periop standards

Standards, Guidelines and

Position Statements for Perioperative Registered Nursing Practice

Promoting Excellence

OPERATING ROOM NURSES ASSOCIATION OF CANADA (ORNAC) 10TH Edition

Copyright registration number

1084471 All rights reserved. No part of this document may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without the written permission of the ORNAC Executive.

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Standards, Guidelines, and Position Statements For Perioperative Registered Nursing Practice

ORNAC Beliefs, Professional Standards and Competencies Introduction

Revision Date: March 2011 of 334

Table of Contents

Page

Foreword ............................................................................................................................................................ 7 A Message From the President ........................................................................................................................... 9

Section 1 ORNAC Beliefs, Professional Standards and Competencies

Part A ORNAC's Fundamental Principles and Position Statements ........................................................................... 12 ORNAC Philosophy ......................................................................................................................................... 13 ORNAC Mission, Values, Vision ..................................................................................................................... 14 National Standards for Perioperative Registered Nursing Practice .................................................................. 15 Conceptual Model for Perioperative Registered Nursing Practice ................................................................... 16 ORNAC Scope of Perioperative Registered Nursing Practice ......................................................................... 17 Scope of Practice for Expanded Perioperative Nursing Practice ...................................................................... 17 Scope of Practice for Advanced Perioperative Registered Nursing Practice .................................................... 18 ORNAC Position Statements a) Staffing the Surgical Suite............................................................................................................. 19 b) Perioperative Certification ............................................................................................................ 21 c) Perioperative Nursing Experience in Basic Nursing Education Programs .................................... 22 d) Environmental Responsibility ....................................................................................................... 24 e) Perioperative Registered Nurses are Essential to Quality Care in the Operating Room ............... 24 f) The Perioperative Registered Nurses’ Role in Primary Healthcare .............................................. 25 Safe Surgery Saves Lives ................................................................................................................................. 26 Part B Standards for Perioperative Registered Nursing Practice ................................................................................. 28 Professional Standards ....................................................................................................................... 29 Professional Standards for Perioperative Registered Nurses .............................................................. 30 Professional Standards for Perioperative Registered Nurse Managers .............................................. 39 Professional Standards for Perioperative Registered Nurse Educators .............................................. 41 Professional Standards for Expanded Practice Perioperative Registered Nurses ............................... 43 Professional Standards for Perioperative Registered Nurse Researchers ........................................... 45 Professional Standards for Advanced Practice Perioperative Registered Nurses ............................... 48 Part C Competencies for Perioperative Registered Nursing Practice .......................................................................... 50

Purpose ............................................................................................................................................... 51 Knowledge and Skills Expected of the Perioperative Registered Nurse Prior to Entering the

Specialty of Perioperative Nursing ..................................................................................................... 52 Characteristics of Each Competency .................................................................................................. 53

Competencies of the Perioperative Registered Nurse ........................................................................ 54 Competencies of the Perioperative Registered Nurse Manager ......................................................... 59 Competencies of the Perioperative Registered Nurse Educator ......................................................... 67 Competencies of the Advanced Practice Perioperative Registered Nurse .......................................... 73 Competencies for Expanded Practice Perioperative Registered Nurses

Registered Nurse First Assist (Appendix A) ..................................................................... 75


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Section 2 Infection Prevention and Control

Routine Practices and Additional Precautions .................................................................................................. 89 Routine Practices .............................................................................................................................................. 89 Airborne Precautions .......................................................................................................................... 91 Droplet Precautions ............................................................................................................................ 94 Contact Precautions ........................................................................................................................... .95 Classic Creutzfeldt-Jakob disease (CJD) .......................................................................................................... 97 Implementing CJD Precautions .......................................................................................................... 97

CJD Perioperative Precautions ........................................................................................................... 98 Reference Guide Assessment Tool (Appendix A) .......................................................................... 102 Environmental Cleaning/Sanitation ................................................................................................................ 104

General Practices .............................................................................................................................. 104 Preliminary Cleaning........................................................................................................................ 106 Intraoperative Cleaning .................................................................................................................... 106 End of Procedure Cleaning (Between Cases) ................................................................................... 107 Terminal Cleaning ............................................................................................................................ 108 Weekly and /or Monthly Cleaning ................................................................................................... 108

Traffic Control ................................................................................................................................................ 109

People ............................................................................................................................................... 110 Supplies and Equipment ................................................................................................................... 111

Dress Code ..................................................................................................................................................... 112

Patients ............................................................................................................................................. 112 Visitors ............................................................................................................................................. 112 Staff .................................................................................................................................................. 113

Scrubbing, Gowning, Gloving ........................................................................................................................ 116 Scrubbing ......................................................................................................................................... 116 Gowning ........................................................................................................................................... 117 Gloving ............................................................................................................................................. 118

Aseptic Technique .......................................................................................................................................... 121

Establishing an Aseptic Environment .............................................................................................. 121 Establishing the Sterile Field ............................................................................................................ 121 Dispensing Sterile Supplies .............................................................................................................. 122 Maintaining the Sterile Field ............................................................................................................ 123 Storage of Sterile Supplies ............................................................................................................... 124

Instrument Management and Reprocessing .................................................................................................... 126

Intraoperative Instrument Care ......................................................................................................... 126 Reprocessing Surgical Instruments .................................................................................................. 127 Loaned and Leased Surgical/Medical Equipment ............................................................................ 129 Packaging for Sterilization ............................................................................................................... 129 Rigid Sterilization Containers .......................................................................................................... 131 Sterilization ...................................................................................................................................... 132 Emergency (Flash) Sterilization ....................................................................................................... 134 High Level Disinfection ................................................................................................................... 135


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Specialized Instruments and Equipment ......................................................................................................... 140 Prosthesis Care and Handling........................................................................................................... 140 Power Equipment Management ....................................................................................................... 141

Single Use Medical Devices (SUMeDs) ........................................................................................................ 142 Selection, care and handling of materials ....................................................................................................... 143 Wrappers, Surgical Gowns, and Drapes ........................................................................................... 143

Bundles ............................................................................................................................................. 145 Skin Preparation (Prep) .................................................................................................................................. 146 Draping .......................................................................................................................................................... 149 Dressing(s), Drain(s), Irrigation ..................................................................................................................... 150

Dressings .......................................................................................................................................... 150 Drains ............................................................................................................................................... 151 Irrigation ........................................................................................................................................... 152

Section 3 Safety/Risk Prevention and Management

Introduction to Risk Management .................................................................................................................. 155 Risk Avoidance/Minimization ........................................................................................................................ 156

Patient Safety .................................................................................................................................................. 160

Ambulatory Patient Care Recommendations ................................................................................... 160 Patient Admission and Identification ............................................................................................... 163 Consent for Surgical Intervention .................................................................................................... 164 Surgical Site Verification ................................................................................................................. 165 Surgical Pause/”Time Out” ............................................................................................................. 166 Surgical Counts ................................................................................................................................ 167 Surgical Positions ............................................................................................................................. 178 Visitors to the Surgical Suite ............................................................................................................ 184 Gathering Medicolegal Evidence in the Surgical Suite .................................................................... 185

Guidelines for Collection of Evidence: (Appendix E) .................................................................... 189 Specimen Management .................................................................................................................... 190 Medication Management .................................................................................................................. 193 Nursing Documentation ................................................................................................................... 196 Electronic Health Records ................................................................................................................ 201 Organ and Tissue Procurement Protocol .......................................................................................... 203

Team Safety .................................................................................................................................................... 206

Credentialing .................................................................................................................................... 206 Occupational Health & Safety .......................................................................................................... 207 Students/Preceptors .......................................................................................................................... 209

Orientation/In-service/Continuing Education .................................................................................. 211 Environmental/Equipment Safety ................................................................................................................... 212

Construction/Renovation .................................................................................................................. 212


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Equipment Selection/Trialing........................................................................................................... 221 Preventative Maintenance Programs ................................................................................................ 225 Risk Alerts/Recalls ........................................................................................................................... 225 Intra-operative Equipment Malfunction ........................................................................................... 226

Specialized Surgical Equipment ...................................................................................................... 226 Electrosurgery (ESU) .......................................................................................................... 226 Laser Safety and Administration .......................................................................................... 234 Minimally Invasive Surgical Equipment .............................................................................. 242

Section 4 Environmental Hazards and Responsibilities

Physical Hazards ............................................................................................................................................ 250 Environmental Factors ..................................................................................................................... 250 Light ...................................................................................................................................... 250 Noise ...................................................................................................................................... 251 Ventilation ............................................................................................................................. 252 Electricity ......................................................................................................................................... 254 Radiation .......................................................................................................................................... 256 Fire/Explosion .................................................................................................................................. 260 Chemical Hazards ........................................................................................................................................... 263 Anesthetic Agents ............................................................................................................................ 263 Sterilizing Agents - Ethylene Oxide ................................................................................................. 264 Other Sterilizing Agents/Disinfectants ............................................................................................. 264 Formaldehyde ........................................................................................................................ 265 Glutaraldehyde ...................................................................................................................... 265 Methyl Methacrylate ........................................................................................................................ 265 Drugs: Cytotoxic, Dyes, Pharmaceuticals ....................................................................................... 266 Waste Management ........................................................................................................................................ 266 Infectious Waste ............................................................................................................................... 266 Latex Sensitivity/Allergy: Staff ...................................................................................................................... 268

Section 5 Nursing Care of the Anesthetised Patient

Preoperative Considerations ........................................................................................................................... 273

Intraoperative Considerations ......................................................................................................................... 275 Postoperative Considerations ......................................................................................................................... 279 Local Anesthesia ............................................................................................................................................ 281 Procedural Sedation/Analgesia ....................................................................................................................... 283


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Intravenous Regional Anesthesia (Bier Block) ............................................................................................. 288 Regional Anesthesia-Spinal, Epidural, Peripheral Nerve Blocks ................................................................... 290 Herbal Remedies ............................................................................................................................................ 292 Blood and Blood Products .............................................................................................................................. 294 Emergency Situations ..................................................................................................................................... 296 Malignant Hyperthermia .................................................................................................................. 296 Latex Allergy ................................................................................................................................... 298 Cardiac Arrest .................................................................................................................................. 300

Disseminated Intravascular Coagulation .......................................................................................... 302 Death ................................................................................................................................................ 304

Glossary .......................................................................................................................................................... 307 Evaluation Form ............................................................................................................................................. 332 CSA Standards ............................................................................................................................................... 333


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FOREWORD ORNAC was inaugurated in 1983, and by June 1986, the Standards Committee had developed “Standards for Operating Room Nursing Practice”. Two years later, in 1988 “Recommended Technical Standards” were published. This was a significant milestone for a young organization. The body of knowledge required in the specialty was defined as required by the Canadian Nurses Association to meet the requirements of a certification process. The two documents were combined in a single issue in 1993 and also included a chapter on competencies. That issue was used as a primary resource for the development of the Canadian Nurses Association (CNA) Certification exam in Perioperative Nursing Practice. The document continued to evolve with the 1998 edition, which reflected the movement towards ambulatory surgery. The 2003 revision incorporated a major format change. This edition was re-designed into modules. The constant rapid change in healthcare requires a design that enables more consistent review/revision. ORNAC is a volunteer organization of committed perioperative Registered Nurses. Revision/review of modules is more easily facilitated on a continuous basis by these volunteers. According to the Canadian Nurses Association (CNA), a standard is a desired and achievable level of performance against which we can measure actual performance. Self regulating professions are characterized by standards of practice, based on the values of the profession. This document is meant to complement not replicate other standards in existence. The 9th edition, 2009 revision was published in a bound format as a result of feedback and requests from perioperative nurses across the country. A bound publication provides assurance that each and every copy contains all of the most current revisions. Committee energy was focused on the fourth and fifth sections of the publication. Minor revisions were made to the remaining sections based on questions the committee received through the ORNAC website. For the current (10th edition) revision, the committee focused on Section 2, with minor revisions to the remaining sections. It is the mandate of the Standards Committee to develop and review standards on an ongoing basis. Content expertise has been provided by perioperative Registered Nurses across Canada and reflects current practice, research, and review of medical/surgical literature. The Standards Committee has endeavoured to develop a “user-friendly” document that will serve as a guide and reference for perioperative Registered Nurses, health care facilities that care for surgical patients, and other professional associations. It is the responsibility of individual perioperative Registered Nurses and health care facilities to ensure that the most recent recommendations are being used. Those who served as reviewers and validators are to be commended for a job well done. Thank-you to the ORNAC Board and Executive, and perioperative Registered Nurses from across the country for their assistance and to colleagues from other specialty areas who assisted us.


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Notes: 1. The intended application of these standards, guidelines, and position statements, is for the perioperative

environment. It is the responsibility of the users of this document to apply it in the context of their individual setting respecting provincial/national and professional regulations and laws within each province and jurisdiction.

2. This document was developed from broad input of perioperative Registered Nurses and the final document

represents consensus of the content. Consensus is defined as agreement in collective opinion and belief. Consensus is more than a simple majority, but not necessarily unanimity.

3. ORNAC standards, guidelines, and position statements are subject to periodic review. 4. “Shall” is used to express a requirement, i.e., a provision that the user is obliged to satisfy in order to

comply with the standard, “should” is used to express a recommendation or that which is advised but not required, and “may” is used to express an option or that which is permissible within the limits of the standard.

Kathy Radcliffe RN, BSN, CPN(C) – Chair, Standards Committee, Ontario

Loraine Best, RN, BSN, CPN(C) – British Columbia

Chris Downey RN, BScN, CPN(C), MSc, RNFA, CMLSO,– Ontario

Cathy Ferguson RN, BScN, RNFA, CNOR, CPN(C) – Nova Scotia

Carol Knudson RN, BN – Manitoba

Rupinder Khotar RN, BScN, CPN(C) – British Columbia

Kelly Kuz RN, BScN, MN, CPN(C) Alberta

Corenia Price RN, CPN(C), CMDRT – Newfoundland & Labrador

Leah Restall RN - Manitoba

Anne Smith RN, – Prince Edward Island

Cathy Timmons, RN – Nova Scotia

Margot Walsh RN – Newfoundland & Labrador

1 10th edition committee members


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A MESSAGE FROM THE PRESIDENT. . . Promoting Excellence Promouvoir l’Excellence A MESSAGE FROM THE PRESIDENT… On behalf of the Operating Room Nurses Association of Canada’s Board and Executive, it is my pleasure to preface the tenth edition of the ORNAC “Standards, Guidelines, and Position Statements for Perioperative Registered Nursing Practice”. During the fall ORNAC strategic planning process, the executive, provincial and affiliate representatives confirmed that the production and continuous review of the Standards is a strategic priority to support best practices in perioperative patient care. This edition represents the ongoing validation and revision of the Standards, necessary to keep pace with the health care environment and maintain safe patient care. As demonstrated by the ORNAC conceptual model, this document is the foundation of registered nursing practice in the perioperative setting and represents our professional practice to our colleagues. While the Standards have evolved since the first publication, ORNAC – Recommended Standards for Operating Room Nursing Practice, June 1986, the intent remains the same – to guide the delivery of safe patient care and perioperative registered nursing practice in Canada. The review and compilation of the Standards document is an enormous task coordinated by the volunteers of the ORNAC Standards committee. Their generous donation of time, knowledge and expertise to develop and inform this document is commendable. The Operating Room Nurses Association of Canada is a professional organization dedicated to the promotion and advancement of excellence in perioperative practice. The ORNAC “Standards, Guidelines, and Position Statements for Perioperative Registered Nursing Practice” provides the vital reference to demonstrate to the public, government and other stakeholders that as a profession, perioperative registered nurses are dedicated to maintaining the public trust and to upholding standards for excellence in professional practice.

Bonnie McLeod, RN, BScN, MN, CPN(C) ORNAC President, 2009 - 2011


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Section 1 ORNAC Beliefs, Professional Standards and

Competencies


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ORNAC Beliefs, Professional Standards and Competencies Section 1


Section 1 ORNAC Beliefs, Professional Standards and Competencies

Part A ORNAC's Fundamental Principles and Position Statements ........................................................................... 12 ORNAC Philosophy ......................................................................................................................................... 13 ORNAC Mission, Values, Vision ..................................................................................................................... 14 National Standards for Perioperative Registered Nursing Practice .................................................................. 15 Conceptual Model for Perioperative Registered Nursing Practice ................................................................... 16 ORNAC Scope of Perioperative Registered Nursing Practice ......................................................................... 17 Scope of Practice for Expanded Perioperative Nursing Practice ...................................................................... 17 Scope of Practice for Advanced Perioperative Registered Nursing Practice .................................................... 18 ORNAC Position Statements a) Staffing the Surgical Suite............................................................................................................. 19 b) Perioperative Certification ............................................................................................................ 21 c) Perioperative Nursing Experience in Basic Nursing Education Programs .................................... 22 d) Environmental Responsibility ....................................................................................................... 24 e) Perioperative Registered Nurses are Essential to Quality Care in the Operating Room ............... 24 f) The Perioperative Registered Nurses’ Role in Primary Healthcare .............................................. 25 Safe Surgery Saves Lives ................................................................................................................................. 26 Part B Standards for Perioperative Registered Nursing Practice ................................................................................. 28 Professional Standards ....................................................................................................................... 29 Professional Standards for Perioperative Registered Nurses .............................................................. 30 Professional Standards for Perioperative Registered Nurse Managers .............................................. 39 Professional Standards for Perioperative Registered Nurse Educators .............................................. 41 Professional Standards for Expanded Practice Perioperative Registered Nurses ............................... 43 Professional Standards for Perioperative Registered Nurse Researchers ........................................... 45 Professional Standards for Advanced Practice Perioperative Registered Nurses ............................... 48 Part C Competencies for Perioperative Registered Nursing Practice .......................................................................... 50

Purpose ............................................................................................................................................... 51 Knowledge and Skills Expected of the Perioperative Registered Nurse Prior to Entering the

Specialty of Perioperative Nursing ..................................................................................................... 52 Characteristics of Each Competency .................................................................................................. 53

Competencies of the Perioperative Registered Nurse ........................................................................ 53 Competencies of the Perioperative Registered Nurse Manager ......................................................... 59 Competencies of the Perioperative Registered Nurse Educator ......................................................... 67

Competencies of the Advanced Practice Perioperative Registered Nurse .......................................... 73 Competencies for Expanded Practice Perioperative Registered Nurses

Registered Nurse First Assist (Appendix A) ...................................................................................... 75


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Part A

ORNAC'S FUNDAMENTAL PRINCIPLES

AND POSITION STATEMENTS


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The Operating Room Nurses Association of Canada (ORNAC) is an organization of professional perioperative Registered Nurses dedicated to the promotion of excellence in perioperative nursing. ORNAC serves as a spokesperson for perioperative Registered Nurses on issues affecting Registered Nurses, nursing practice, patient care, and societal needs/ expectations. We believe:

Perioperative nursing is a dynamic process guided by theoretical knowledge, ethical principles, research, specialized clinical skills, and caring practice.

Perioperative Registered Nurses respond to complex and changing clinical needs during a crucial

period of a person’s surgical experience.

The scope of perioperative nursing practice is continually evolving as Registered Nurses respond to societal and technological changes.

