2022 Guidelines: New Evidence-Based Practices to Implement Now

A new round of guideline updates is now available in 2022 Guidelines for Perioperative Practice. Six guidelines have been updated in the print and electronic versions of the book based on recent evidence, including a shift to recommend adjunct technology to reduce count discrepancies that can lead to unintentionally retained surgical items (RSIs).

“AORN Guidelines are the gold standard for evidence-based perioperative nursing,” notes Guidelines Editor-In-Chief Erin Kyle, DNP, RN, CNOR, NEA-BC. “Perioperative RNs, teams, and organizations who stand on them as the foundation of their practice can be sure that they are delivering the best patient care.”

Periop Today spoke with Kyle and Julie Cahn, DNP, RN, CNOR, RN-BC, ACNS-BC, CNS-CP, author of the significantly revised guideline on preventing unintentional RSIs, to understand how the evidence supports AORN recommended changes in the six updated guidelines.

Key Practice Updates

1. Preventing Unintentional RSIs

The biggest change to the Guideline for Preventing Unintentionally Retained Surgical Items is the new recommendation for adjunct technology to account for soft goods.

“Evidence on retained surgical soft goods suggests that the accuracy of manual counting is unlikely to dramatically improve without assistance,” Cahn says. She says some types of adjunct technology devices have been shown to reduce the rate of count discrepancies, decrease time reconciling count discrepancies related to soft goods, and decrease costs associated with count discrepancies, such as costs for radiological imaging.”

Cahn stresses that adjunct technology should never replace manual counting because it remains an important step to account for surgical items used in the wound.

Other practice updates specific to preventing unintentional RSIs include:

• A new section on preventing retained foam pieces from negative-pressure wound therapy devices, such as by cutting the foam only when necessary to fit in the wound and limiting the number of pieces of foam used when possible.
• New recommendations in the section on preventing retained fragments during intravascular device use, such as guidewire fragments, provides new practices for instrument inspection before and immediately after use at the point of care.

2. Radiation Safety
   The most significant changes to the Guideline on Radiation Safety are around the use of shielding for patients because research shows that incorrectly placed patient shields can increase the radiation dose received by the patient instead of protecting them, Kyle explains. “This research led to our recommendation to consult with the radiation safety officer or the radiology professional in the room regarding the use and placement of protective shielding or garments between the patient and the source of radiation, including protective shielding for the fetus in pregnant patients.”

Other practice updates specific to radiation safety include:

• A new section dedicated to the roles and responsibilities of the radiation safety committee.
• A new recommendation to perform a radiation safety timeout before the start of surgical procedures or as part of the procedural timeout to verify that safety measures are being employed correctly among every person in the room.
• Enhanced recommendations in the section on radionuclides with new information on radiopharmaceutical safety and emergency response.

3. Preoperative Patient Skin Antisepsis

The updated AORN Guideline for Preoperative Patient Skin Antisepsis includes a new section on decolonization with the recommendation that an interdisciplinary team determine the need for a preoperative decolonization program at their facility. Other updates based on new research cover preoperative bathing; surgical site hair management; and selecting, applying, handling, and storing antiseptics.

4. Complementary Care

Updates to the Guideline for Complementary Care reflect a more comprehensive review of the growing literature on practices to reduce perioperative pain and anxiety and to apply holistic methods to optimize patient health and well-being. 

New sections in the guideline include:

• Selecting interventions
• Patient assessment
• Planning interventions
• Policies and procedures, and
• Additional interventions such as dietary and herbal, stress diversion, visualization, electrical stimulation, and biofield interventions.

5. Care of the Patient Receiving Moderate Sedation/Analgesia

The updated Guideline for Care of the Patient Receiving Moderate Sedation/Analgesia includes new evidence on the effects of cannabis and opioid use on moderate sedation. 

Other updates in this guideline include:

• New recommendations for additional assessment of pediatric and older adult patients receiving moderate sedation.
• New language describing monitoring patients that is changed from “continuous” to “continual” to emphasize the importance of perioperative nurses administering propofol for moderate sedation/analgesia to be fully dedicated to patient monitoring.

6. Surgical Smoke Safety

The Guideline for Surgical Smoke Safety has been updated with the most recent literature and reorganized to align with the hierarchy of controls from the Centers for Disease Control and Prevention and the National Institute for Occupational Safety and Health. 

Other updates for surgical smoke safety include:

• More information about how to establish a smoke-free environment.
• The addition of filtration to the smoke evacuation recommendations.
• A new emphasis that respiratory protection should be a SECONDARY protection against surgical smoke.

Respiratory protection should never be used as a first line of defense against surgical smoke, Kyle stresses. “Where this came through in the literature was specifically significant for open procedures involving the liver where research has demonstrated high concentrations of fine and ultrafine particles in surgical smoke from liver tissue.”