federal and state health regulatory agencies. Locations where formalin is used must have posted signs warning of formaldehyde use, eyewash stations available within the immediate area, and ventilation systems with adequate capacity to maintain levels below the permissible exposure limits (ie, eight-hour total weighted average of 0.75 ppm or 15-minute short-term exposure limit of 2.0 ppm).

    Resources:

    •Guideline for specimen management. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc. 
    •NIOSH Pocket Guide to Chemical Hazards. DHHS (NIOSH) Publication No. 2005-149 ed. Cincinnati, OH: National Institute for Occupational Safety and Health; 2007. 
    •CFR 1910.1048: Hazardous substances. Formaldehyde. Occupational Safety and Health Administration. Accessed October 27, 2014.
    •OSHA FactSheet: Formaldehyde. 2011. Occupational Safety and Health Administration. Accessed October 27, 2014.


    Updated November 6, 2014


  • How much formalin should be used for preservation of surgical specimens?

    Answer:

    Specimens should be fully immersed in a ratio of fixative volume to specimen volume determined by the pathologist or receiving pathology laboratory personnel. The volume of formalin required for tissue fixation is not generally agreed upon. The literature is inconclusive regarding the amount of solution that should be used for specimen preservation and the suggested amounts vary.

    Resources:

    •Guideline for specimen management. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc. 
    •Buesa RJ, Peshkov MV. How much formalin is enough to fix tissues? Ann Diagn Pathol. 2012;16(3):202- 209.
    •Di Novi C, Minniti D, Barbaro S, Zampirolo MG, Cimino A, Bussolati G. Vacuum-based preservation of surgical specimens: an environmentally-safe step towards a formalin-free hospital. Sci Total Environ. 2010;408(16):3092- 3095.
    •Bell WC, Young ES, Billings PE, Grizzle WE. The efficient operation of the surgical pathology gross room. Biotechnic Histochem. 2008;83(2):71-82.
    •Yaziji H, Taylor CR, Goldstein NS, et al. Consensus recommendations on estrogen receptor testing in breast cancer by immunohistochemistry. Appl Immunohistochem Mol Morphol. 2008;16(6):513-520.


    Updated November 6, 2014


Sterile Technique

  • Why should health care practitioners double-glove during invasive procedures?

    Answer:

    Health care practitioners should double glove (wear two pairs of gloves, one over the other) during invasive procedures to:

    •reduce the risk of glove perforation,
    •reduce the risk of surgical site infection for the patient,
    •protect the wearer from exposure to bloodborne pathogens, and
    •minimize the amount of blood exposure during needlestick injuries.

    In addition, using perforation indicator systems as part of double gloving can assist the wearer to identify glove failure.

    Resources:

    •Recommended practices for prevention of transmissible infections in the perioperative practice setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:331-364.
    •Recommended practices for sterile technique. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:91-120.


    Updated January 28, 2013 

  • Why does a sterile field opened prior to a procedure need to be monitored continuously?

    Answer:

    A sterile field established in advance of a procedure should be monitored continuously because sterility is event-related. The purpose of monitoring the sterile field is to observe for, or prevent, an event leading to contamination of the sterile field. These events may be caused by personnel, falling objects, or other means such as insects. Taping the door shut is not acceptable because it does not prevent all events from occurring or provide a means to observe the occurrence.

    Resource:

    •Recommended practices for sterile technique. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:91-120.

    Updated January 28, 2013

  • Are there specific recommendations for gowning and gloving for clean-contaminated procedures (i.e. tonsillectomy, cystoscopy)?

    Answer:

    There is no distinction between procedure types in the practice of gowning and gloving. The purpose of gowning and gloving, as well as wearing other appropriate surgical attire such as caps, masks, and eye protection is to prevent microbial transference to the sterile field, surgical site, and patient during the surgical procedure. As part of Standard Precautions, this practice also reduces the risk of occupational exposure to bloodborne pathogens and other potentially infectious materials.

    Resources:

    • Recommended practices for sterile technique. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:91-120.
    • Recommended practices for prevention of transmissible infections in the perioperative practice setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:331-364.

    Updated January 28, 2013


  • Can the same sterile field setup be used for two different areas on the same patient if both are classified as clean procedures (eg, anterior and posterior spine)?

    Answer:

    Yes, from a sterile technique standpoint, the same sterile supplies and instrumentation can be used when moving from one sterile area to another sterile area if the move is from a clean area to another clean, clean-contaminated, contaminated, or dirty area on the same patient. The same sterile supplies and instrumentation should not be used when moving from a clean-contaminated, contaminated, or dirty area to a clean area on the same patient. For example, it would be acceptable to move from a clean anterior neck to a clean posterior neck, but not from the perineum to a clean anterior neck.