Standards of nursing practice, as well as collegial and interdisciplinary collaboration, enhance

perioperative nursing practice.

People are unique individuals whose needs change and may be compromised during the perioperative experience. They have a right to high-quality health care that promotes informed and responsible decision making.

Health encompasses the whole being and is influenced by one's environment. Using a wellness

approach, individuals and communities shall be proactive and responsible for achieving optimal health.

Education is an ongoing life-long process and perioperative Registered Nurses are responsible for

their learning. ORNAC is committed to enabling perioperative Registered Nurses to meet this responsibility.

The introduction to perioperative nursing should be a component of the basic nursing curriculum.

To fully practice the scope of perioperative nursing, the Registered Nurse needs to acquire additional knowledge and clinical skills.

ORNAC’s Motto “Promoting Excellence” demonstrates commitment to meeting the needs of its

members and society. Approved by Board and Executive: April 1994 Revised: May 2003, June 2007, February 2009, March 2011

ORNAC Philosophy


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The Operating Room Nurses Association of Canada (ORNAC) is a professional organization of perioperative Registered Nurses dedicated to:

The promotion and advancement of excellence in the provision of perioperative care to our patients. The professional growth, competence and personal enhancement of perioperative Registered Nurses.

The ongoing development of Standards, Guidelines and Position Statements for Perioperative Registered

Nursing Practice

The promotion and advancement of perioperative nursing practice at a regional, provincial and national level through political activity.

Vision Statement

The Operating Room Nurses Association of Canada (ORNAC) is a strong, unified national association that enhances and advances the practice of perioperative Registered Nurses.

Values reflect the basic beliefs that are most important to the Operating Room Nurses Association of Canada (ORNAC): KNOWLEDGE We recognize and are committed to education and research which are essential

components guiding our practice. We promote and demonstrate critical thinking skills in the delivery of

perioperative nursing care. RESPECT We recognize the worth, quality, diversity, and importance of the patients we care for,

and of each other. PROFESSIONALISM We promote and continually develop our unique specialized body of knowledge.

We encourage all perioperative Registered Nurses to become certified through the Canadian Nurses Association (CNA). We collaborate with nurses, organizations /agencies, other disciplines and medical industries that impact our practice. We are responsible and accountable for our actions and decision-making. We comply with the Canadian Nurses Association (CNA) Code of Ethics.

CONTINUOUS QUALITY We strive to achieve excellence in perioperative practice, and the activities influencing our Association.

Mission Statement

Values Statement


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LEADERSHIP We are role models who communicate a vision and who empower others to achieve perioperative nursing excellence.

PATIENT ADVOCACY We promote the perioperative patient’s right to be informed and to make autonomous decisions regarding their care.

We strive to protect the rights, health and safety of the patient throughout the perioperative experience.

STEWARDSHIP We strive to be fiscally and environmentally responsible while optimizing patient

outcomes.

National Standards for Perioperative Registered Nursing Practice ORNAC holds the following beliefs regarding standards: The implementation of standards contributes to the continued improvement of safe patient care and

perioperative registered nursing practice in Canada. Standards assist the perioperative Registered Nurse in attaining and maintaining competence in the

performance of quality patient care. Standards define safety measures for patients and the health care team. Standards provide a baseline and tool for measurement when evaluating perioperative registered nursing

practice. Standards are an integral part of a facility's quality assurance and improvement program. Standards provide a consistent reference base for programs such as orientation, in-service, continuing

education, research, and formal perioperative post basic education programs. Standards are the benchmark from which the perioperative Registered Nurse Manager and Educator

provide the structure, resources, and environment for the health care team.


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CONCEPTUAL MODEL FOR PERIOPERATIVE REGISTERED NURSING PRACTICE

The conceptual model provides direction for perioperative registered nursing practice. The surgical patient is the focus of perioperative registered nursing practice, which has as its’ foundation professional and clinical standards, and competencies. The professional standards provide guidelines for the perioperative Registered Nurse on which to base decisions in such areas as ethics, legal aspects, and professional conduct. The competency statements reaffirm that perioperative Registered Nurses are responsible and accountable for the nursing care of the surgical patient during the perioperative phase. In order to implement the standards and develop competence, the perioperative Registered Nurse shall be cognizant of the qualities necessary to become a Registered Nurse. Competence integrates the characteristics of knowledge, clinical and ethical decision-making, communication skills, psychomotor skills, safety, accountability, responsibility, team organization, continuing education, and leadership skills. The perioperative Registered Nurse is guided in the clinical area by these characteristics in order to function both independently and in collaboration with other members of the health care team. The clinical standards provide a basis for consistent, uniform, and acceptable outcomes of nursing practice. The perioperative Registered Nurse is systematically guided through the perioperative phase. The clinical standards are the benchmarks for quality improvement. The standards are implemented during the immediate preoperative, intraoperative, and immediate postoperative phases of the surgical patient's experience. Administration and management provide support, direction, leadership, resources, and commitment to the practice of these standards.


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ORNAC Scope of Practice for Perioperative Registered Nurses

The Scope of Perioperative Registered Nursing Practice is a continuum of nursing activities that focuses on identifying and meeting the individual needs of the surgical patient throughout the perioperative experience. This nursing practice occurs in, but is not limited to operating rooms, ambulatory care settings, clinics, and physician’s offices.

The perioperative Registered Nurse provides excellent care to the surgical population using critical thinking

skills guided by the ORNAC Standards, Guidelines and Position Statements for Perioperative Registered Nursing Practice and provincial legislation. Basic and expanded nursing knowledge is used to address the physiological, psychological, socio-cultural, and spiritual responses of the patient to the surgical event.

The perioperative Registered Nurse possesses the knowledge, skills and abilities to provide quality care for

all perioperative patients.

Working in collaboration with the health care team, the perioperative Registered Nurse performs skills supported by perioperative nursing education and evidence-based research within the boundaries of the health care facility’s policies and procedures.

The perioperative Registered Nurse precepts and mentors colleagues.

BIBLIOGRAPHY Canadian Nurses Association (2007). CNA joint position statement Promoting Continuing Competence for the Registered Nurse. Ottawa: Author. International Council of Nurses (R2007). The ICN position statement on Ethical Nurse Recruitment. Geneva: Author. Watson D. S. (2008). Patient Safety, an Issue of Perioperative Nursing Clinics. Toronto: Elsevier. Registered Nurse Anesthesia Assistant- RNAA The experienced perioperative Registered Nurse, with additional education, knowledge and skills in anesthesia assists the anesthesiologist to facilitate quality care of patients undergoing anesthetic procedures. The increasing complexity of patient condition and anesthetic procedures provides the perioperative Registered Nurse who has expanded perioperative nursing education with the opportunity to practice in collaboration with and under the direction of the anesthesiologist. The scope of practice of the Registered Nurse Anesthesia Assistant is part of perioperative nursing practice and encompasses the preoperative, intraoperative, and postoperative phases of the anesthetic experience.

Scope of Practice for Expanded Perioperative Nursing Practice


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BIBLIOGRAPHY

Nagelhout, J. J. & Plaus, K. (2010). Nurse Anesthesia (4th ed.). Toronto: Elsevier/Mosby. Registered Nurse First Assistant - RNFA The experienced perioperative Registered Nurse, with additional education, knowledge and skills in surgery assists the surgeon to facilitate quality care of patients undergoing surgical procedures. The increasing complexity of patient conditions, diagnoses, and surgical procedures provides the perioperative Registered Nurse who has expanded perioperative nursing education with the opportunity to practice in collaboration with and under the direction of the surgeon. The scope of practice of the RNFA is part of perioperative nursing practice and encompasses the preoperative, intraoperative, and postoperative phases of the surgical experience.

BIBLIOGRAPHY

Schroeder, J. L. (2008). Acute Care Practitioner: An Advanced Practice Role for RN First Assistants. AORN, 87(6), 1205-1215. The scope of Advanced Nursing Practice focuses on a specialty clinical service (i.e. Perioperative), providing support to clients and the healthcare team, as a consultant, researcher, administrator, educator, and clinical practitioner. Advanced Practice Nurses include Nurses Practitioners (NP) and Clinical Nurse Specialists (CNS).

BIBLIOGRAPHY Canadian Nurses Association. (2008). Advanced Nursing Practice: A National Framework. Ottawa: Author. Canadian Nurses Association. (2008). Nursing Leadership: Do We Have a Global Social Responsibility. Ottawa: Author. Canadian Nurses Association (2008). Advanced Nursing Practice A National Framework. Ottawa: Author. Girard, N. J. (2009). Leadership an Issue of Perioperative Nursing Clinics. Toronto: Elsevier/Mosby. MacDonald, M., Schreiber, R. & Davis, L. (2005). Exploring New Roles for Advanced Nursing Practice, A Discussion Paper. Ottawa: CNA.

Scope of Practice for Advanced Perioperative Nursing Practice


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ORNAC POSITION STATEMENTS

STAFFING THE SURGICAL SUITE For the patient undergoing surgical intervention, one of the most critical periods of care occurs in the operating room theatre. Every patient has a right to an optimal level of nursing care, and each facility has the responsibility to provide appropriate staffing in order to:

Meet individual patient's needs and surgical complexity.

Maintain acceptable levels of safety for patients, personnel and physicians.

Function within legal limitations of the provincial scope of practice.

Facilitate appropriate initial and specialty orientation, and continuing education.

Attain and maintain perioperative Registered Nurse competency.

Each surgical patient care encounter occurs in an environment where each individual theatre is a specific unit of care that shall be staffed independently with the staffing levels as defined.

To promote excellence in perioperative nursing care, the position of the Operating Room Nurses Association of Canada (ORNAC) is:

The surgical patient in each theatre shall be under the direct supervision of an appropriately experienced

perioperative Registered Nurse who is physically present in each theatre, and who is immediately available, i.e. Circulating Role to respond to unstable, unpredictable and emergency situations.

That in order to maintain competency in the circulating role, the perioperative Registered Nurse shall be

competent in the scrub role.

Each case or surgical procedure shall be staffed by a minimum of two perioperative professional nurses competent within their scope of practice. The circulating role shall be assigned only to a perioperative Registered Nurse. The scrub role may be filled by another healthcare professional. A second perioperative Registered Nurse shall be immediately available within the surgical suite. It may be necessary for additional circulating perioperative Registered Nurses and competent healthcare personnel to be present in the theatre to provide care within their scope of practice or job description. Only a perioperative Registered Nurse may relieve the circulating Registered Nurse for coffee, lunch, or other duties.

Each procedure or case shall be staffed with a minimum of one perioperative Registered Nurse and a second perioperative Registered Nurse immediately available.

Documentation shall include all personnel in attendance and clearly identify who provided direct patient care.

The surgical theatre shall be managed by an experienced perioperative Registered Nurse.


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BIBLIOGRAPHY Bull, R. & FitzGerald, M. (2006). Research Paper, Nursing in a technological environment: Nursing care in the operating room, International Journal of Nursing Practice, 12, 3-7. Canadian Health Services Research Foundation (CHSRF), (2006). Staffing for Safety: A Synthesis of the Evidence on Nurse Staffing and Patient Safety, CHSRF, Ottawa, ON retrieved March 29, 2009 from www.chsrf.ca Canadian Health Services Research Foundation (CHSRF), (2006). Evidence Boost Implement nurse staffing plans for better quality of care, The Problem: Current nurse staffing strategies are not adequate to improve patient safety, CHRSF, Ottawa: Author. Canadian Nurses Association. (2007). C NA Policy Brief # 2, Meeting Future Health-Care Needs Through Innovations to Nursing Education. Ottawa: Author. Canadian Nurses Association. (2006). CNA joint Position Statement, Practice Environments: Maximizing Client, Nurse and patient Outcomes. Ottawa: Author. Canadian Nurses Association. (2005). CNA Position Statement Interprofessional Collaboration. Ottawa: Author. Canadian Nurses Association (CNA), (2005). Evaluation Framework to Determine the Impact of Nursing Staff Mix Decisions. Ottawa: Author. Canadian Nurses Association. (2003). Patient Safety: Developing the Right Staff Mix, Report of the Think Tank. Ottawa: Author. Craddick, S. (2009). Quality Indicators, An Issue of Perioperative Clinics. Toronto: Elsevier/Mosby Garrett, C. (2008). Effective Nurse Staffing Patterns on Medical Errors and Nurse Burnout. AORN, 87(6), 1191-1204. International Council of Nurses, (ICN). (2008). Nurse Retention & Migration. Geneva: Author Springer, P. J., Corbett, C. & Davis, N. (2006). Enhancing Evidence-based Practice through Collaboration, The Journal of Nursing Administration, 36(11), 534-537.


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PERIOPERATIVE CERTIFICATION The certification program for perioperative Registered Nurses was established in 1995 by Canadian Nurses Association (CNA) in collaboration with Operating Room Nurses Association of Canada (ORNAC), whose motto is “Promoting Excellence”. The certification exam measures the knowledge, skills, abilities, attitudes, and judgments in specific competency areas required of perioperative Registered Nurses in Canada. The mission of ORNAC includes the promotion and advancement of excellence in perioperative patient care, and the professional and personal enhancement of perioperative Registered Nurses. One of the objectives of the Canadian Nurses Association is to promote high standards of registered nursing practice in specialty areas in order to promote quality nursing care in Canada. Certification confirms this pursuit for quality and excellence. ORNAC supports the CNA certification/ recertification program and recommends that perioperative Registered Nurses in perioperative nursing practice write the certification exam and earn the national credential of Certified Perioperative Nurse (Canada) CPN(C), in order to:

promote high standards of perioperative nursing practice for optimal patient care;

validate competency in perioperative nursing;

meet national standards in perioperative nursing;

confirm commitment to nursing excellence and personal achievement;

confirm professional accountability for continuing education;

promote risk management principles; (CNA, 2006, p. 108)

enhance qualifications;

maintain accountability to the public; and

provide a nationally recognizable level of competency to the employer.

REFERENCES

Canadian Nurses Association. (2006). Perioperative nursing certification exam prep guide. Ottawa: Author


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PERIOPERATIVE NURSING EXPERIENCE IN BASIC REGISTERED NURSING EDUCATION PROGRAMS

The Operating Room Nurses Association of Canada (ORNAC) believes that perioperative clinical experience is the primary means by which student nurses attain knowledge and skills in the management of care for the surgical patient. Whereas the Canadian Nurses Association (CNA) has an ideal opportunity to influence future changes in basic nursing education, and whereas consistency in the basic preparation of nurses is desirable, ORNAC recommends CNA endorse the perioperative experience as an integral component of basic nursing education. Perioperative registered nursing practice encompasses professional and clinical nursing activities, which focus on identifying and meeting the needs of the surgical patient while applying the nursing process. The perioperative Registered Nurse performs in a collaborative role with other members of the health care team. Learning Assumptions

The student nurse gains experience in the perioperative setting as a member of the multidisciplinary team through the use of a conceptual model, the nursing process, and standards of perioperative nursing practice.

The surgical suite provides the best environment for learning perioperative registered nursing practice.

The theory and clinical experiences are best retained when the student can immediately apply what has been

taught. Active participation is the most effective method of teaching and learning.

Advantages of Perioperative Experience 1. For the Student Students gain knowledge and skills through their perioperative experience. Advantages include, but are not limited to:

1.1 Participating in the active management of surgical patients during the preoperative, intraoperative and immediate postoperative phases;

1.2 Developing confidence and assertiveness in the ability to make decisions regarding the care of the surgical patient;

1.3 Improving observational and organizational skills by practicing in an environment where

activities shall be performed quickly and accurately;

1.4 Developing critical-thinking skills through the identification of priorities and the organization of patient care;

1.5 Developing collaborative working relationships within the perioperative environment;

1.6 Communicating effectively with patients and members of the health care team;

1.7 Developing and enhancing leadership skills;

1.8 Developing specialized clinical skills;

1.9 Developing proficiency in the application of aseptic technique;


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1.10 Increasing knowledge of anatomy and pathophysiology by observing the surgical intervention;

1.11 Recognizing how the surgical intervention impacts postoperative care and recovery;

1.12 Recognizing the legal and ethical responsibilities and accountability of the perioperative Registered Nurse and other health care team members; and

1.13 Developing the role of patient advocate.

2. For the Patient Patients benefit from the knowledge and skills that the student nurse gains from experience in the surgical suite. Advantages include but are not limited to: 2.1 Higher quality of care;

2.2 Decreased preoperative and postoperative apprehension, discomfort, and stress due to the Registered Nurse's understanding, empathetic approach, and confidence;

2.3 Improved education for the surgical patient and family due to the Registered Nurse’s increased knowledge base; and

2.4 Reduced risk of infection through improved aseptic technique. 3. For the Employing Agency The employing agency will benefit from the student’s perioperative nursing experience due to their increased understanding of effects of surgical intervention. Advantages include but are not limited to:

3.1 Increased interest in perioperative nursing after graduation, thereby enhancing recruitment and retention strategies;

3.2 Increased knowledge and ability to provide comprehensive care to a wider range of patients;

3.3 Increased understanding of legal issues related to surgical interventions e.g., informed consent, surgical counts;

3.4 Experience functioning as members of the surgical multidisciplinary team;

3.5 Improved communication between departments, health care facilities and schools of nursing; and

3.6 Potential for increased patient satisfaction.


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ENVIRONMENTAL RESPONSIBILITY The Operating Room Nurses Association of Canada (ORNAC) supports the environmental responsibility principles of Reduce, Reuse, Recycle, Recover, and Re-educate. Perioperative Registered Nurses should participate in and support waste management programs and waste reduction initiatives. We must be influential in setting standards and effecting change through environmental awareness within surgical suites, health care facilities, with medical suppliers, and on a professional level. In addition, ORNAC supports compliance with applicable federal, provincial, and municipal government regulations regarding environmental protection issues.

BIBLIOGRAPHY

Canadian Council of Ministers of the Environment (CCME). (1992). Guidelines for the Management of Biomedical Waste in Canada. www.ccme.ca Canadian Nurses Association. (2008). Role of Nurse in Addressing Climate Changes. Ottawa: Author. Canadian Standards Association (CSA) Standard, CAN/CSA-Z317.10-01 (R2006). Handling of Waste Materials in Health Care Facilities & Veterinary Health Care Facilities. Toronto: Author. www.csa.ca Joint Canadian Nurses Association (CNA)/Canadian Medical Association (CMA) (2000). Position Statement – Environmentally Responsible Activity in the Health Sector.

PERIOPERATIVE REGISTERED NURSES ARE ESSENTIAL TO QUALITY PATIENT CARE IN THE OPERATING ROOM

The scope of Perioperative Registered Nursing practice is a continuum ranging from a novice to an expert level of professional nursing that focuses on identifying and meeting the individual needs of the surgical patient, preoperatively, intraoperatively, and immediately postoperatively. Perioperative Registered Nurses are:

professionally responsible and accountable for their practice coordinators of patient care leaders and educators in the health care field cost effective (multi-skilled and cross trained) patient and family advocates risk managers (protect the patient, personnel, and the environment) health promoters

Perioperative Registered Nurses have:

critical-thinking skills a broad knowledge of human and natural sciences specialized surgical nursing knowledge including anatomy, physiology/ pathophysiology, pharmacology,

aseptic technique and assessment skills a functional knowledge of medical legal aspects


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a certification process (examination established by the Canadian Nurses Association) a Code of Ethics through the Canadian Nurses Association which guides nursing practice

Perioperative Registered Nurses:

establish respectful, trusting, therapeutic relationships with patients and their families use the nursing process to direct care use evidence based practice in the provision of nursing care assume new responsibilities in response to the changing needs of patients work independently and collaboratively to provide focused care recognize that all surgery is a major life event for each patient define and direct their practice (Scope of Practice) articulate their roles and expectations as defined by the standards for perioperative Registered Nursing

practice develop and implement policies and protocols to provide safe patient care establish professional working relationships with members of the multidisciplinary team coordinate multidisciplinary team activities care for patients with both predictable and unpredictable outcomes.

Perioperative Registered Nurses will:

develop professionally in response to the changing needs of patients, the health care systems and society.

BIBLIOGRAPHY

Canadian Nurses Association. (2006). Nursing Information and Knowledge Management. Ottawa: Author. Canadian Nurses Association. (2004). Nurses and Patient Safety: A Discussion Paper CNA & Univ. of Toronto Nrsg. Ottawa: Author. Keegan-Doody, M. (2007, June). Walk or be driven? Canadian Operating Room Nursing Journal, 25 (2), 30, 31, 33-35.

THE PERIOPERATIVE REGISTERED NURSES’ ROLE IN PRIMARY HEALTH CARE

The Operating Room Nurses Association of Canada (ORNAC) supports the Canadian Nurses Association’s beliefs that Registered Nurses have a key role in making primary health care a reality in our country. While perioperative Registered Nurses have traditionally not been involved in the provision of initial health care services, a clinical aspect of perioperative nursing practice is broadening in scope within the preoperative, intraoperative and immediate postoperative patient care. This provides the opportunity for more patient and family contact. Within this scope, perioperative Registered Nurses are able to perform direct patient care, teach and educate patients, family, health care personnel and as well the community. Perioperative Registered Nurses support and/or perform research and supervise/manage health care services. Examples of the perioperative Registered Nurse as a primary health care provider are evident in the promotion of:

Healthy lifestyle choices that may prevent possible surgical intervention Participation in health and wellness-related organizations so that activities can be proactive instead of

reactive.


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Surveillance of disease conditions, recurrent operative procedures and patients requiring infection control follow-up.

Health education to patients, students and the public: - Perioperative assessment clinics and/or admission to the operating room suite - Nurse educators and staff to teach students and/other health care team members - Promotion of events such as “National Perioperative Nurses Day”

Collaboration with other primary health care personnel in providing patient care. Effectiveness of services through Quality Improvement Programs with particular emphasis on the effect of

such services on primary health care.

BIBLIOGRAPHY

Canadian Nurses Association. (2005). Unregulated Health Workers A Canadian and Global Perspective, A Discussion Paper. Ottawa: Author. Canadian Nurses Association. (2005). National Planning for Human Health Resources in the Health Sector. Ottawa: Author. Canadian Nurses Association. (2005). Nursing Now Issues and Trends in Canadian Nursing, Nursing Staff Mix: A Key Link to Patient Safety. CNA, 19, Ottawa: Author.

SAFE SURGERY SAVES LIVES: SURGICAL SAFETY CHECKLIST

The Operating Room Nurses Association of Canada (ORNAC) endorses the global efforts to enhance the safety of surgical procedures, to protect patients from harm and ultimately, to save lives. ORNAC is committed to assisting perioperative Registered Nurses in providing the safest care for each surgical patient. ORNAC is aware of the World Health Organization’s (WHO) work to assist in the provision of safe surgery for all patients. The second Global Patient Safety Challenge: “Safe Surgery Saves Lives” is a campaign established by the WHO ‘World Alliance for Patient Safety’ to improve the safety of all surgeries. The goal established was to define global safety standards, which could be applied in all perioperative settings. An International team met in Geneva, January 2008 and created the WHO Surgical Safety Checklist. The WHO Surgical Safety Checklist was launched in North America in June 2008, with prior endorsement of many organizations including the Canadian Anesthesiology Society, Canadian Medical Association, Canadian Nurses Association, International Federation of Perioperative Nurses, Royal College of Physicians and Surgeons of Canada, and the Operating Room Nurses Association of Canada. Toronto General Hospital, University Health Network, was one of the eight global pilot sites for the implementation of the Checklist. There was a significant reduction in deaths and complications for lower income sites using the checklist, and also a reduction in deaths and complications in higher income sites. When surgeons were asked if they would want the checklist used if they were having surgery, nearly 100% of them reported that they would. The research results can be reviewed in the issue of the New England Journal of Medicine identified below. The WHO Surgical Safety Checklist was designed as a template for facility adaption. The Canadian Patient Safety Institute facilitated a working group that adapted the WHO Surgical Safety Checklist to meet the Canadian healthcare context. The Canadian adaption was formally launched at a national meeting in Toronto on March 4, 2009. ORNAC has been represented at each of these activities. ORNAC strongly encourages all perioperative Registered Nurses to use a Surgical Safety Checklist for every patient with every surgical procedure.


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BIBLIOGRAPHY Haynes AB, Weiser TG, Berry, WR, et al (2009). A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population. New England Journal of Medicine, 360 (5), 491-497.

http://content.nejm.org/cgi/content/full/NEJMsa0810119

RESOURCES www.patientsafetyinstitute.ca www.ornac.ca www.safesurgerysaveslives.ca www.who.int/safesurgery


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Part B

STANDARDS

FOR

PERIOPERATIVE REGISTERED NURSING PRACTICE


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STAND

PROFESSIONAL STANDARDS

STANDARD 1: Perioperative Registered Nursing Practice Requires Knowledge From Nursing, The

Sciences, And The Humanities.

STANDARD 2: Perioperative Registered Nursing Practice Requires The Effective Use Of The Nursing Process For Clinical Decision-Making.

STANDARD 3: Perioperative Registered Nursing Practice Requires Perioperative Registered Nurses To Be

Professionally Responsible And Accountable.

STANDARD 4: Perioperative Registered Nursing Practice Requires That A Specific Perioperative Registered Nurses(s) (Specialty Service Team Leader) Shall Be Assigned and Accountable For A Specific Service Or Service Areas, Theatre(s), And/or Coordination Of Multidisciplinary Team Members In The Provision Of Patient Care.

STANDARD 5: Perioperative Registered Nursing Practice Requires That The Perioperative Registered

Nurse Manager Coordinates The Direction And Availability Of Resources At A Departmental Level.

STANDARD 6: Perioperative Registered Nursing Practice Requires That The Perioperative Registered

Nurse Educator Facilitates And Supports The Role Of The Perioperative Team. STANDARD 7: Perioperative Registered Nursing Practice Requires That The Expanded Practice

Perioperative Registered Nurse Facilitates And Supports The Role Of The Perioperative Team and the Perioperative Client.

STANDARD 8: Perioperative Registered Nursing Practice Requires That Perioperative Registered Nurses

Facilitate, Conduct and Support Research. STANDARD 9: Perioperative Registered Nursing Practice Requires that the Advanced Practice Nurse

(Perioperative) Facilitates and Supports the Perioperative Health Needs of Client and the Healthcare Team.


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PROFESSIONAL STANDARDS FOR PERIOPERATIVE REGISTERED NURSES

STANDARD 1: Perioperative Registered Nursing Practice Requires Knowledge From Nursing, The Sciences, And The Humanities. KNOWLEDGE 1.1 Perioperative registered nursing practice requires the use of a conceptual model to

give direction for nursing practice. The perioperative Registered Nurse shall practice in a manner that: 1.1.1 demonstrates knowledge, adheres to and promotes the mission, vision, values, philosophy, objectives, goals, policies and procedures of the organization, while providing patient care; 1.1.2 accomplishes goals consistent with professional perioperative registered nursing standards. These goals

shall contribute to the overall goals of the health care team; 1.1.3 demonstrates knowledge of the health care facilities and surgical suite's organizational charts; 1.1.4 demonstrates knowledge of position description, scope of practice and limitations for surgical suite

personnel; 1.1.5 participates in the formulation and revision of surgical suite goals, objectives, policies and procedures; 1.1.6 ensures a caring, compassionate, and respectful approach is used in meeting the needs and concerns of the

patient and family/significant others; 1.1.7 provides specific care relating to the probable origin of the patient's actual or potential health problem; 1.1.8 improves or maintains the well-being of the patient applying consistency throughout the surgical intervention; 1.1.9 promotes and supports the role of the perioperative Registered Nurse; 1.1.10 helps create a respectful environment that minimizes stress and anxiety; 1.1.11 identifies priority nursing diagnoses through a complete perioperative nursing assessment of the patient; 1.1.12 identifies appropriate nursing interventions specific to individual patients requiring surgical intervention; 1.1.13 evaluates and supports the expected outcomes for the perioperative patient; 1.1.14 promotes the concept of self-care for the perioperative patient; 1.1.15 is based on knowledge of perioperative policies and procedures;


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1.1.16 promotes and participates in orientation of staff, continuing education and maintenance of competence; 1.1.17 promotes and facilitates communication among all members of the health care team; 1.1.18 communicates and collaborates with management to promote and facilitate a progressive surgical suite

consistent with professional nursing standards, ORNAC standards and delivery of quality patient services; and

1.1.19 exhibits clinical, operational, organizational and leadership skills to facilitate achievement of the surgical

suite’s mission, vision, values, philosophy, objectives, and goals in the delivery of safe patient care.

1.2 Perioperative registered nursing practice requires a base of knowledge, skills, and competencies that are current and practical for meeting the needs of the surgical patient.

The perioperative Registered Nurse shall practice in a manner that: 1.2.1 uses current and accepted rationale when implementing nursing actions designed to meet the individual

needs of the surgical patient; 1.2.2 consistently applies the principles of Standard Precautions and additional precautions in reducing the risk of

infection to patients and the health care team; 1.2.3 consistently applies the principles of aseptic technique to reduce the potential risk of infection to the patient

and health care team; 1.2.4 consistently applies safety measures and risk management strategies for all patients and the health care

team; 1.2.5 implements, promotes, and facilitates the scrub, circulating, education, research, leadership roles, as well as

Registered Nurse First Assist (RNFA) and other expanded roles of the perioperative Registered Nurse; 1.2.6 complies with legal and professional requirements to participate in, implement, and maintain a safety and

risk management program that protects the patient and health care team from adverse consequences; 1.2.7 uses and manages human, material, and financial resources effectively; 1.2.8 values, initiates, promotes and participates in ethically approved research projects that are designed to

improve and/or evaluate patient care; 1.2.9 promotes change in nursing practice to strive for the best patient outcome based on the results of such

research; 1.2.10 consistently demonstrates competency in perioperative Registered Nursing practice progressing toward

expert levels; 1.2.11 exemplifies the perioperative Registered Nurse as a role model, preceptor and mentor; 1.2.12 shares knowledge and skills, and supports a positive learning environment for the healthcare team;


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1.2.13 actively pursues, contributes to, plans, and organizes educational activities that maintain current perioperative nursing practice levels consistent with professional nursing standards and ORNAC Standards, Guidelines, and Position Statements For Perioperative Registered Nursing Practice;

1.2.14 incorporates reflective practice; 1.2.15 strives to advance the image of the perioperative Registered Nurse with competent and progressive clinical,

educational, research, leadership and administrative skills; 1.2.16 uses appropriate and professional communication skills (i.e., written, electronic, verbal, and non-verbal) for

the benefit of the patient, health care team, and health care facility; and 1.2.17 actively participates in collaborative practice utilizing positive reinforcement and constructive feedback

among the health care team and self-evaluation.

STANDARD 2: Perioperative Registered Nursing Practice Requires The Effective Use Of The Nursing Process For Clinical Decision-Making

CLINICAL DECISION-MAKING 2.1 Perioperative Registered Nurses are required to collect data during the

perioperative period. The perioperative Registered Nurse shall practice in a manner that: 2.1.1 includes a preoperative assessment prior to surgery through a systematic collection of data using appropriate

sources, including patient, family, significant others, physicians, unit nurses, and other health care team members;

2.1.2 uses appropriate techniques for data collection including interview, consultation, observation, and relevant health record review; 2.1.3 encourages the patient to confirm the assessment, allowing time to identify and discuss concerns and

expectations relative to the impending surgery and care; 2.1.4 provides information, resources, and/or other personnel to assist the patient/ legal designate in making

informed decisions and addressing concerns; 2.1.5 uses detailed assessment, intuitive, and observation skills to obtain information when the patient is unable to

participate and family/legal designate are not available; 2.1.6 encourages the expression of individual diversity regarding culture, race, age, sexual orientation, gender,

beliefs and values; and 2.1.7 respects patient’s and/or family's/significant others, or legal designate’s wishes i.e., a living will, power of

attorney, and personal care directives. 2.2 Perioperative Registered Nurses are required to analyze data collected in

accordance with the goals of perioperative registered nursing practice and knowledge from related fields.


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The perioperative Registered Nurse shall practice in a manner that: 2.2.1 effectively integrates and utilizes all data collected by the health care team to reduce redundant and

repetitive practices of questioning and review;

2.2.2 validates the assessment with the patient, and/or others as required to facilitate interpretation of the data collected;

2.2.3 reassures the patient that the surgical team will analyze data and determine/identify actual and potential

problems; 2.2.4 communicates relevant data to the patient and appropriate others regarding identified actual and/or potential

problems; and 2.2.5 identifies and records specific nursing diagnoses and observations that define individual needs of the patient. 2.3 Perioperative Registered Nurses are required to plan their nursing actions based

upon the identified actual and/or potential problems. The perioperative Registered Nurse shall practice in a manner that: 2.3.1 identifies and establishes priorities of patient care based on the preoperative assessment and nursing

diagnosis related to actual and/or potential health problems recognizing the patient’s individual diversities; 2.3.2 selects appropriate nursing actions based on the identified needs of the patient; 2.3.3 assists in identifying and reducing risk factors, actual or potential, that may compromise the patient, the

health care team, and the health care facility; 2.3.4 affirms the patient's readiness and willingness for the surgical intervention; 2.3.5 strives to provide environmental conditions that are conducive to positive patient outcomes; 2.3.6 strives to provide the required staffing and material resources for the specific patient needs; 2.3.7 communicates the plan of care to the patient, specified family members/designate, and the health care team;

and 2.3.8 provides a mechanism for, and actively participates in communication and problem solving with the patient,

family/legal designate, and the health care team. 2.4 Perioperative Registered Nurses are required to perform nursing actions, which

implement the nursing care plan. The perioperative Registered Nurse shall practice in a manner that: 2.4.1 encourages patient and family/significant other’s participation in implementation of nursing actions,

recognizing their individual diversities;


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2.4.2 presents a competent, professional and caring approach, which includes identifying themselves, their role and responsibilities throughout the perioperative experience;

2.4.3 assists the patient to anticipate and understand steps in the care provided; 2.4.4 demonstrates responsibility, and accountability in implementing the nursing plan of care; 2.4.5 appropriately communicates nursing assessments, care activities, and interventions to the health care team; 2.4.6 appropriately delegates patient care activities to the health care team within their scope of practice and job

description; 2.4.7 effectively uses the appropriate human and material resources for patient care; 2.4.8 provides optimal care by adjusting the surgical theatre environment to meet the specific patient needs; 2.4.9 effectively communicates nursing interventions to the patient and/or family/legal designate; 2.4.10 consistently applies knowledge, and uses skills, competencies, and safety measures; 2.4.11 assists the anesthesiologist in providing patient care consistent with the knowledge, competencies, and skills

of the perioperative Registered Nurse; 2.4.12 provides psychological and physical support to the patient during local anesthesia and conscious sedation; 2.4.13 monitors and accurately documents patient parameters during local anesthesia and in procedures when an

anesthesiologist is not present; 2.4.14 assists, facilitates, and supports the surgical team's activities throughout the perioperative experience; 2.4.15 provides appropriate response to emergency situations; 2.4.16 maintains accurate, legible, timely and complete documentation, using only accepted abbreviations of the

health care facility; and

2.4.17 contributes to and maintains a communication network that facilitates a progressive, integrated, successful, positive, and safe work environment.

2.5 Perioperative Registered Nurses are required to evaluate all steps of the nursing

process. The perioperative Registered Nurse shall practice in a manner that: 2.5.1 evaluates and communicates the outcomes of patient care; and 2.5.2 respects the individual diversity of the patient while recommending, supporting and implementing

modifications to the nursing care plan.


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STANDARD 3 Perioperative Registered Nursing Practice Requires Perioperative Registered Nurses To Be Professionally Responsible And Accountable.

PROFESSIONAL RESPONSIBILITY AND ACCOUNTABILITY 3.1 Perioperative Registered Nurses are required to comply with legislation and policies

relevant to the profession and the Surgical Suite. The perioperative Registered Nurse shall practice in a manner that: 3.1.1 adheres to the professional and legally recognized scope of practice for the protection of the patient, self,

employer, and the health care team; 3.1.2 complies with organizational and regulatory body policies and legalities pertaining to perioperative

registered nursing practice; 3.1.3 reports and documents errors, near misses, unsafe practice, incapacity, incompetence, or professional

misconduct to the appropriate person(s); 3.1.4 is based on knowledge, and practice requirements related to registration, competence, credibility and

licensure of the perioperative Registered Nurse; and 3.1.5 demonstrates the responsibility to notify their employer that they are unable to give appropriate care if they

do not have the necessary physical, mental or emotional health.

3.2 Perioperative Registered Nurses are required to be professionally responsible and accountable.

The perioperative Registered Nurse shall practice in a manner that: 3.2.1 values, and meets the needs of, patients and the health care team; 3.2.2 provides appropriate documentation and effective reporting of sentinel events, crisis situations and near

misses; 3.2.3 provides appropriate and safe patient care regardless of personal limitations or prejudices; 3.2.4 exercises prudent and reasonable judgment in completing perioperative nursing activities in a timely

fashion; 3.2.5 delivers clinical practice that reflects current evidence-based knowledge; 3.2.6 consistently demonstrates responsibility and accountability for own actions; 3.2.7 monitors actions of the health care team that constitute non-compliance and reports/documents

appropriately; 3.2.8 promotes patient advocacy and practices patient safety; 3.2.9 promotes professional perioperative registered nursing activities;


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3.2.10 encourages, participates in, and supports programs that provide professional development; 3.2.11 encourages, participates in, and supports preceptorship and mentoring of students, novices, and newly hired

perioperative Registered Nurses, colleagues and auxiliary personnel; 3.2.12 uses knowledge, skills, and competencies consistent with the standards for perioperative registered nursing

care and other related standards; 3.2.13 confirms that emergency equipment and supplies are available at all times and has knowledge of their use; 3.2.14 exhibits knowledge of, and participation in, safety programs that protect the patient, self, and the health care

team; and 3.2.15 demonstrates awareness of the evacuation routes out of the surgical suite and is familiar with disaster plans. 3.3 Perioperative Registered Nurses are required to comply with the Code of Ethics for

Registered Nurses. The perioperative Registered Nurse shall practice in a manner that: 3.3.1 complies with the Canadian Nurses Association Code of Ethics for Registered Nurses. 3.4 Perioperative Registered Nurses are required to function as an integral member of

the health care team. The perioperative Registered Nurse shall practice in a manner that: 3.4.1 maintains a collaborative and professional working relationship with the health care team, including but not

limited to, surgeons, anesthesiologists, nursing units, administration, interdisciplinary teams, auxiliary staff and colleagues, to achieve and maintain an efficient, effective safe working environment;

3.4.2 actively promotes and collaborates with administration to facilitate empowerment and job satisfaction; 3.4.3 promotes and exhibits skills in conflict resolution, interpersonal relationships, and leadership; 3.4.4 demonstrates respect, a caring attitude, and professional conduct; 3.4.5 encourages and provides collaboration with the health care team to complete the nursing process; 3.4.6 facilitates coordination of patient care within a multidisciplinary team; 3.4.7 demonstrates efficient management of human, material, and financial resources; 3.4.8 assigns and evaluates the use of resources in collaboration with the surgical suite team to determine staffing,

equipment and resources necessary to comply with safety standards and guidelines; and 3.4.9 demonstrates zero tolerance for violence, bullying, harassment and discrimination in the workplace.