    However, there may be times when even though acceptable within the rules of sterile technique, perioperative personnel should consider using two setups in order to avoid the potential risk of contamination. For example, although a breast biopsy would be considered a clean case, separate setups should be used if doing biopsies on both the both breasts on the same patient in order to avoid the potential seeding of cancer cells. Another example might be when performing a clean-contaminated cholecystectomy, and a rectocele repair on the same patient. Although acceptable if no bile spillage occurred, it might be aesthetically unpleasant to use the same set up for both procedures.


    Resources:

    •Recommended practices for sterile technique. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:91-120

    Updated July 18, 2013


  • What should a scrubbed team member do if they sneeze?

    Answer:

    The scrubbed team member should distance themselves from the sterile field before sneezing, if possible. Following the sneeze, the person should discard the sterile gown and gloves and leave the room to remove and discard the mask. At this time, the team member may don a clean surgical mask, perform a surgical hand scrub, and return to the OR to don a sterile gown and gloves.

    Resources:

    •Van Wicklin S. Scrubbed personnel who are sneezing. [Clinical Issues]. AORN J. 2013;97(5):592-593.

    Updated August 7, 2013 


  • How often should a surgical mask be changed?

    Answer:

    According to the AORN Recommended Practices for Surgical Attire, the surgical mask should be changed when it becomes wet or soiled. Researchers Barbosa and Graziano found that surgical masks may need to be changed when worn continuously for more than four hours.

    Resources:

    •Van Wicklin S. Length of time after which a surgical mask should be changed. [Clinical Issues]. AORN J. 2013;97(5):593-594.
    •Recommended practices for surgical attire. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:51-62.
    •Barbosa MH, Garziano KU. Influence of wearing time on efficacy of disposable surgical masks as microbial barrier. Braz J Microbiol. 2006;37(3):216-217.

    Updated August 7, 2013



Sterilization

  • What conditions are necessary for storage of sterile supplies?

    Answer:

    Sterile items should be stored under environmentally controlled conditions, which means a temperature of approximately 75°F (24°C), a maximum relative humidity of 70%, a positive air flow pressure in relation to adjacent areas, and a minimum of four air exchanges per hour. To comply with fire code regulations and reduce the risk of contamination, sterile supplies should be stored at least 8 to 10 inches from the floor, at least 18 inches from the ceiling, and at least 2 inches from outside walls. Fire codes specify minimum distances below the ceiling to ensure the effectiveness of sprinkler systems.

    Resources:

    • Recommended practices for sterilization. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:513-540.

    Updated January 28, 2013

  • How heavy can instrument sets be for sterilization?

    Answer:

    AORN and the Association for the Advancement of Medical Instrumentation (AAMI) recommend that instrument sets and trays prepared for sterilization not exceed 25 pounds. This weight limit includes the combined weight of the pan and the instruments. Sets exceeding 25 pounds present an increased risk of ergonomic injury to personnel handling the sets and result in wet loads unless the sterilization drying time is extended.

    Resources:

    •Recommended practices for sterilization. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:513-540.

    Updated January 28, 2013

  • What is the best way to transport "flashed" items to point of use and prevent contamination?

    Answer:

    AORN recommends the use of rigid sterilization containers designed and intended for specific sterilization modes (ie, Immediate Use Steam Sterilization (IUSS), flash sterilization, abbreviated, short, rapid) if items must be sterilized using sterilization modes other than conventional processing. AORN and the Association for the Advancement of Medical Instrumentation (AAMI) state that items should be delivered to the point of use and sterile field in a manner that maintains sterility.

    Resources:

    •Recommended practices for sterilization. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:513-540.

    Updated January 28, 2013

  • Should instruments with sharp points and edges (eg, towel clips) be sterilized in the open or closed position?

    Answer:

    All hinged instruments should be sterilized in the open position, unless the manufacturers instructions advise against this practice. If hinged instruments are on stringers, racks, or instrument pegs, the instruments should be kept open and unlocked. The rationale behind the practice is to expose all surfaces to the sterilant.

    To manage sharp points and edges, loose-fitting tip protectors for sharp and delicate instruments should be used if they have been validated for use with the method of sterilization and according to manufacturer's instructions.

    Resource:

    Recommended practices for cleaning and care of surgical instruments and powered equipment. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:485-504.

    Updated January 28, 2013

  • How many Immediate Use Steam Sterilization (IUSS) cycles (flash sterilization) are acceptable in a month?

    Answer:

    IUSS (flash) rates may be calculated by dividing the number of IUSS (flash) cycles per month by the number of procedures per month. Health care organizations may benefit from benchmarking IUSS (flash) rates against themselves as part of quality improvement initiatives for decreasing IUSS utilization.

    Resource:

    •Denholm, BG. Calculating flash sterilization rates. [Clinical Issues]. AORN Journal. 2011;93(2):296-297.

    Updated January 28, 2013

  • Can the pack be used it if is only wet on the inside?

    Answer:

    There is no definitive evidence to support that moisture inside a closed container is sterile; therefore, the pack is considered contaminated and should not be used. Often, moisture can act as a wicking agent and may cause pathogens to come in contact with the items in the pack.