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STANDARD 4: Perioperative Registered Nursing Practice Requires That A Specific Perioperative

Registered Nurse(s) (Specialty Service Team Leader) Shall Be Assigned And Accountable For A Specific Service Or Service Areas, Theatre(s), And/or Coordination Of Multidisciplinary Team Members In The Provision Of Patient Care.

4.1 Perioperative registered nursing practice requires a complex level of coordination of

multidisciplinary team members to provide surgical intervention, which encompasses a significant number of risk potentials. A theatre, surgical suite or service area(s) require an assigned perioperative Registered Nurse to coordinate activities.

The perioperative Registered Nurse assigned a service, theatre, or group of theatres shall practice in a manner that: 4.1.1 confirms that an identified, qualified, perioperative Registered Nurse is assigned to and accountable for the

care of patients in that service; 4.1.2 maintains and expands specialty knowledge, implements and communicates changes in the specialty

service; 4.1.3 demonstrates leadership skills to support and advance the practice of the health care team; 4.1.4 coordinates preoperative communication with the health care team i.e., changes in the scheduled surgery

time; 4.1.5 builds and promotes a collegial relationship between other units and the surgical suite for continuing

education, service delivery, and continuous quality improvement that will benefit and enhance patient care; 4.1.6 collaborates with administration to maintain and acquire appropriate instrumentation, equipment and new

technology; and 4.1.7 maintains a relationship with vendor representation in accordance with corporate policies and that assists in

the provision of education for the health care team. 4.2 Perioperative Registered Nurses assigned a service, theatre, or group of theatres

shall establish a collaborative relationship and environment that facilitates the role of the surgeon.

The perioperative Registered Nurse shall practice in a manner that: 4.2.1 verifies accurate scheduling information for each patient and resolves discrepancies; 4.2.2 identifies and monitors staff identification of problems related to resource limitations or equipment

deficiencies in order to facilitate alternate plans; 4.2.3 organizes surgery times in consultation with staff and physicians, to meet the needs of the patient and the

health care team;


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4.2.4 monitors requirements for surgical assistance and/or equipment in consultation with the surgeon for specific types of surgery, ensuring availability of equipment; and

4.2.5 confirms the environment and personnel are prepared in sufficient time to facilitate surgical procedures. 4.3 Perioperative Registered Nurses assigned a service, theatre, or group of theatres shall

establish a collaborative relationship and environment that facilitates the role of the anesthesiologists.

The perioperative Registered Nurse shall practice in a manner that: 4.3.1 confirms that theatre and anesthetic equipment, supplies, and required drugs are available prior to the

admission of the patient to the theatre;

4.3.2 acknowledges the importance and critical nature of anesthesia by being present to assist with pre-induction, induction, positioning, and emergence;

4.3.3 assists with, and effectively communicates complications or difficult situations/crisis to the appropriate

personnel; and 4.3.4 serves as a resource and mentor to other perioperative Registered Nurses regarding effectively and

efficiently assisting the anesthesiologist. 4.4 Perioperative Registered Nurses assigned a service, theatre, or group of theatres

shall establish a collaborative relationship and environment with auxiliary personnel and interdisciplinary members of the health care team.

The perioperative Registered Nurse shall practice in a manner that: 4.4.1 maximizes resources and experience in assigning scrub, circulating, charge and preceptor duties for patient

care, teaching and staff development; 4.4.2 promotes a work environment that minimizes stress, anxiety, and respects individual health care team

members;

4.4.3 supports an environment that integrates and maximizes collaboration with the health care team by taking appropriate action when non-supportive or unacceptable behaviors occur;

4.4.4 assists in the orientation of perioperative personnel and provides positive and constructive feedback related

to performance; 4.4.5 identifies and monitors areas for improvement with specific recommendations; 4.4.6 apprises administration of activities, problems, solutions, recommendations, and performance of the health

care team; 4.4.7 assigns auxiliary personnel to maximize patient care, efficiency, and resources; 4.4.8 acts as a resource to staff in the management of equipment and instrumentation with respect to safety,

aseptic technique, preventative maintenance, care, and handling according to health care facility protocols and manufacturer's recommendations; and


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4.4.9 monitors compliance with policies, procedures, and promotes ORNAC Standards, Guidelines and Position Statements For Perioperative Registered Nursing Practice.

4.5 Perioperative Registered Nurses assigned a service, theatre, or group of theatres

shall establish a supportive environment for the patient. The perioperative Registered Nurse shall practice in a manner that: 4.5.1 supports the patient throughout the perioperative phases by acting as a patient advocate; 4.5.2 reduces waiting time to a minimum for the patient waiting in the preoperative phase in the surgical suite; 4.5.3 reduces the stresses of the pre-induction phase by coordinating and organizing activities, providing physical

comfort, controlling temperature, and reducing noise levels; 4.5.4 strives to reduce patient risk; 4.5.5 facilitates positive patient outcomes in an expedient and effective manner; and 4.5.6 communicates with family/designate/significant other.

PROFESSIONAL STANDARDS FOR PERIOPERATIVE REGISTERED

NURSE MANAGERS STANDARD 5 Perioperative Registered Nursing Practice Requires That The Perioperative

Registered Nurse Manager Coordinates The Direction And Available Resources At A Departmental Level.

MANAGEMENT 5.1 The perioperative Registered Nurse manager works collaboratively with all

members of the health care team to ensure appropriate resource allocation and to provide direction.

The perioperative Registered Nurse manager shall practice in a manner that: 5.1.1 ensures the facility mission; vision, values, philosophy, objectives and goals are communicated and

available to the health care team; 5.1.2 ensures surgical suite objectives and goals are compatible with those of the facility, and are communicated

and available to the health care team; 5.1.3 assures current policies, procedures, and protocols, ORNAC Standards, Guidelines and Position statements

for Perioperative Registered Nursing Practice, perioperative nursing resource material and relevant CSA standards are available for the health care team;

5.1.4 ensures the health care team is compliant with facility policies, procedures, and protocols, local, provincial


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and federal legislation, and professional standards of practice; 5.1.5 provides the health care team with a current organizational chart outlining department structure, lines of

reporting, communication, authority and accountability; 5.1.6 maintains current position descriptions; 5.1.7 ensures the health care team is knowledgeable about expectations, roles, responsibilities and

accountabilities; 5.1.8 completes a review of department policies, procedures and protocols based on standards of practice, job

descriptions, and health care team input according to the frequency required by the health care facility; 5.1.9 promotes patient advocacy and supports the patient’s right to self-determination; 5.1.10 facilitates, promotes and encourages interdisciplinary perioperative activities, projects, audit reviews and

research; 5.1.11 facilitates, promotes, and encourages perioperative Registered Nurses to participate in the development,

review, and revision of policies and procedures, related to perioperative Registered Nurses’ documentation; 5.1.12 ensures compliance with documentation requirements and incorporation of current standards; 5.1. 13 provides the health care team with appropriate educational opportunities for improvement of identified learning needs; 5.1.14 facilitates and encourages staff development, continuing education and membership in perioperative professional organizations; 5.1.15 ensures an appropriate orientation program is provided by the perioperative educator or a qualified

designate; 5.1.16 employs health care team members with knowledge, experience, attitude, skills, competencies, and

attributes to support excellence in patient care within a positive high-performance team; 5.1.17 facilitates, promotes and encourages active participation of the health care team in responsible and efficient

management of human, material and financial resources; 5.1.18 provides health and wellness information, and promotes regular attendance at work;

5.1.19 completes performance appraisals in a timely manner, including review of accomplishments and

competencies, assisting the team members to perform self-assessment, establishment of goals for performance improvement, competency enhancement and professional development;

5.1.20 maintains effective risk management strategies including prevention, reporting, investigation, and resolution

of unusual occurrences and sentinel events; 5.1.21 ensures implementation of a safety program with a focus on prevention of adverse events for patients and

the health care team; and 5.1.22 promotes a practice environment that supports effective interdisciplinary communication, professional responsibility and accountability, critical-thinking and problem-solving.


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5.2 The Perioperative Registered Nurse manager encourages continued professional development of health care team members.

The perioperative Registered Nurse manager shall practice in a manner that: 5.2.1 encourages and promotes health care team members to participate and collaborate in research; 5.2.2 encourages evidence-based decision-making in the formulation of policies and procedures affecting surgical

suite practices; 5.2.3 facilitates and promotes respect, caring, and professional conduct among all health care team members; 5.2.4 establishes and promotes an open and positive interpersonal communication network; and 5.2.5 models, promotes and encourages the acquisition and maintenance of Certification in Perioperative Nursing

for perioperative Registered Nurses. 5.3 The Perioperative Registered Nurse manager implements a continuous quality

improvement program. The perioperative Registered Nurse manager shall practice in a manner that: 5.3.1 collaborates with quality improvement personnel to promote enhancement of perioperative care; 5.3.2 ensures professional nursing standards, ORNAC Standards, Guidelines, and Position Statements for Perioperative Registered Nursing Practice, and appropriate CSA Standards are easily accessible; 5.3.3 provides human and material resources within the existing budget of the health care facility while

maintaining standards of patient care; 5.3.4 encourages staff to participate in the quality improvement cycle; and 5.3. 5 reviews quality improvement reports, evaluates recommendations, shares information with the health care

team in a timely manner, and ensures appropriate changes are implemented and sustained.

PROFESSIONAL STANDARDS FOR PERIOPERATIVE REGISTERED

NURSE EDUCATORS STANDARD 6 Perioperative Registered Nursing Practice Requires That The Perioperative

Registered Nurse Educator Facilitate And Supports The Role Of The Perioperative Team.

6.1 The perioperative team requires a variety of specific skills and knowledge for a high

level of performance, which is best achieved when the perioperative Registered Nurse educator facilitates and supports the learning needs of the team.


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The perioperative Registered Nurse educator shall practice in a manner that:

6.1.1 demonstrates leadership as it relates to health trends and issues for perioperative nursing; 6.1.2 encourages staff and students to identify their learning needs; 6.1.3 facilitates staff and student learning to acquire the requisite skills and knowledge in the appropriate job

classification; 6.1.4 co-ordinates resources for appropriate orientation for students and new staff members; 6.1.5 supports staff and students in establishing expectations of performance, competency, goals, and

opportunities at time of hire;

6.1.6 facilitates staff and students’ learning opportunities; 6.1.7 provides professional and educational resources as required; 6.1.8 facilitates, supports, and/or contributes to resources required for ongoing post basic education, certification,

and expanded/advanced perioperative registered nursing roles;

6.1.9 provides assistance to staff and students who are developing educational materials and presentations; 6.1.10 facilitates opportunities for continuing education, such as specialty development, and emerging

technologies; 6.1.11 facilitates staff and students in problem-solving and goal attainment; 6.1.12 demonstrates a team approach in coordinating educational activities; 6.1.13 assists perioperative team members to apply theory to perioperative practice; 6.1.14 monitors and adjusts efficacy of educational activities for continuous quality improvement of learner and

patient outcomes; 6.1.15 supports and contributes to a learning environment that is appropriate for the patient care and services that

are provided; 6.1.16 facilitates and supports an environment that demonstrates zero tolerance for violence, bullying, harassment and discrimination in the workplace; 6.1.17 facilitates an environment that is conducive to change and encourages collaborative practice; 6.1.18 collaborates with a multidisciplinary team to solve problems and change processes to improve function,

quality of patient care, and support systems; 6.1.19 develops and supports specialty service team leaders, preceptors and mentors; 6.1.20 facilitates a structured means to improve performance of team members not meeting expected standards in a

timely and progressive manner ; 6.1.21 demonstrates knowledge of the strategic plan of the organization and anticipates the related educational

needs;


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6.1.22 contributes to the development and revision of standards of nursing practice; 6.1.23 monitors compliance with policies, procedures, and promotes ORNAC Standards, Guidelines and Position

Statements for Perioperative Registered Nursing Practice; 6.1.24 promotes and encourages research; 6.1.25 shares relevant research findings with staff, students and colleagues formally and informally; 6.1.26 demonstrates excellent organizational skills and facilitates processes for staff to achieve excellence in

perioperative patient care; 6.1.27 co-ordinates the monitoring of probationary performance through consultation processes for the completion of appraisals; 6.1.28 supports the health care team’s understanding of the importance of compliance with departmental

policies, procedures and protocols; and 6.1.29 supports and encourages staff and students to actively participate in their professional groups or organizations.

BIBLIOGRAPHY

Association of PeriOperative Registered Nurses. (2008). Perioperative standards and recommended practices. Denver: Author. Canadian Nurses Association. (2008). Code of ethics for Registered Nurses. Ottawa: CNA. Philips, N. (2007). Berry & Kohn’s operating room technique. (11th ed.). Toronto: Mosby.

PROFESSIONAL STANDARDS FOR EXPANDED PRACTICE PERIOPERATIVE REGISTERED NURSES

STANDARD 7: Perioperative Registered Nursing Practice Requires That The Expanded Practice

Perioperative Registered Nurse Facilitates And Supports The Role Of The Perioperative Team and the Perioperative Client.

Perioperative nursing is a specialized area of practice. Perioperative registered nursing practice encompasses a wide range of specialties. Currently in Canada, there are two recognized roles for expanded practice, the Registered Nurse First Assistant (RNFA) and the Registered Nurse Anesthetic Assistant (RNAA). These roles require the perioperative Registered Nurse to obtain, through formal education, preparation that includes supervised clinical practice, development of cognitive, psychomotor and affective behaviors that are necessary to function in a collaborative relationship with the operating surgeon and/or anesthesiologist and other members of the health care team. (Vaiden, 2005, p.1). Registered Nurse First Assistants and Registered Nurse Anesthetic Assistants progress from novice to expert, as nurses generally function at a variety of levels depending on knowledge, skills, work environment, and experience.


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7.1 The expanded practice perioperative Registered Nurse is accountable and responsible for their actions within accepted legal, professional and ethical standards established by their regulatory body.

The expanded practice perioperative Registered Nurse shall practice in a manner that: 7.1.1 is responsible for continuing education and maintaining competence; and 7.1.2 is accountable for their own level of competence while acting in this role and seeks consultation as required. 7.2 The expanded practice perioperative Registered Nurse demonstrates competencies

relevant to their own perioperative practice environment. The expanded practice perioperative Registered Nurse shall practice in a manner that: 7.2.1 delivers expert care drawn from integrated knowledge and experience, and integrates knowledge from other

disciplines into their practice; 7.2.2 demonstrates knowledge grounded in nursing and medical theory, professional standards, competencies,

and ethical reasoning; 7.2.3 facilitates the integration of research-based knowledge into their practice; 7.2.4 demonstrates the ability to influence health policy by using critical thinking skills; and 7.2.5 promotes a practice environment that supports continuous professional development of standards, which are

evidence based.

7.3 The expanded practice perioperative Registered Nurse advocates for patients. The expanded practice perioperative Registered Nurse shall practice in a manner that: 7.3.1 promotes a practice environment that advocates for the patients; and 7.3.2 promotes a safe environment facilitating optimal patient outcomes.

REFERENCES

Association of PeriOperative Registered Nurses. (2005). Core Curriculum for the RN First Assistant. (4th Ed.). Denver: Author. Vaiden, R. E. (ed) (2005). Core Curriculum for the RN First Assistant. (4th Ed.). Denver: AORN.


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BIBLIOGRAPHY

Arpin, J. (2005). Nurse First Assistant, (NFSA) Canadian Operating Room Nursing Journal, 23(4), 32- 36. Australian College of Operating Room Nurses. (2006). ACORN Standards for Perioperative Nursing Practice including Nursing Roles, Guidelines, Position Statements and Competency Standards, Anesthetic Nurses, NR1. Adelaide: ACORN. Australian College of Operating Room Nurses. (2006). ACORN Standards for Perioperative Nursing Practice including Nursing Roles, Guidelines, Position Statements and Competency Standards, Perioperative Nurse Surgeon’s Assistant, (PNSA). Adelaide: ACORN. Australian College of Operating Room Nurses. (2006). ACORN Standards for Perioperative Nursing Practice including Nursing Roles, Guidelines, Position Statements and Competency Standards, Advanced Practice Nursing Role, (NR5). Adelaide: ACORN. College of Registered Nurses of Nova Scotia. (2005). Position statement on Registered Nurse First Assistant Role, Halifax: CRNNS. Giannidis, R. (2005). RNFAs: one innovative solution as hospitals cope with doctor shortage, Hospital News, 18(1), 17. Groezsch, G. (2004). Why An RN First Assistant? A Look at the Benefits. Canadian Operating Room Nursing Journal, 21(2), 21-23. Ilton, S. (2002). The Benefits of Registered Nurse First Assistant Practice, Canadian Nurse, 98(6), 22-27. National Health System. (2006). National Practitioner Program Physician Assistant Factfile, UK, NHS. Nurses Association of New Brunswick, (2003). Position Statement Registered Nurse First Assistant, (RNFA), Saint John, NANB. Phillips, N. (2007). Berry & Kohn’s Operating Room Techniques. (11th ed.). St Louis: Mosby. Rothrock, J. (2007). Alexander’s Care of the Patient in Surgery. (13th ed.). St. Louis: Mosby. Spry, Cynthia. (2005). Essentials of Perioperative Nursing, 3rd (ed.). Sudbury Mass: Jones & Bartlett. Weeks, M. (2002). Determining the cost-effectiveness of the Registered Nurse First Assistant: the Research Link. Canadian Operating Room Nursing Journal, 20(4), 16-21.

PROFESSIONAL STANDARDS FOR PERIOPERATIVE REGISTERED NURSES CONDUCTING RESEARCH

STANDARD 8: Perioperative Registered Nursing Practice Requires That Perioperative Registered

Nurses Facilitate, Conduct and Support Research. As nursing practice is evidence-based, nursing research related to clinical practice, education, and management within the perioperative setting is essential to the achievement and maintenance of optimal patient outcomes. Research is a professional obligation and assists in providing and ensuring evidence- based practice that is safe and effective. Registered Perioperative Nurses assume different roles in the research process as appropriate to their education, competence, roles and responsibilities. (CRNBC, 2005)


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8.1 The perioperative Registered Nurse shall conduct research according to the nursing research process. This process will be ethical, open, honest and transparent.

The perioperative Registered Nurse conducting research shall practice in a manner that includes:

8.1.1 writing the research proposal; 8.1.2 identifying and focusing on the issue; 8.1.3 defining the aims of the study; 8.1.4 establishing and ensuring its’ ethical status; 8.1.5 measuring, collating and analyzing the data; 8.1.6 making conclusions and recommendations; and 8.1.7 reporting and disseminating the findings. 8.2 Perioperative Registered Nursing research shall be conducted within the parameters

of competent, professional, safe, and ethical registered nursing research practice. The perioperative Registered Nurse conducting research shall practice in a manner that: 8.2.1 performs research within the accepted legal, professional, and ethical standards; 8.2.2 functions within the policies and guidelines of specific organizations, federal and provincial/ territorial

legislation; 8.2.3 respects the rights of patients, their families, and individuals involved in a research project; 8.2.4 promotes a research environment that supports patient advocacy, participation and safety; and 8.2.5 is professionally accountable and responsible while practicing within a research environment. 8.3 Research-based knowledge shall be integrated into practice to improve the quality of

perioperative patient care. The perioperative Registered Nurse shall practice in a manner that:

8.3.1 uses research to demonstrate the relationship between nursing interventions and patient outcomes; 8.3.2 promotes a practice environment, which supports the conduct of research; 8.3.3 facilitates closing the gap between theory and practice in order that the results of research may be safely

implemented; and 8.3.4 demonstrates cognizance of topics requiring research. 8.4 Perioperative Registered Nurses shall participate in nursing research.


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The perioperative Registered Nurse shall practice in a manner that: 8.4.1 participates in research activities such as data collection, dissemination of research results, implementation

of recommendations, and identifying areas for further research; 8.4.2 recognizes areas of patient care, which may be improved through research; 8.4.3 informs colleagues of research activities; 8.4.4 advocates for ongoing research designed to identify best nursing practices and for collection and interpretation of nursing case data at a national level (CNA Code of Ethics, 2002); and 8.4.5 promotes a work environment, which supports and enhances research.

REFERENCES Canadian Nurses Association. (2008). Code of ethics for Registered Nurses. Ottawa: CNA. College of Registered Nurses of British Columbia, (2005). Position statement Nursing and Research. Vancouver: CRNBC.

BIBLIOGRAPHY

Association of PeriOperative Registered Nurses. (2008). Perioperative standards and recommended practices. Denver: Author. Australian College of Operating Room Nurses. (2006). ACORN Standards for Perioperative Nursing Practice including Nursing Roles, Guidelines, Position Statements and Competency Standards, Anesthetic Nurses, NR1. Adelaide: ACORN. Beyea, Suzanne C. (2004). Evidence-based practice in perioperative nursing. American journal of Infection Control, 32(2), 97-100. Canadian Nurses Association. (2002). Position statement on expanded nursing practice. Ottawa: Author. Canadian Nurses Association (2002). Everyday Ethics- Putting the code into practice (2nd ed.). Ottawa: Author. College of Registered Nurses of British Columbia, (2005). Position statement Nursing and Research. Vancouver: CRNBC. Wilkes, Lesley, (2005). Role Conflict: appropriateness of a nurse researchers actions in the clinical field. Nursing Research, 14(5), 57-70.


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PROFESSIONAL STANDARDS FOR ADVANCED PRACTICE NURSES (PERIOPERATIVE)

STANDARD 9: Perioperative Registered Nursing Practice Requires that the Advanced Practice Nurse

(Perioperative) Facilitates and Supports Meeting the Perioperative Health Needs of Individuals, Families, Groups, Communities, and Populations.

Definition: “Advanced nursing practice is an umbrella term describing an advanced level of clinical nursing practice that maximizes the use of graduate educational preparation, in-depth nursing knowledge and expertise in meeting the health needs of individuals, families, groups, communities, and populations” (CNA, 2008, p. 9). Advance Practice Nurses (APN) include both Nurse Practioners (NP) and Clinical Nurse Specialists (CNS). APNs are change agents who function as consultants, researchers, educators, administrators and practicing caregivers. Accountability and Responsibility 9.1 The APN (Perioperative) is accountable and responsible to the public for safe,

competent, effective, evidence-based, and ethical nursing practice whether providing direct perioperative healthcare or through a supportive/consultative role .

APNs (Perioperative) have greater autonomy with a high level of accountability and shall practice in a manner that: 9.1.1 is appropriate for nurses who have acquired education at the graduate level to meet the needs of the

perioperative population (Masters or Doctorate with an advanced practice concentration); 9.1.2 contributes to the evolution of the role; 9.1.3 requires continued competence to meet the evolving challenges of health care delivery. 9.1.4 promotes perioperative nursing research and generates new knowledge (CNA, 2008); and 9.1.5 uses academic preparation, synthesis and knowledge-transfer skills to interpret and incorporate new knowledge into clinical practice (CNA, 2008, p. 13) 9.2 The APN (Perioperative) continuously evaluates their practice based on defined core

competencies. Advocate 9. 3 The APN (Perioperative) is an active client advocate. The APN (Perioperative) will advocate for clients in a manner that: 9.3.1 consistently demonstrates autonomy of practice in collaboration with other

disciplines; 9.3.2 promotes an environment where advocacy is the norm; and 9.3.3 acts to influence organizational and health care policy.


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REFERENCES Canadian Nurses Association. (2008). Advanced Nursing Practice a National Framework. Ottawa: Author. Hamric, A.B., Spross, J.A., and Hanson, C.M., (2005). Advanced nursing practice: An integrative approach. Philadelphia: W.B.Saunders Company.

BIBLIOGRAPHY

Canadian Nurses Association. (2008). Position Statement - Workplace Violence. Ottawa: Author. Canadian Nurses Association. (2004). Position Statement - Promoting Culturally competent Care. Ottawa: Author. Canadian Nurses Association. (2004). Joint Position Statement - Promoting Continuing Competence. Ottawa: Author. Newland, C. E. M. (2007, June). The joys of perioperative nursing. Canadian Operating Room Nursing Journal,25 (2), 20, 22, 23, 25-28, 36. Reseoul, S. L. (2008). Making a Difference Through Research. AORN Journal, 88 (5). Rothrock, J. C. (2009). Education an Issue of Perioperative Nursing Clinics. Philadelphia: Elsevier/Mosby. Saskatchewan Registered Nurses Association (SRNA), (2007). Standards and Foundation Competencies for the

Practice of Registered Nurses. Regina: Author.


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Part C

COMPETENCIES

FOR

PERIOPERATIVE REGISTERED NURSING PRACTICE


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Competencies range in progression from those expected of the beginner/novice to those essential in the expert. These stages may be defined as follows:

The novice states and/or demonstrates knowledge and skills but is still learning to anticipate and incorporate perioperative skills into efficient planning, actions, and clinical decision-making. Performance requires supervision, coaching, and preceptoring.

The intermediate practitioner confidently and accurately applies knowledge and skills in the clinical setting, is capable of anticipating, and is prepared to function independently and be supportive to others, in usual or unusual circumstances. Performance may require occasional supervision and coaching. The intermediate practitioner is able to assist, guide, teach, and supervise the beginner and take charge of limited situations. The expert's scope of knowledge and skills is such that all actions are directed toward anticipated outcomes. The expert intuitively adapts to changing situations and implements the appropriate action(s) prior to the event(s) or demand(s) of patient care. The expert perioperative Registered Nurse will independently supervise, teach and coach/precept health care team members, manage direct patient care, and the specific theatre or the entire surgical suite. The expert practices as a role model and mentor and is able to take charge and effectively manage complex situations.

PURPOSE OF COMPETENCY STATEMENTS

Competency statements for perioperative Registered Nurses shall:

affirm that perioperative Registered Nurses are responsible for the nursing care they provide to the surgical patient during the perioperative period;

state the knowledge, skills, professional practice, and leadership required for accountable clinical decision-

making; assist in the development and maintenance of the perioperative Registered Nurses’ position descriptions;

provide the basis for orientation and continuing/formal educational programs;

provide perioperative Registered Nurses with a tool for performance appraisal and self-evaluation;

enhance the professional image of perioperative Registered Nurses;

assist in the development of a standard guideline for working with CNA and all schools of nursing in

promoting perioperative experience in basic nursing education;

assist in the development, revision, and integration of the Canadian Standards Association (CSA) Standards; and

provide a basis for clinical advancement, career development, leadership opportunities, and expanded

perioperative practice.


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Knowledge, Skills and Attributes Expected of the Registered Nurse Entering The Specialty of Perioperative Nursing

A Registered Nurse shall bring:

a holistic approach to patient care that incorporates knowledge of the biological, physiological, psychological, social, cultural, environmental, and spiritual needs of the patient;

the ability to relate disease processes, trauma, and illness to health and wellness, recognizing the impact of

the environment and support systems on overall patient outcomes;

knowledge of the natural and social sciences (anatomy, physiology, microbiology, psychology, sociology, and pharmacology);

the ability to apply the nursing process in problem-solving and clinical decision-making using evidence-

based knowledge;

a caring attitude that includes acting as a patient advocate;

the ability to assist and support patients or their designates to make informed choices;

effective and positive communication and interpersonal skills;

the ability to provide quality education to patients and their families/significant others;

personal commitment to the nursing profession, which is demonstrated by accountability and responsibility for continuing education, maintenance of competencies, quality improvement in nursing practice, and involvement in professional associations;

a positive attitude, willingness and ability to mentor/preceptor members of the health care team;

psychomotor dexterity that indicates the ability to accurately perform complex skills in limited time periods;

and

the ability to recognize and manage personal stress and stressful situations in a constructive and positive manner.


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CHARACTERISTICS OF EACH COMPETENCY

The specialty of perioperative nursing requires that specific competencies be identified, progressing from the beginner to expert practitioner. All of the following characteristics are integrated components for each competency statement:

knowledge; respect; clinical decision-making; communication skills; team-work skills; accountability and responsibility; organizational skills; and teaching and leadership ability.

COMPETENCIES OF PERIOPERATIVE REGISTERED NURSES

COMPETENCY 1: Practices Professionally

COMPETENCY 2: Provides Physical Care

Circulating Role Scrub Role

COMPETENCY 3: Provides Supportive Care

Client/Designate Health Care Team Members

COMPETENCY 4: Promotes A Safe Environment COMPETENCY 5: Responds To Urgent/Emergency Situations COMPETENCY 6: Manages Resources


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COMPETENCIES OF THE PERIOPERATIVE REGISTERED NURSE

COMPETENCY 1: Practices Professionally LEGAL PRACTICE The perioperative Registered Nurse shall practice in a manner that: 1.1 is congruent with the CNA Code of Ethics and healthcare facility ethical guidelines; 1.2 demonstrates commitment to continually improve the knowledge and skills required to respond with

compassion to the patient’s health care needs; 1.3 is congruent with ORNAC, CNA, and provincial professional association standards of practice/regulatory

body, as well as the policies and procedures of the health care facility; and 1.4 incorporates promotion of, and compliance with, the health care facility mission, vision, values, philosophy,

objectives, goals, policies, and procedures for perioperative registered nursing. PROFESSIONAL PRACTICE The perioperative Registered Nurse shall practice in a manner that: 1.5 complies with the legal requirements of the professional association/regulatory bodies, current legislation,

policies of the healthcare facility, and standards of care; 1.6 maintains and continually improves competence by identifying learning needs and seeking opportunities for

improvement; 1.7 establishes and maintains respectful, collaborative and therapeutic professional relationships; 1.8 exemplifies characteristics of a mentor/role model by sharing expertise, experience, and skills; 1.9 involves participation in, contribution to, and support of, professional perioperative registered nursing

activities; 1.10 takes responsibility for developing leadership skills; 1.11 is accountable and responsible for their actions and decisions at all times; 1.12 adapts to changes within the health care system that impact their practice; 1.13 understands, participates in, identifies and recommends quality management activities in relation

to perioperative patient care; and 1.14 identifies, documents and reports unprofessional conduct.


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COMPETENCY 2: Provides Physical Patient Care CIRCULATING ROLE The perioperative Registered Nurse shall practice in a manner that: 2.1 assesses the physical status of the patient; 2.2 develops, modifies and documents the individualized plan of care, or a clinical pathway to meet the specific

needs of the patient; 2.3 provides resources for the health care team to function efficiently; 2.4 provides physical comfort measures specific to each surgical patient; 2.5 provides appropriate care during the admission, pre-induction, induction, intraoperative, and emergence

phases; 2.6 performs the surgical count procedure concurrently with the scrub nurse and documents accurately; 2.7 uses a surgical conscience to maintain and monitor the integrity of the sterile field; 2.8 reduces risk by providing continuous, astute, and vigilant observation of the surgical team throughout the

surgical phase meeting the health care team and patient's needs;

2.9 acts as the patient's advocate throughout the perioperative period; 2.10 responds appropriately to complications and unexpected events during the perioperative period; 2.11 organizes and coordinates appropriate resources in a timely manner in preparation for the subsequent

patient; 2.12 provides and assists with procedures/devices required to complete patient care following the

surgical procedure; 2.13 assists in the patient transfer and postoperative positioning; 2.14 accurately and appropriately documents nursing, surgical, and other health care team activities during the

perioperative period; 2.15 promotes appropriate communication techniques to keep noise levels at a minimum; 2.16 assists with patient transport to a receiving unit and communicates pertinent patient information; and

2.17 organizes and coordinates appropriate resources to ensure an efficient theatre turnover. SCRUB ROLE The perioperative Registered Nurse shall practice in a manner that: 2.18 sets priorities and expedites an efficient aseptic set-up for each surgical procedure;


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2.19 applies knowledge and skills while anticipating and adapting to changes in the surgical procedure; 2.20 is vigilant and attentive throughout the surgical procedure, and responds appropriately to complications and

unexpected events; 2.21 uses a surgical conscience to monitor aseptic technique throughout the procedure; 2.22 performs the surgical count concurrently with the circulating perioperative Registered Nurse and accounts

for all items; 2.23 demonstrates knowledge and function of instruments and equipment; 2.24 identifies malfunction or breakage of surgical instruments and equipment, and responds appropriately to

ensure patient and health care team safety; 2.25 acts as the patient's advocate during the surgical procedure; 2.26 appropriately teaches and coaches learners throughout the surgical procedure; 2.27 promotes appropriate communication techniques to keep noise at a minimum; and 2.28 dismantles the surgical set-up in a timely manner to contribute to an efficient turnover.

COMPETENCY 3: Provides Supportive Care TO THE PATIENT AND FAMILY/DESIGNATE The perioperative Registered Nurse shall practice in a manner that: 3.1 establishes a supportive relationship that fosters trust and respect; 3.2 remains attentive to the needs of the patient throughout the perioperative period; 3.3 provides explanations and demonstrates a caring attitude; 3.4 provides an environment in which the patient feels safe; 3.5 conveys a collaborative team concept for the patient;

3.6 effectively advocates and supports the right to make informed decisions; and 3.7 responds appropriately to complications, unusual occurrences and sentinel events. TO THE HEALTH CARE TEAM The perioperative Registered Nurse shall practice in a manner that: 3.8 confirms the presence of appropriate staff with the required skills are available for the intended surgical

procedure;


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3.9 contributes to and encourages collaborative and positive working relationships promoting team problem-solving and decision-making;

3.10 supports and assists in sharing knowledge, expertise, and skills; 3.11 manages stressful situations in a positive manner; and 3.12 advocates for time and support to be available as needed to debrief team members following crisis

situations. COMPETENCY 4: Promotes A Safe Environment The perioperative Registered Nurse shall practice in a manner that: 4.1 uses a surgical conscience to practice, teach, and monitor aseptic technique, environmental control, and

other infection control practices; 4.2 provides immediate and appropriate action when safety is compromised; 4.3 prevents and/or effectively responds to fires, disasters, and other crisis events; 4.4 practices and facilitates compliance with Workplace Hazard Materials Information System

(WHMIS) regulations, safety policies and procedures; 4.5 follows regulations related to the care, handling, use, and documentation of narcotics and controlled drugs; 4.6 follows regulations and guidelines regarding registration and tracking of implanted devices, transplanted organs, cells and tissue; 4.7 practices, teaches, and supervises the protocol for the principles of Routine Practices and additional

precautions in reducing the risk of infection to patients and the health care team; 4.8 confirms equipment and instruments are in proper working condition and that required resources are

available; 4.9 manages surgical specimens according to facility policy; 4.10 assists law enforcement with medico-legal evidence gathering when appropriate; 4.11 practices within the scope established by current legislation, and facility policy; 4.12 conducts the surgical count in an accurate and efficient manner following the facility’s policies and procedures; 4.13 documents unusual occurrences, near-misses and sentinel events and follows up appropriately; 4.14 participates in quality improvement activities; and 4.15 participates in ongoing educational activities.


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COMPETENCY 5: Responds To Urgent/Emergency Situations

The perioperative Registered Nurse shall practice in a manner that: 5.1 recognizes and responds effectively and appropriately to urgent and emergency situations in the surgical

suite; 5.2 anticipates, prioritizes, and prepares for the management of urgent and emergency situations; 5.3 directs, assists, and supervises other members of the health care team to effectively respond to urgent and

emergency situations; 5.4 advocates for debriefing opportunities following urgent and emergency situations, identifies

opportunities for improvement, and makes recommendations; and 5.5 follows facility emergency preparedness processes, policies, procedures, and guidelines.

COMPETENCY 6: Manages Resources

The perioperative Registered Nurse shall practice in a manner that: 6.1 plans, organizes, and prioritizes care and resources to meet patient needs; 6.2 delegates and coordinates team members to provide effective patient care; 6.3 identifies and reports to administration any issues that compromise patient care; 6.4 participates with administration in problem-solving, decision-making and quality improvement; 6.5 assembles, prepares for use, and disassembles equipment and supplies for each surgical procedure; 6.6 uses materials in a manner that provides safe patient care, reduces waste, is cost effective, respects

environmental concerns, and maintains safe working conditions for the health care team; 6.7 organizes and coordinates patient care with the health care team maximizing efficient use of resources and

time; 6.8 monitors and evaluates progress of activities, delegated duties, and patient outcomes; 6.9 participates in the clinical evaluation of products and equipment; 6.10 participates in research activities; 6.11 monitors expenditures, usage and waste contributing information for budget process; and 6.12 encourages appropriate time management.


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BIBLIOGRAPHY

Association of PeriOperative Registered Nurses. (2008). Perioperative standards and recommended practices. Denver: Author. Australian College of Operating Room Nurses. (2006). Standards for Perioperative Nursing including Nursing Roles, Guidelines, Position Statements, Competency Standards. Adelaide: ACORN College and Association of Registered Nurses of Alberta. (2005). Nursing Practice Standards. Edmonton: Author. Canadian Nurses Association. (2008). Code of ethics for Registered Nurses. Ottawa: Author. Canadian Nurses Association. (2004). Everyday Ethics Putting the Code into Practice. Ottawa: Author. National Association of Theatre Nurses. (2005). Standards and Recommendations for Safe Perioperative Practice. Harrogate, UK: NATN Phillips, N. (2007). Berry & Kohn’s operating room technique. (11th ed.) Toronto: Mosby. Nurses Association of New Brunswick (2005). Standards of Practice for Registered Nurses. Spry, C. (2008). Essentials of Perioperative Nursing. (4th ed.). Sudbury: Jones & Bartlett. .