    Resources:

    •Recommended practices for sterilization. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:513-540.
    •Spry C. Understanding current steam sterilization recommendations and guidelines. AORN J. 2008;88(4):537-550.


    Updated January 28, 2013 


  • What are the reasons for wet packs?

    Answer:

    Several variables contribute to wet packs:

    •poor steam quality
    •sterilizer cycle and drying times
    •tray configuration and design
    •type of load (eg, heavy instrument sets, sets with excess density)
    •type of wrap used as a packaging system for sterilization
    •location of the pack in the sterilizer


    Resources:

    •Recommended practices for selection and use of packaging systems for sterilization. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:505-512.
    •Spry C. Understanding current steam sterilization recommendations and guidelines. AORN J. 2008;88(4):537-550.

    Updated January 28, 2013



  • How can we prevent wet packs?

    Answer:

    The occurrence of wet packs can be minimized by the following actions:

    •Precondition the load by placing instruments inside the steam sterilizer with the door closed for 10 to 15 minutes before starting the cycle.
    •Place a towel between the bottom of trays with wire mesh bottoms and between layers of instruments (unless contraindicated by the instrument and container manufacturer).
    •Divide sets if they are excessively heavy or dense.
    •Do not enclose peel pouches in instrument sets.
    •Do not overload the sterilizer.
    •Inspect steam line drains for clogs.
    •Instrument sets that weigh more than 25 lbs are difficult to dry without a lengthy dry time.
    •Document and track wet packs according to the facility policy to identify any problems that may exist with the sterilizer and take steps to correct problems.

    Resources:

    •Recommended practices for selection and use of packaging systems for sterilization. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:505-512.
    •Recommended practices for sterilization. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:513-540.
    •Spry C. Understanding current steam sterilization recommendations and guidelines. AORN J. 2008;88(4):537-550.

    Updated January 28, 2013



Transmissible Infections

  • What is MERS-CoV and what precautions should be taken for suspected or confirmed cases in the perioperative setting?

    Middle East Respiratory Syndrome Coronavirus (MERS-CoV) is a respiratory illness caused by coronavirus. It was first reported in Saudi Arabia in 2012 and has since spread to several other countries, including the United States. Most patients with MERS-CoV have developed severe acute respiratory illness with symptoms of fever, cough and shortness of breath. Healthcare providers should evaluate patients for MERS-CoV infection according to CDC recommendations. Guidance from the CDC on MERS is rapidly evolving due to the current lack of a safe and effective vaccine and chemoprophylaxis, a possible high rate of morbidity and mortality among infected patients, and incompletely defined modes of transmission of MERS-CoV.

    Because MERS-CoV affects the respiratory system, surgical interventions are not typically indicated for treatment. Elective surgery for patients with suspected or confirmed MERS-CoV should be decided on a case-by-case basis by the provider and local health department. Preoperative screening should include:
    •fever  
    •symptoms of respiratory illness (eg, pneumonia, ARDS, cough, shortness of breath) 
    •close contact with a confirmed MERS case while the case was ill 
    •travel within 14 days to countries with ongoing MERS-CoV transmission (eg, Arabian Peninsula: Bahrain, Iran, Israel, Jordan, Kuwait, Lebanon, Oman, Qatar, Saudi Arabia, the United Arab Emirates, and Yemen; Republic of Korea) 

    Perioperative team members caring for patients with MERS-CoV should follow standard, contact, and airborne precautions (eg, gown, gloves, N95 respirator, and eye protection).

    Resources:

    •CDC MERS Information  
    •CDC Healthcare Professional Guidance   
    •CDC Infection Control Guidance   
    •Guideline for Prevention of Transmissible Infections in the Perioperative Setting. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

    Updated June 16, 2015.

  • Do observers in the OR have to meet immunization requirements?

    Answer:

    Yes, observers of operative or other invasive procedures (eg, students, visiting physicians) should be immunized according to the health care organization's policy for healthcare personnel.

    Resources:

    •Wood A. Immunization recommendations for perioperative observers. [Clinical Issues]. AORN J. 2013;97(5):587-589.

    Updated August 7, 2013

  • Do prescription eye glasses provide adequate eye protection for scrubbed team members?

    Answer:

    Standard prescription eye glasses are not considered eye protection by the CDC. Appropriate eye protection should fit snug on the brow and have solid side shields, in addition to having anti-fog properties. A face shield may also be worn to protect the eyes and face from splash or splatter.

    Resources:

    •Ogg M. Types of acceptable eye protection. [Clinical Issues]. AORN J. 2013;98(2):195-196.

    Updated August 7, 2013 

Nursing Consultation

AORN members may consult with nurse specialists from AORN's Center for Nursing Practice on clinical questions. Call (800) 755-2676 Tuesdays and Wednesdays, 9 a.m. - 1 p.m. MT. Please have your AORN membership number available when you call.