COMPETENCIES OF THE PERIOPERATIVE REGISTERED NURSE MANAGER COMPETENCY 1: Professional and Clinical Practice COMPETENCY 2: Managerial Skills and Expertise

COMPETENCY 3: Human Resource Management

COMPETENCY 4: Financial Management: Budget; Human, Material and Capital Resources

COMPETENCY 5: Communication and Interpersonal Skills COMPETENCY 6: Team Building COMPETENCY 7: Legal and Ethical Responsibilities COMPETENCY 8: Technology: Understanding and Use COMPETENCY 9: Quality Management COMPETENCY 10: Systems Thinking, Strategic Planning and Project Management COMPETENCY 11: Collaboration with Surgeons COMPETENCY 12: Collaboration with Anesthesiologists


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COMPETENCIES OF THE PERIOPERATIVE REGISTERED NURSE MANAGER

COMPETENCY 1: Professional and Clinical Practice

The perioperative Registered Nurse manager shall practice in a manner that:

1.1 is a role model who exemplifies ORNAC, CNA and other related associations' standards of practice; 1.2 contributes to the development and upgrading of standards of practice as knowledge increases and practices

change; 1.3 confirms that staff members follow standards of practice in the delivery of patient care; 1.4 expects and facilitates a high level of performance among staff members; 1.5 exemplifies and expects a professional work environment from all health care team members; 1.6 promotes an environment that respects confidentiality, privacy of patients, team members, and health

information in a professional manner and as defined by various regulatory bodies; 1.7 facilitates an environment that is conducive to change and encourages collaborative practice; 1.8 demonstrates zero tolerance for violence, bullying, harassment and discrimination in the workplace; 1.9 supports and contributes to a learning environment that is appropriate for the patient care and services that

are provided; and 1.10 promotes an environment that encourages research.

COMPETENCY 2: Managerial Skills and Expertise The perioperative Registered Nurse manager shall practice in a manner that:

2.1 provides appropriate resources for the health care team to support surgical patient care;

2.2 organizes the human and material resources in the right quality, quantity, skill set, place, and time;

2.3 hires appropriate numbers of staff members with the required skills and knowledge, in the appropriate job

classification for duties intended; 2.4 provides resources for appropriate orientation for new staff members; 2.5 provides resources for continuing education, specialty development, and new technology training;

2.6 facilitates, supports, and contributes to resources required for ongoing post basic education, certification,

expanded perioperative nursing roles, and advanced degrees;


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2.7 establishes an expectation for, contributes to, and promotes a learning environment; 2.8 maintains a current organizational chart which is readily available to staff; 2.9 collaborates with staff in designing a framework for clinical practice that encompasses roles,

responsibilities, and accountabilities by staff categories, staff mix, scope of practice, and limitations, avoiding a "quick-fix" approach;

2.10 demonstrates exceptional organizational skills and facilitates processes for staff to achieve excellence in

patient care; 2.11 develops, in collaboration with the health care team/organization, and executes appropriate priority setting

based on current needs, activity, resources, and safety; 2.12 demonstrates decision making that is efficient, effective, inclusive, ethical, legal, fair, and transparent when

possible; and 2.13 promotes an environment that meets biological, chemical, mechanical, environmental, and physical safety

standards.

COMPETENCY 3: Human Resource Management


3.1 manages the human resource component of the surgical suite; 3.2 promotes a practice environment that is accepting and respectful of all job classifications and employees of

varied backgrounds and experience; 3.3 interviews, checks references, and hires appropriate skilled professional staff to meet patient care needs and

specialty expertise; 3.4 interviews, checks references, and hires appropriate support staff with skill sets for specific positions, tasks

and duties; 3.5 establishes expectations of performance, competency standards, attitude, goals, and opportunities at time of

hire; 3.6 provides current position descriptions to new employees; 3.7 maintains current position descriptions; 3.8 confirms the probationary performance is closely monitored, peers are consulted, and appraisals are

completed which accurately reflect the expectation of continued employment; 3.9 provides regular performance appraisals for staff members, based on current position descriptions,

performance expectations, and written protocols, that are reflective of practice, constructive, and promote personal development;

3.10 provides a structured means to manage performance of health care team members not meeting standards of

expectation in a timely and progressive manner;


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3.11 terminates staff that are determined, through due process, to be lacking in competency and overall performance;

3.12 removes staff who present a risk to patients or health care team members from the area, in a timely and

respectful manner, pending appropriate outcomes; 3.13 replaces vacant positions in a timely manner, with the most qualified staff available, which assists in

reducing training costs, stress, and the impact on the patient and surgical suite; 3.14 is conversant with and follows union contracts and labor laws; 3.15 is accountable for staff schedules, rotations, daily assignments, and vacation planning that is coordinated

with contract requirements and with departmental, organizational, and staff needs; and 3.16 encourages a positive environment that promotes wellness.

COMPETENCY 4: Financial Management-Budget, Human, Material and Capital Resources


4.1 plans and monitors the approved operational budget; 4.2 integrates the strategic, fiscal, and change requirements of the facility; 4.3 facilitates a team approach to obtain a balanced budget; 4.4 participates collaboratively within the system to acquire appropriate materials in a timely, and efficient

manner; 4.5 participates collaboratively in the decisions regarding the tendering, evaluation, approval, and acquisition of

materials; 4.6 collaboratively plans, prioritizes, and requests capital equipment replacement; 4.7 maintains existing equipment in good repair, facilitates necessary preventative maintenance processes, and

maintains a record of historical data for equipment problems, repairs, and down-times due to malfunctioning equipment; and

4.8 participates collaboratively to develop contingency plans for inadequate or unavailable resource

components.

COMPETENCY 5: Communication and Interpersonal Skills


5.1 demonstrates effective communication with the health care team and external partners and representatives;


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5.2 utilizes effective listening skills to maximize understanding of the issues; 5.3 provides a comfortable, respectful, and confidential environment that encourages health care team members

to discuss issues; 5.4 promotes an environment that encourages health care team members to resolve issues in a respectful, non-

confrontational manner; 5.5 ensures compliance with policies related to zero tolerance of abuse in the workplace; 5.6 facilitates negotiation, collaboration, and conflict resolution; 5.7 incorporates knowledge and expertise in coaching, facilitating, and promoting group dynamics; and 5.8 is cognizant of, and provides direction and resources to enable staff to deal with personal stress and health

problems.

COMPETENCY 6: Team Building


6.1 facilitates, supports, and encourages a multidisciplinary department that promotes team building; 6.2 collaborates with the health care team supporting decision making at the point of care/service;

6.3 facilitates and encourages empowerment of teams with associated accountability and responsibility; 6.4 collaborates with a multidisciplinary team to solve problems, change processes, and improve the function

and quality of patient care and support systems; 6.5 demonstrates respect and the value of each health care team member; and 6.6 provides support to improve dysfunctional processes and strengthen the health care team.

COMPETENCY 7: Legal and Ethical Responsibilities


7.1 confirms proof of required licensure prior to hiring; 7.2 confirms security clearance, if applicable, prior to hiring; 7.3 assures confirmation of annual professional licensure of regulated staff; 7.4 facilitates the development and maintenance of applicable department policies that are current and available to staff;


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7.5 provides policies that reflect current legal expectations and meet various regulatory requirements; 7.6 supports health care team members in understanding the implication and importance of policies and

compliance with current departmental policies; 7.7 confirms that all practicing surgeons have the required surgical privileges granted by the designated medical

authority; 7.8 confirms that the health care team members work within their mandated scope of practice; 7.9 monitors any restrictions or limitations of practice; 7.10 monitors compliance with policies and procedures related to patient care; 7.11 confirms investigation of all incidents in a timely manner according to the health care facility protocol; 7.12 removes impaired, fraudulent or negligent staff from the environment until the appropriate investigation is

completed and the individual is approved to practice; 7.13 notifies the specific medical designate immediately in the event of negligent or impaired activities involving a physician; and 7.14 declares when there is a personal conflict of interest.

COMPETENCY 8: Technology: Understanding and Use


8.1 facilitates and supports the advancement of technology that improves patient care; 8.2 lobbies and promotes the need for computer technology that facilitates data analysis; 8.3 understands, uses, and facilitates the provision for ongoing staff development to support technology; 8.4 integrates department statistics with benchmarking, economic, and financial information for decision

making; 8.5 prepares a business plan which forecasts the impact of new technology leading to changes in practice; and

8.6 informs the appropriate departments and healthcare team members regarding the introduction of new

technology and practices.

COMPETENCY 9: Quality Management


9.1 is committed to a process/program of quality improvement;


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9.2 facilitates and confirms that a quality management process is in place; in which health care team members are integral and outcomes are managed;

9.3 decides in collaboration with the health care team, the performance indicators to be measured; 9.4 facilitates a consistent, accurate means of data collection; 9.5 confirms that processes are in place for data validation; 9.6 reports the data results, outcome measures, and recommendations as determined by the health care facility

policy; 9.7 analyzes data to determine if improvement measures are successful; and 9.8 implements measures that reduce risk for the patient and surgical team.

COMPETENCY 10: Systems Thinking, Strategic Planning and Project Management


10.1 integrates the facility’s mission, vision, values, philosophy, objectives and goals into department activities,

direction, and decisions; 10.2 maintains goals and objectives that are current and congruent with strategic direction of the facility; 10.3 incorporates visionary approach into strategic decision making; 10.4 manages an environment that facilitates partnerships, teams, and relationships that incorporate and support

the overall mission, goals, and focus of the health care facility; 10.5 collaborates closely with Departments of Surgery, Anesthesiology and other services that utilize and

support patient care in the surgical suite; 10.6 communicates effectively with senior administration; 10.7 participates in disaster services planning on an organizational level; 10.8 participates in collective bargaining and labor action planning/impact on an organizational level; 10.9 follows the health care facility policy for media requests; 10.10 collaborates and assists in the coordination of reduced activity/downsizing of activity; 10.11 participates in organizational meetings and activities; 10.12 understands the organization is a system and uses systems thinking in planning and decision making; 10.13 uses change management theories and practices; 10.14 incorporates clinical, technological, and research concepts into decision making;


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10.15 incorporates evidence-based research into policy, procedure, and practice changes; 10.16 coordinates inter and intra departmental and external resources to maintain efficient surgical suite functions;

and 10.17 facilitates communication and respects limitations and resources of supporting departments. COMPETENCY 11: Collaboration with Surgeons The Perioperative Manager shall practice in a manner that: 11.1 develops open communication and positive relationships with surgeons and their offices; 11.2 facilitates systems which support the delivery of appropriate and timely care of patients based on the surgeon’s information; 11.3 monitors and manages systems that will promote efficient use of time while in the operating room; 11.4 manages the allocation of operating room time/resources for surgeons; 11.5 promotes respect and professional interactions between staff and surgeons; 11.6 prepares for and participates in interviews for prospective and new surgeons; 11.7 prepares appropriate additional funding requests for new surgeon requirements; 11.8 ensures adequate operating time, supplies and other resources will be available for additional surgeons; 11.9 receives, processes, and reviews information on new products, requests, procedures and information, and participates in processes that will ensure due process to either approve or disapprove new technology, products or procedures; and 11.10 appropriately addresses behavior issues that affect the department and the staff. COMPETENCY 12: Collaboration with Anesthesiologists The Perioperative Manager shall practice in a manner that: 12.1 collaborates with the Department of Anesthesiology to maximize safety and effective use of resources to

meet the patient needs; 12.2 ensures a tripartite process of handling patient priorities which includes anesthesia, surgeons and nursing;


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12.3 facilitates the education and practice process of nursing skills to effectively and consistently assist the anesthesiologist throughout the perioperative period;

12.4 uses and promotes effective problem solving techniques to resolve issues surrounding anesthesia concerns; 12.5 promotes respect and professional interactions between staff and anesthesiologists; and 12.6 appropriately addresses behavior issues that affect the department and the staff.

COMPETENCIES OF THE PERIOPERATIVE REGISTERED

NURSE EDUCATOR

COMPETENCY 1: Professional and Clinical Practice


1.1 is a role model who exemplifies CNA, ORNAC, CSA, and other related associations' standards of practice; 1.2 demonstrates accomplishment within perioperative nursing (e.g. publishes work, conference speaker); 1.3 actively participates in committees or professional interest group activities; 1.4 demonstrates leadership as it relates to health trends and issues for perioperative Registered Nurses;

COMPETENCIES OF THE PERIOPERATIVE REGISTERED NURSE EDUCATOR

COMPETENCY 1: Professional and Clinical Practice COMPETENCY 2: Educator Skills and Expertise

COMPETENCY 3: Human Resource Support

COMPETENCY 4: Communication and Interpersonal Skills COMPETENCY 5: Team Building COMPETENCY 6: Legal and Ethical Responsibilities COMPETENCY 7: Technology: Understanding and Use COMPETENCY 8: Quality Management



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1.5 contributes to the development and improvement of standards of practice as knowledge increases and practices change;

1.6 facilitates and supports the health care team to comply with Standards of practice in the delivery of patient

care; 1.7 exemplifies a role model of professional behavior for the health care team; 1.8 promotes an environment that respects confidentiality, privacy of patients, health care team members, and

health information in a professional manner and as defined by various regulatory bodies; 1.9 facilitates an environment that is conducive to change and encourages collaborative interdisciplinary

practice; 1.10 facilitates and supports an environment that does not tolerate violence, bullying, harassment and

discrimination in the workplace; 1.11 supports and contributes to a learning environment that is appropriate for the patient care and services that

are provided; 1.12 promotes, encourages and participates in research; and 1.13 functions as a change agent and perioperative leader.

COMPETENCY 2: Educator Skills and Expertise The perioperative Registered Nurse educator shall practice in a manner that:

2.1 encourages staff to identify their learning needs; 2.2 uses the principles of adult learning to support/provide education that assists staff to meet their learning

needs; 2.3 demonstrates knowledge of the strategic plan of the organization and anticipates the related educational

needs; 2.4 liaises with other perioperative Registered Nurses, educators and managers; 2.5 facilitates staff learning to acquire the requisite skills and knowledge, in the appropriate job classification; 2.6 co-ordinates resources for appropriate orientation for new staff members and students; 2.7 facilitates opportunities for continuing education, specialty development, and new technology training; 2.8 facilitates, supports and/or contributes to resources required for ongoing post basic education, certification,

expanded and advanced perioperative nursing roles, and advanced degrees; 2.9 establishes an expectation for, contributes to and promotes a learning environment;


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2.10 collaborates with staff and management in designing a framework for perioperative clinical practice that encompasses roles, responsibilities, competencies and accountabilities by staff categories, skill mix, and scope of practice;

2.11 demonstrates optimal organizational skills and facilitates processes for staff to achieve excellence in perioperative patient care; 2.12 demonstrates economical use of resources to develop and implement educational programs; 2.13 provides professional and educational resources as requested; 2.14 demonstrates decision making that is efficient, effective, inclusive, ethical, and transparent when possible; 2.15 promotes an environment that meets biological, chemical, mechanical, environmental, and physical safety

standards; 2.16 assists the health care team to bridge perioperative theory to evidence-based practice;

2.17 demonstrates consistent improvement in educational activities based on learner and patient outcomes; 2.18 demonstrates decision making based on current research and standards of practice; 2.19 demonstrates accountability for the outcomes of their educational activities; and

2.20 creates opportunities for the healthcare team to build critical and reflective thinking skills promoting problem-solving strategies.

COMPETENCY 3: Human Resource Support


3.1 promotes a practice environment that is accepting and respectful of all job classifications and employees of

varied backgrounds and experience; 3.2 supports new staff in establishing expectations of performance, competencies, goals, and opportunities at

time of hire; 3.3 supports the health care team to maintain practice competencies; 3.4 supports the perioperative Registered Nurse manager in maintaining current job descriptions; 3.5 co-ordinates the monitoring of probationary performance through consultation processes and facilitates the completion of appraisals; 3.6 collaborates in the completion of regularly scheduled performance appraisals for staff members; 3.7 facilitates a learning plan to improve performance of health care team members not meeting required

standards; 3.8 demonstrates sensitivity to workplace constraints which interfere with learning, and works


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proactively towards the reduction or elimination of these constraints whenever possible;

3.9 encourages staff to enhance their knowledge base by collaborating with mentors, colleagues, and other health care team members;

3.10 encourages a positive environment that promotes health and wellness; 3.11 effectively redirects issues, which require non-educational strategies; 3.12 counsels and supports nursing staff in advancement opportunities; and 3.13 develops preceptors or experts as resources for clinical skills. COMPETENCY 4: Communication and Interpersonal Skills


4.1 demonstrates effective interpersonal communication strategies;

4.2 uses effective listening skills to maximize understanding of the issues;

4.3 demonstrates a willingness to be accessible to staff; 4.4 provides a comfortable, respectful, and confidential environment for health care team members to discuss

issues; 4.5 promotes an environment that encourages health care team members to resolve issues in a respectful, non-

confrontational manner; 4.6 facilitates negotiation, collaboration, and conflict resolution; 4.7 incorporates knowledge and expertise in coaching, facilitation, and group dynamics; and 4.8 is cognizant of, and provides direction and resources for nursing staff to deal with personal stress and health

issues.

COMPETENCY 5: Team Building


5.1 facilitates, supports, and encourages a multidisciplinary department that promotes team building; 5.2 demonstrates a team approach in coordinating educational activities; 5.3 collaborates with the health care team supporting decision-making at the point of care/service; 5.4 facilitates and encourages accountability and responsibility within the health care team;


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5.5 facilitates health care team members to develop problem-solving and coping techniques for use during stressful or emotional situations;

5.6 promotes an open and supportive learning environment; 5.7 functions as a resource to assist nursing staff to develop educational materials and presentations; 5.8 demonstrates a willingness to modify educational program content based on evaluation feedback and/or

outcomes; 5.9 supports and encourages nursing staff to actively participate in their professional groups; 5.10 distributes relevant research findings to nursing staff and colleagues formally and informally; 5.11 collaborates with a multidisciplinary team to solve problems, change processes to improve function, quality

of patient care, and support systems; and 5.12 demonstrates respect and values each health care team member.

COMPETENCY 6: Legal and Ethical Responsibilities


6.1 facilitates the development and management of policies that reflect current legal expectations, standards of

practice, and meet various regulatory requirements; 6.2 promotes resolution of ethical dilemmas in a nonjudgmental environment; 6.3 supports health care team members to understand the importance of compliance with policies; and 6.4 monitors compliance with policies and procedures.

COMPETENCY 7: Technology: Understanding and Use


7.1 facilitates and supports the learning needs of perioperative staff as it relates to current, advanced and

emerging technologies.

COMPETENCY 8: Quality Management


8.1 is aware of, and committed to, a process/program of quality improvement;


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8.2 ensures the health team has the knowledge to actively and appropriately participate in quality processes; 8.3 views challenging situations as opportunities for improvement; 8.4 confirms that the learner’s needs and objectives are met; and 8.5 collaborates with the health care team in the development of the performance indicators to be measured.



9.1 encourages an environment that facilitates partnerships, teams, and relationships that incorporate and

support the organization’s mission, vision, values, objectives and goals;

9.2 instills the knowledge and understanding of systems thinking within the health care team;

9.3 collaborates closely with surgeons, anesthesiologists and other professionals that support or provide patient care in the surgical suite;

9.4 communicates effectively with management and administration; 9.5 participates in disaster services planning on a unit/organizational level; 9.6 participates in facility meetings and activities; 9.7 applies change management theories and practices; 9.8 supports and facilitates clinical, technological, and research concepts into decision making; and 9.9 supports and facilitates evidence-based research into policy, procedure, and practice changes.

BIBLIOGRAPHY

Council on Collegiate Education for Nursing. (2002). Nurse Educator Competencies. Retrieved January 5, 2007, from http://www.sreb.org/programs/nursing/publications/Nurse_Competencies.pdf National League for Nursing. (2005). Core competencies of nurse educators with task statements. Retrieved January 5, 2007, from http://www.nln.org/profdev/corecompetencies.pdf Vigeant, D., Lefebure, H., & Reidy, M. (2008). The Use of video as a pedagogic tool for the training of perioperative nurses: a literature review. Canadian Operating Room Nursing Journal, 26(1), 8, 9, 14, 15, 17-20.


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PROFESSIONAL COMPETENCIES FOR ADVANCED PRACTICE

NURSES (PERIOPERATIVE)

COMPETENCY 1: Advanced Practice Nurses-(Perioperative) Possess Required Core Competencies that Incorporate Advanced Perioperative Nursing Knowledge, Theory and Research Augmented by Clinical Experience. Competencies for advanced nursing practice are based on an appropriate depth, breadth and range of nursing knowledge, theory and research, enhanced by extensive clinical experience (CNA, 2008) Advanced Practice Nurses (Perioperative) shall practice in a manner that incorporates: 1.1 clinical expertise;

1.2 advanced assessment and intervention strategies for clients;

1.3 the use of qualitative and quantitative data from a multitude of sources when making clinical decisions and

managing/facilitating change; 1.4 the analysis of the sociological, psychological, and physiological processes; the determinants of health, and

the client’s lived experience;

1.5 the wide range of client responses to actual or potential health problems and recommended actions; 1.6 decision making skills in complex clinical situations; 1.7 engaging clients and members of the healthcare team in resolving issues at the individual, organizational

and healthcare system levels; 1.8 the ability to identify and assess trends or patterns that have health implications for clients; 1.9 the generation and incorporation of new nursing knowledge and development of new standards of care,

programs and policies; 1.10 planning and implementation of educational programs as determined by needs, priorities and resources; 1.11 research; 1.12 identifying and implementing research-based innovations for improving client care, organizations or

healthcare systems; 1.13 collaboration with members of the healthcare team or the community to identify, conduct and support

research that enhances and /or benefits nursing practice; 1.14 research findings in practice at the individual and systems levels; 1.15 data collection, outcomes evaluations and advanced nursing practice for clients, the nursing profession and

the healthcare system;


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1.16 research interpretation, application and dissemination; 1.17 a contribution to nursing and the healthcare system by disseminating new knowledge through formal and

informal channels including presentations and publications; 1.18 leadership and change; 1.19 advocating for clients in relation to treatment, the healthcare system and policy decisions that affect health

and quality of life; 1.20 the learning needs of nurses and other members of the healthcare team and finding or developing programs

or resources to meet those needs; 1.21 mentoring and coaching nursing colleagues, members of the healthcare team, and students; 1.22 advocating for and promoting the importance of healthcare access to healthcare professionals, legislators,

and policy makers; 1.23 contributing to and advocating for an organization culture that supports professional growth, continuous

learning and collaborative practice; 1.24 evaluating programs in the organization and community and developing innovative approaches to complex

issues; 1.25 understanding and integrating the principles of resource allocation and cost-effectiveness in organizational

and system level decision making; 1.26 the development of partnerships to manage identified gaps in the healthcare system; 1.27 development and articulation of the vision for nursing practice; 1.28 guiding and advising clients, members of the healthcare team, the community, healthcare institutions and

organizations, and policy makers on issue related to nursing, health, and healthcare; 1.29 identification of problems and initiating change to meet challenges at the individual, organizational or

systems level; 1.30 developing strategies to improve health, healthcare access and policies by understanding socio-political

issues that influence health policy; 1.31 consultation and collaboration; 1.32 the development of quality improvement and risk management strategies in consultation with members of

the healthcare team; 1.33 working with others to gather information on determinants of health; 1.34 collaborative practice and building coalitions; 1.35 the application of theories related to group dynamics and roles; 1.36 the demonstration of skill and knowledge in communication, negotiation and conflict resolution; 1.37 articulating the role of the Advanced practice Nurse within the healthcare team;


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1.38 collaborative practice with academic institutions; and 1.39 advocating for change in health policy by participating on regional, provincial/territorial and federal

committees that influence decision making.

REFERENCES Canadian Nurses Association. (2008). Advanced Nursing Practice A National Framework. Ottawa: CNA.

BIBLIOGRAPHY Hamric, A.B., Spross, J.A., and Hanson, C.M., (2005). Advanced nursing practice: An integrative approach. Philadelphia: W.B.Saunders Company.

ADDITIONAL RESOURCES

Canadian Nurses Association. Position Statements, Discussion papers, Briefs, Nurse One Portal www.cna-nurses.ca

Canadian Nurses Protective Society. www.cnps.ca Canadian Patient Safety Institute. Surgical Safety Checklist & Scorecard: Canada, Version 1. Edmonton, AB: Canadian Patient Safety Institute; 2009 Jan 9. www.safesurgerysaveslives.ca Canadian Standards Association. www.csa.ca Health Canada. www.hc-sc.gc.ca Provincial/Territorial professional nursing associations. Provincial/Territorial government health ministries Michael Villeneuve & Jane MacDonald, (2006). Toward 2020 visions for Nursing, CNA, Ottawa, ON

Appendix A:

REGISTERED NURSE FIRST ASSIST Competency 1

The registered nurse first assist (RNFA) is competent to apply the nursing process in all facets of the

nurse first assist role.

Measurable Criteria:

Applies the nursing process in the RNFA role as the theoretical framework for patient care.

Examples:

Possesses and applies expert knowledge of the principles of biological, physical, and


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behavioral sciences; clinical observation; and communication theory to contribute to the

surgical patient’s optimal outcome.

Evaluates each patient individually and determines appropriate application of knowledge and

skills according to patient’s needs.


Conducts systematic, ongoing assessment of the patient’s health status throughout the perioperative

experience.

Examples:

Collects data from the appropriate multiple sources (e.g., physician’s office, clinic, admissions

system, operating room, post-anesthesia care unit [PACU]), continuing throughout the

patient’s postoperative course. Recognizes the importance of chronic or concomitant diseases;

malignancies; routine or preoperative prescribed, herbal, and over-the-counter medications;

previous surgery or injuries; and/or preexisting infections that may affect the patient’s health

status and the outcome of the planned surgical interventions and takes appropriate action.

Performs an appropriate and focused nursing assessment based on the planned surgical

intervention(s). Assesses for possible risk factors that may be present (e.g., age, weight,

nutritional status, developmental stage, medical history, diagnosis[es], laboratory values,

immunological/hydration/perfusion status, comorbidity).

Assesses patient’s intraoperatively for prevention or early detection of perioperative

complications (e.g., recognizes early symptoms of cardiac complications secondary to acid-

based imbalance, cardiac dysfunction, cervical spine injury, electrolyte imbalance, anesthetic

agents, medications, vagal stimulation, surgical manipulation).

Monitors and assesses patient’s immediate postoperative status to determine progress toward

expected outcomes or signs and symptoms of potential postoperative complications.


Formulates and modifies nursing diagnoses based on patient assessment throughout the perioperative

continuum.

Examples:

Synthesizes and interprets health assessment data to identify and prioritize patient health

problems amenable to collaboratively prescribed intervention(s).

Demonstrates ability to support nursing diagnoses with current scientific knowledge and/or

research.

Documents and communicates identified nursing diagnoses based on patient’s condition and

clinical situation.

Communicates changes in patient’s situation to appropriate members of the health care team


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as intervention progresses


Identifies and communicates desired patient outcomes.

Examples:

Establishes individualized, realistic outcomes with patient based on the identified nursing

diagnoses. Communicates patient’s goals to appropriate members of the health care team.

Outcome statements specify measurable criteria for determining the relationship between

nursing intervention and outcome achievement.


Develops an individualized plan of care that directs the intervention(s) of the RNFA.

Examples:

Selects, analyzes, and interprets relevant assessment data to develop a plan of care that meets

individual patient needs, is age specific, and reflects professionally recognized standards of

care based on the nursing process.

Addresses collaborative problems* and potential complications with

physicians to achieve consensus regarding delegated medical functions and prescribed nursing

interventions.

Communicates RNFA plan of care with other members of the surgical team to achieve

consistency of purpose and action during the intraoperative phase of care.


Implements and manages the perioperative plan of care consistent with RNFA practice.

Examples:

Reviews and uses history, physical assessment, and preoperative test results to establish a

physiologic baseline.

In collaboration with the surgeon, anesthesia care provider, and other perioperative team

members, initiates interventions efficiently, safely, and skillfully using sound clinical

judgment.

Provides knowledge-based technical assistance to the surgeon during the operative procedure

according to licensure, provincial/territorial regulation, and facility/practice protocols. (See

competency 4 for intraoperative assisting knowledge and skills)

Works closely with RN circulator, and scrub nurse (RN/LPN/RPN), collaborating with and

participating in perioperative nursing interventions as appropriate.

Serves as an information resource for RN circulator and scrub nurse (RN/LPN), and other

member of the surgical team throughout the perioperative course by applying/sharing expert

surgical knowledge of aseptic practice, hemostasis, tissue handling, wound healing, and


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surgeon’s preferences. Intervenes as appropriate to specific circumstance(s).

Applies principles of problem solving in response to changes in the patient’s condition during

any/all phase(s) of the surgical encounter. Modifies, communicates, and implements plan of

care accordingly.

Maintains flexibility and adaptability when emergencies or unanticipated events occur.

Documents patient/family preoperative care and teaching, operative notes following surgical

procedure, postoperative care/assessment, and discharge planning, as determined by guidelines

of practice and institutional policy.


Evaluates the effect of RNFA/nursing interventions as part of the ongoing assessment process.

Examples:

In collaboration with the patient, evaluates patient outcomes by comparing patient responses

to nursing interventions, current practice standards, and anticipated outcomes.

In collaboration with surgeon and other members of the perioperative team, evaluates personal

surgical performance and patient outcomes.

Attends postoperative visits in clinic to assess patient surgical outcomes (i.e.: wound healing).

Competency 2:

The RNFA is competent to exercise critical thinking skills in all aspects of the RNFA role.


Uses critical thinking theory in the application of nursing knowledge and perioperative patient care.

Examples:

Analyzes and synthesizes as a means of approaching a situation, issue, or decision.

Exercises analytical problem-solving techniques and sound principles of proficient decision

making when encountering new situations.

Bases critical thinking on previous experience and theoretical knowledge. Continuously

builds acquired knowledge as a result of critical thinking.

Competency 3:

The RNFA is competent to establish and maintain a safe perioperative environment.


As a primary patient advocate is continually vigilant, using acquired and intuitive knowledge to anticipate,

prevent, and/or respond to circumstances that could compromise the patient’s well-being.

Examples:

Recognizes potential hazards and initiates preventive and/or corrective actions at any time

throughout the perioperative continuum.

Ensure safe, aseptic environment consistent with infection control principles and safe


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operating procedures.

Transfers patient safely (e.g., locks transport vehicle wheels; secures IV lines, catheters,

feeding tubes; protects patient’s extremities during transfer; uses transfer devices as

appropriate).

In partnering with the surgeon, the RNFA directs, manages, and/or participates in positioning

the anesthetized patient.

In collaboration with the surgeon and anesthesia care provider, assumes accountability for

positioning patient safely. Demonstrates expert knowledge of anatomy and physiology, safe

positioning principles, and the function and correct use of positioning equipment to avoid

circulatory and neurological compromise.

Protects patient from thermal, electrical, chemical, and/or mechanical injury.


Is cognizant of and can recognize possible adverse reactions patient may experience during the surgical

encounter.

Examples:

Anticipates and assesses the effects of routine and preoperative pharmacological agents and

herbal remedies. Intervenes as appropriate to the situation.

Verifies patient allergies. Reviews, analyzes, and interprets information from the patient’s

history and physical examination noting any intolerance that might signify an unsafe surgical

encounter.


Accountable for verification of the correct surgical site.

Examples:

Verifies site with patient, surgeon, and other members of surgical team.


Demonstrates knowledge of patient safety standards published by regulatory bodies.

Examples:

Volunteers to participate in facility-wide safety programs. Seeks opportunities to promote

patient safety as work ethic. Teaches colleagues. Models desired behaviors.

Competency 4:

The RNFA is competent to provide technical first assistance to the primary surgeon in the

operating room and throughout the perioperative period.


Demonstrates clinical expertise.

Examples:


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Is familiar with proposed surgical procedures, surgeon approach, and clinical anatomy.

Recognizes anatomical abnormalities that may impact the surgical intervention.

Applies cognitive and technical skills obtained throughout the continuum of basic nursing

education, perioperative nursing education, and formal RNFA educational programs.


Possesses the essential mental discipline and fine motor skills to provide technical assistance to the surgeon.

Examples:

Continually demonstrates attention to detail, thoroughness, stamina, continued competence of

surgical assisting skills, and concentration during the surgical procedure.


Strictly adheres to principles of aseptic technique to prevent infection and promote optimal wound healing.

Examples:

Demonstrates knowledge and command of principles of surgical asepsis.

Creates and monitors sterile field. Identifies and corrects breaks in aseptic technique.

Identifies and addresses factors that place the patient at risk for infections.


Accepts appropriate delegated restricted activities as defined within the RNFA scope of practice.

Examples:

Performs preoperative activities as ordered by surgeon (e.g., venipuncture for preoperative

blood test).

Initiates and performs intraoperative activities as directed by the surgeon.

Monitors wound healing.


Uses surgical instruments to assist the surgeon and facilitate the surgical intervention.

Examples:

Demonstrates thorough understanding of the underlying principles for using surgical

instruments. Understands the design and use principles/action of surgical instruments used

and the resultant effect on tissue.

Demonstrates skill and manual dexterity in instrument use.


Handles tissue safely.

Examples:

Employs principles of safe tissue handling. Handles tissues with a gentle touch to preserve

neurovascular structures and promote wound healing.

Applies knowledge regarding tissue response to injury, wound healing, and wound


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classification (i.e., identifies and assesses risk factors that impair wound healing and/or

encourage wound complications).

Exercises independent clinical judgment when identifying specific types of tissue and

selecting appropriate instrument(s) for handling that tissue (e.g., muscle, fat, and most organ

tissues are easily lacerated when clamped or pulled; skin, fascia, cartilage, ligament, and bone

tissues are generally tough and may be handled with toothed tissue forceps or Kocker clamps).


Provides exposure of operative site to promote a safe and effective surgical procedure.

Examples:

Exercises independent judgment in selecting and employing various methods to provide

exposure of the surgical site, including patient positioning, use of retractors and other

instruments, retraction sutures, and/or packing materials as dictated by procedural need.

Selects, places, and moves proper retractor(s) to provide surgical site exposure and reduce

tissue injury.

Packs wound as appropriate.

Suctions surgical site as necessary to remove smoke, blood, and fluids from the site to

improve visualization and decrease biohazard exposure.


According to individual provincial/territorial regulation and facility policy, dissects tissue as delegated and

supervised by the primary surgeon.

Examples:

Under the direction of the operating surgeon, uses appropriate tissue dissection techniques to

facilitate an optimum surgical outcome. For example, privileges may

be granted to qualified RNFAs to perform specialized tissue handling, such as trocar

placement, preparation of allografts, and saphenous vein harvesting.


According to individual provincial/territorial regulation and facility, policy assists with and/or performs

wound closure.

Examples:

Uses suture and suturing techniques in a manner consistent with principles that promote

wound healing.

Differentiates one type of suture from another, having knowledge of the physical

characteristics and biological responses to various suture materials

Selects appropriate suture material for the type of closure to be performed.

Demonstrates proficiency in knot-tying techniques with consideration to knot security, suture


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selection, and tissue characteristics.

Demonstrates proficiency in wound closure using a skin stapler.

Competency 5:

The RNFA is competent to work as a professional colleague with the physician and to enhance the

effectiveness of patient care.


Partners with the physician to collaboratively direct the patient’s perioperative course.

Examples:

Prepares the patient preoperatively for surgical intervention, performs intraoperative surgical

assisting, and collaboratively manages the patient’s postoperative regimen.

Understands and applies current theories and concepts of antimicrobial prophylaxis, ensuring

that the appropriate medication is administered at the correct time to maximize effectiveness.

Participates with physician in determining product use and/or therapies to be used.

In collaboration with surgical team, directs and/or manages patient care activities during the

intraoperative phase of care.

Implements and directs (as appropriate) use of environmental control measures and

standard/transmission-based precautions to prevent undue patient and provider exposure to

and infection from bloodborne pathogens.

Accepts appropriate responsibility if surgeon becomes incapacitated; protects the surgical

wound, maintains hemostasis, and maintains sterility of the operative field until the

replacement surgeon accepts responsibility for procedure completion.

Makes postoperative rounds in conjunction with or at the direction of physician.

Plans and/or collaborates, with other members of the health care team, for patient discharge,

accessing community resources as appropriate.


Serves as educator, mentor, consultant, and resource to patients, colleagues, other health care professionals,

and the community.

Examples:

Provides individualized patient and family education by applying principles of learning,

actively involving the learner, and providing and environment conducive to teaching/learning.

Consults effectively with the surgeon and other member of the health care team to promote

efficient use of time, supplies, equipment, and personnel.

Monitors emerging technology. Analyzes new products to determine risk/benefit for patients

and the facility.

Participates in and consults on facility and nursing committees, nursing associations, and


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medical/industry focus groups.

Serves as a source of information, including procedural instruction and/or policies and

procedures to both nursing colleagues and multidisciplinary students (i.e.: surgical procedure,

urinary catheterization, wound closure, and use of various surgical equipment).

Serves as a community resource to educate the public and promote quality patient care.

Educates the public and other health care professionals about the role of the RNFA.

Competency 6:

The RNFA is competent to promote professionalism and to model professional behaviors to

other health care providers.


Bases professional and practice behaviors on the knowledge and application of the scope of practice for the

specific job category as defined by the provincial/territorial licensing bodies, professional practice

standards, and facility guidelines to practice.

Examples:

Possesses knowledge of and works within appropriate regulatory guidelines and legal

constraints, exercising caution to not extend into the practice of medicine.

Completes credentialing process as defined by facility(ies) in which the RNFA practices.

Obtains and maintains clinical privileges for activities to be performed.

Practices according to recognized standards of nursing practice, such as the ORNAC

“Recommended Standards, Guidelines, and Position Statements for Perioperative Registered

Nursing Practice” {and the AORN “Standards of perioperative professional performance.”}


Maintains professional credentials.

Examples:

Meets the necessary requirements to obtain and maintain certification-CPN(C), advanced

cardiac life support – ACLS, pediatric advanced life support - PALS.

Actively participates in self, peer, and colleague review processes.


Demonstrates knowledge of risk management, professional liability, and malpractice issues.

Examples:

Is encouraged to secure and maintain individual liability insurance, either independently or as

a member of a Professional Regulatory body or physician practice group (if so employed).

Collaborates with facility risk manager to identify potential risk-inducing behaviors in the

practice arena. Initiates appropriate teaching and/or practice change to reduce risk.

Is vigilant in staying abreast of patient safety issues and published standards to promote


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patient safety.


Practices in an ethical manner.

Examples:

Respects patient’s dignity and autonomy. Maintains patient confidentiality.

Actively participants in and accesses expert resources to resolve ethical dilemmas.


Seeks out and participates in lifelong learning opportunities.

Examples:

Builds upon the knowledge base and skill level of an assistant-at-surgery through experiential

learning and ongoing education.

Pursues formal advanced education to further his/her nursing career (i.e.,

baccalaureate/graduate degrees).

Networks with other health care professionals to promote the practice of RNFAs and to

discuss practice issues.

Participates in professional nursing activities at the local, provincial, and federal levels.

Attends local and national conferences and specialty forums to expand knowledge base and

stay abreast of emerging technology.


Participates in professional activities and defined processes directed towards improving patient care.

Examples:

Actively participates in multidisciplinary activities in the workplace (e.g., institutional grand

rounds, committees, quality improvement activities).

Identifies and analyzes situations in which collaborative consensus for patient care

interventions cannot be attained. Takes actions appropriate to the specific situation.

Initiates process review mechanisms.

Influences interdisciplinary relationships by enhancing collaborative processes, “corporate

culture,’ institutional values, and professionalism.

Identifies situations in which additional education and/or disciplinary action is indicated and

takes appropriate action.

Considers factors such as developmental age or cultural background when planning effective

education for patients and families.


Participates in the research process to build and promote RNFA clinical practice thereby contributing to the

body of nursing knowledge, with particular interest in perioperative nursing and the RNFA role.


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Examples:

Searches the literature to identify pertinent existing research data.

Evaluates and interprets published research for its relationship to clinical practice.

Conducts and/or participates in research studies to advance not only RNFA practice, but all

nursing practice.

Uses evidenced-based practices relevant to perioperative patient care management and RNFA

practice.

Seeks publication of articles and/or research studies pertinent to RNFA practice.


Participates in public policy development.

Examples:

Maintains awareness of proposed/pending legislation affecting nursing and the RNFA role.

Makes contact with provincial/territorial and federal legislators and administrators, as

appropriate, to provide information and insight regarding health care issues and regulations.

Actively supports public policy promoting quality care and RNFA practice.

Campaigns and contributes to success of candidate(s) of choice who promote(s) RNFA

practice and quality patient care. (Reproduced with permission)

*Collaborative problem: Patient problems requiring intervention using both a medical and nursing model.

Oucharek Mattheis, A. (2004) Registered Nurse First Assist Competencies: A Project in partial fulfillment

of a Master of Nursing. Unpublished Master’s project, University of Saskatchewan, Saskatoon,

Saskatchewan, Canada.

Adapted with permission from AORN, RN First Assistant Guide to Practice, 2nd edition.

Copyright 2005 AORN, Inc, 2170 S Parker Road, Suite 300, Denver, CO 80231


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Section 2

Infection Prevention and Control


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Infection Prevention and Control Section 2


Section 2 Infection Prevention and Control

Routine Practices and Additional Precautions .................................................................................................. 89 Routine Practices .............................................................................................................................................. 89 Airborne Precautions .......................................................................................................................... 91 Droplet Precautions ............................................................................................................................ 94 Contact Precautions ............................................................................................................................ 95 Classic Creutzfeldt-Jakob disease (CJD ........................................................................................................... 97 Implementing CJD Precautions .......................................................................................................... 97

CJD Perioperative Precautions ........................................................................................................... 98 Preoperative Risk Assessment Tool (Appendix A) .......................................................................... 102 Environmental Cleaning/Sanitation ................................................................................................................ 104

General Practices .............................................................................................................................. 104 Preliminary Cleaning........................................................................................................................ 106 Intraoperative Cleaning .................................................................................................................... 106 End of Procedure Cleaning (Between Cases) ................................................................................... 107 Terminal Cleaning ............................................................................................................................ 108 Weekly and /or Monthly Cleaning ................................................................................................... 108

Traffic Control ................................................................................................................................................ 109

People ............................................................................................................................................... 110 Supplies and Equipment ................................................................................................................... 111

Dress Code ..................................................................................................................................................... 112

Patients ............................................................................................................................................. 112 Visitors ............................................................................................................................................. 112 Staff .................................................................................................................................................. 113

Scrubbing, Gowning, Gloving ........................................................................................................................ 116

Scrubbing ......................................................................................................................................... 116 Gowning ........................................................................................................................................... 117 Gloving ............................................................................................................................................. 118

Aseptic Technique .......................................................................................................................................... 121

Establishing an Aseptic Environment .............................................................................................. 121 Establishing the Sterile Field ............................................................................................................ 121 Dispensing Sterile Supplies .............................................................................................................. 122 Maintaining the Sterile Field ............................................................................................................ 123 Storage of Sterile Supplies ............................................................................................................... 124

Instrument Management and Reprocessing .................................................................................................... 126

Intraoperative Instrument Care ......................................................................................................... 126 Reprocessing Surgical Instruments .................................................................................................. 127 Loaned and Leased Surgical / Medical Equipment .......................................................................... 129 Packaging for Sterilization ............................................................................................................... 129 Rigid Sterilization Containers .......................................................................................................... 131 Sterilization ...................................................................................................................................... 132 Emergency (Flash) Sterilization ....................................................................................................... 134 High Level Disinfection ................................................................................................................... 135


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Specialized Instruments and Equipment ......................................................................................................... 140 Prosthesis Care and Handling........................................................................................................... 140 Power Equipment Management ....................................................................................................... 141

Single Use Medical Devices (SUMeDs) ........................................................................................................ 142 Selection, care and handling of materials ....................................................................................................... 143 Wrappers, Surgical Gowns, and Drapes ........................................................................................... 143

Bundles ............................................................................................................................................. 145 Skin Preparation (Prep) .................................................................................................................................. 146 Draping .......................................................................................................................................................... 149 Dressing(s), Drain(s), Irrigation ..................................................................................................................... 150

Dressings .......................................................................................................................................... 150 Drains ............................................................................................................................................... 151 Irrigation ........................................................................................................................................... 152


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Routine Practices and Additional Precautions

1.1 Routine Practices

Routine Practices (RP), formerly known as Standard Precautions or Universal Precautions shall be used when caring for all patients. Additional precautions (Airborne, Droplet and/or Contact) shall be used to manage infections spread by those specific methods of transmission.

PRACTICE RATIONALE

1.1.1 All members of the health care team shall

use Routine Practices, which include but are not limited to, the following requirements:

- Hand washing shall be done with an

approved antimicrobial agent or an approved alcohol gel prior to and immediately after each patient contact;

after contact with contaminated items; immediately upon removing gloves and; at the end of each procedure, with specific attention to areas between thumb and first digit to reduce microbes; - Gloves are not required for routine

patient care activities in which contact is limited to patient's intact skin.

- Gloves should be used as an additional

measure, not as a substitute for hand washing

Gloves shall be changed between care activities and procedures with the same patient after contact with materials that contain high concentrations of

The principles of Routine Practices are based on the premise that all clients/patients/residents, their secretions, excretions and body fluids and their environment might be potentially contaminated with harmful microorganisms. By following simple preventative practice at all times regardless of whether or not an illness is ‘known’ staff will be protecting client/patients/ residents and themselves from an unknown, undiagnosed infectious risk. (Best Practices for Environment Cleaning for Infection Prevention and Control in Health Care Settings, December 8, 2009 p. 35). The need for additional precautions will depend on the routine practices used by the health care facility, and the microorganisms encountered. Gloves do not provide complete protection against hand contamination. The use of gloves does not replace the need for hand hygiene (Best Practices for Environment Cleaning for Infection Prevention and Control in Health Care Settings, December 8, 2009 p. 35).


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PRACTICE RATIONALE

microorganisms (e.g. urinary catheter, endotracheal tubes, etc).

- appropriate personal protective equipment (PPE) such as gloves, fluid-resistant gowns, head and foot coverings, face shields, masks, and eye protection when there is a potential for exposure to blood, body fluid substances, or other potentially infectious material(s);

- impervious gowns shall be worn during procedures that are likely to result in splashes or where excessive irrigation will be used;

- masks, protective eyewear, or eye/face shields shall be worn by the scrub team during surgery;

- all PPE should be removed immediately following use and placed in an appropriately designated area or container;

- reusable PPE must be decontaminated between uses as per the manufacturer’s instructions;

- all procedures involving blood or potentially infectious materials should be performed in a manner that minimizes splashing and/or spraying; and

- body fluids and any infectious material(s) shall be confined and contained.

1.1.2 Clean mouthpieces, resuscitation bags, or

other ventilation devices shall be provided for use where the need to resuscitate is likely to occur.

Care of the patient may be provided without cross-contamination to the health care team.

1.1.3 Health care team members with exudative lesions or weeping dermatitis shall refrain from providing direct patient care or invasive procedures.

Cuts, abrasions, and hangnails tend to ooze serum and are a potential risk for infection between health care team and the patient. Microorganisms grow readily in exudate and open skin lesions.

1.1.4 Blood/body fluid splashes in the eyes, or mucous membrane and/or skin punctures shall be reported to the Occupational Health Department and the health care facility's protocol followed.

Hepatitis and HIV are examples of diseases, which may enter through the mucous membranes or via skin puncture.


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PRACTICE RATIONALE

1.1.5 Used/contaminated needles shall not be recapped, bent, sheared, broken, or resheathed by hand. Safety engineered needles (SENs) are the recognized best practice.

1.1.6 All disposable sharps shall be placed in a designated puncture-resistant container located in the area where the items were used.

The move to needleless systems or needle-protection systems prevents percutaneous injuries. Risk of injuries escalates when recapping needles, and/or handling sharps. Occupational Health and Safety Regulations have been passed in several provinces regarding the use of safety engineered devices in an effort to reduce exposure to blood borne pathogens. Health care facilities should protect workers by implementing SEN systems whenever possible, and facilitating safe work procedures and practices related to the use of needles.

1.1.7 Specimens shall be placed in leak proof containers clearly labeled "Biohazard" for handling and transport. Any specimen container received from the sterile field shall be placed into a fluid resistant bag and similarly labeled.

All specimens are potentially infectious.

1.1.8 Hepatitis B Virus (HBV) immunization shall be made available to all perioperative staff as per facility policy and procedure.

Immunization against HBV is effective in preventing the disease and should be given before occupational exposure occurs.

Additional Transmission Based Precautions

1.2 Airborne Precautions (used in addition to Routine Practices) PRACTICE

RATIONALE

1.2.1 Airborne Precautions shall be used for patients who are suspected or known to

have certain infections as outlined by the health care facility, including but not limited to:

- Tuberculosis; - Varicella; - Rubeolla; -Sudden Acute Respiratory Syndrome (SARS); and

- emerging respiratory communicable diseases.

All members of the health care team shall follow the facility’s infection prevention and control policy/procedure for Airborne Precautions which may include, but is not limited to: - placing a surgical mask on a patient

during transport and ensuring the

Airborne microorganisms are widely dispersed by air currents and can be inhaled. These can deposit on surfaces or on a susceptible host. “Airborne particles range in size from 0.001 microns to several hundred microns” (AORN, 2010, p. 241). Occlusive fitting 0.1 micron filter masks provide personal protection in cases where airborne infection


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patient is transported directly into the theatre;

- health care workers caring for a patient known or suspected to have microorganisms transmitted by the airborne route shall wear NIOSH approved N95 or equivalent respirator/mask when in the same room with the patient;

- Fit testing for N95 masks shall comply with federal, provincial, and facility policies;

- respirators/masks should be closely fitted to the face to prevent leakage around edges and shall be fit tested;

- Airborne Precaution signs shall be posted on theatre doors. All doors to the theatre shall be kept closed. Strict traffic control shall be enforced;

- Air pressure in operating room should be changed from positive to negative; and

- for suspected SARS, or an emerging communicable respiratory disease, refer to federal and provincial directives.

is suspected or confirmed.

1.2.2 Staff susceptible to chicken pox or measles shall be excluded from caring for patients with active measles, chicken pox or shingles (Health Canada 1999). Personnel who have had unprotected contact with active untreated pulmonary tuberculosis shall be notified; shall report to the Occupational Health

Department; and shall follow the health care facility's protocol.

1.2.3 The same between case cleaning procedures used in other theatres in the facility should be used (Gruendemann & Mangum, 2001, p. 352). An approved hospital grade germicide/ disinfectant that is not tuberculocidal may be used.

Extraordinary attempts to disinfect or sterilize environmental surfaces are not required. Walls, floors, and other environmental surfaces are rarely associated with transmission of infections to patients or health care workers.

1.2.4 Theatres should remain vacant in order to allow for a complete air exchange. The time is dependent on number of room air exchanges per hour. The airborne precaution sign must remain on the door

Time is needed to allow for appropriate ventilation air exchanges. Follow CSA Heat, Ventilation and Air Conditioning (HVAC) guidelines (CSA Z317.2-01).


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until sufficient time has elapsed (Best Practices for Environment Cleaning for Infection Prevention and Control in Health Care Settings, December 8, 2009 p96). 1.2.5 If the room is urgently needed before the air has been sufficiently cleared of tubercle bacilli, an N95 respirator must be worn during cleaning; and removed only after leaving the room and the door has been closed.

It is preferable to wait for sufficient air exchanges to clear the air before cleaning the room (Best Practices for Environment Cleaning for Infection Prevention and Control in Health Care Settings, December 8, 2009 p. 96).

1.2.6 Disposable anesthetic equipment shall be used on all patients with suspected or known airborne diseases.

1.2.7 When pulmonary TB is known or suspected, a TB specific bacterial filter shall be placed on the patient's endotracheal tube or at the expiratory side of the anaesthesia breathing circuit.

Helps reduce risk of contaminating equipment or discharging tubercle bacilli into the ambient air (Phillips, 2007, p. 239).

REFERENCES Association of PeriOperative Registered Nurses. (2010). Perioperative Standard and Recommended Practices. Denver: AORN. Canadian Standards Association (2008). CSAZ317.2-01 (R2008) Special requirements for heating, ventilation, and

air conditioning (HVAC) systems in health care facilities. Toronto: Author. Gruendemann, B. & Mangum, S. (2001). Infection prevention in surgical settings. Toronto: W.B. Saunders. Phillips N. (2007). Berry & Kohn’s Operating room technique. (11th ed.). Toronto: Mosby. Provincial Infectious Diseases Advisory Committee (PIDAC), (December 8, 2009) Best Practices for Environment Cleaning for Infection Prevention and Control in Health Care Settings. Ontario. Siegel, J., Rhinehart, E., Jackson, M., & Chiarello, L., the Healthcare Infection Control Practices Advisory Committee, (2007). Guidelines for Isolation Precautions: Agents in Healthcare Settings.


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BIBLIOGRAPHY Association of Anaesthetists of Great Britain and Ireland (AAGBI), (2008). AAGBI Safety Guideline Infection Control in Anaesthesia, AAGBI, London. www.aagbi.org McKay, M., & Farley, M. (2006 December). Infection control circle of safety. Canadian Operating Room Nursing Journal, 24, (4), 20-24, 41. Neil, J. A. (2008). The Perioperative Care of the Patient with Tuberculosis. AORN, 88 (6) 942-960. Provincial Infectious Diseases Advisory Committee (PIDAC), (December 8, 2009) Best Practices for Environment Cleaning for Infection Prevention and Control in Health Care Settings. Ontario. Siegel, J., Rhinehart, E., Jackson, M., & Chiarello, L., the Healthcare Infection Control Practices Advisory Committee, (2007). Guidelines for Isolation Precautions: Agents in Healthcare Settings. For current information on SARS, refer to the website www.SARSReference.com

1.3 Droplet Precautions (to be used in addition to Routine Practices) 1.3.1 Droplet Precautions shall be used for

patients who are suspected or known to have certain infections as outlined by the health care facility or Infection Prevention and Control department, including but not limited to: -parainfluenza; -croup; -pertussis; -influenza; -bacterial meningitis caused by haemophilus influenza and neisseria meningitis; -rubella; -mumps; and -parvovirus B19.

Precautions may differ for pediatric and adult patients (check with the facility infection control practitioner).(Canada Communicable Disease Report, 1999, p. 42)

1.3.2 Follow facility's Infection Prevention and Control procedures for Droplet Precautions which may include, but is not limited to: - placing a surgical mask on a patient during transport and ensuring that they are transported directly into the theatre; -posting Droplet Precaution signs on theatre doors; -a high efficiency mask shall be worn when working within 2 meters of patients (the high efficiency mask approved for operating room use provides sufficient protection when worn according to manufacturer’s instructions); and - eye protection shall be worn when there is

As it is not possible to predict when droplets will be


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a chance that droplets may be expelled into the eyes of staff.

encountered it is preferable to err on the side of caution and wear eye protection at all times.

Staff susceptible to measles and/or chicken pox shall be excluded from assignments that pose a risk of exposure to these microorganisms (Health Canada, 1999).

1.4 Contact Precautions (to be used in addition to Routine Practices) 1.4.1 Contact Precautions shall be used for

patients who are suspected or known to have certain infections as outlined by the health care facility and the Infection Prevention and Control Department, including but not limited to: - scabies, impetigo, herpes simplex and other skin infections; - antibiotic resistant organisms (ARO)

e.g.: MRSA/VRE; - gastrointestinal infections e.g. Hepatitis

A and E; - pseudomonas - clostridium difficile ; - respiratory syncytial virus (RSV); - wound infections such as necrotizing

fasciitis; and - major burn wound infection.

Most microorganisms are spread by direct or indirect contact. They are often transferred via hands but may be spread by patient care equipment and other objects. Contact transmission precautions may differ between the adult and pediatric population, therefore adherence to the health care facility's policy is crucial. (Canada Communicable Disease Report, 1999, p. 46)

1.4.2 Follow the facility's Infection Prevention and Control procedures for Contact Precautions which may include but is not limited to: - when possible, schedule these surgical

procedures as the last case of the day in a specific theatre;

- removing unnecessary equipment from the theatre;

- posting Contact Precaution signs on theatre doors;

- ensuring that an additional circulator is assigned outside the theatre to assist with obtaining items throughout the procedure, the recovery, and the cleanup;

- wearing gloves when touching a patient,or coming in contact with items that may contain a high concentration of microorganisms;

- gowning when clothing will have direct

Reduces time delays and possible cancellations due to the cleaning time required post case. Removal of unnecessary equipment and supplies from the room prior to the patient’s arrival will assist in controlling replacement costs as exposed items that cannot be reprocessed must be discarded. It is important that appropriate barriers are used to reduce the opportunity of transmission of microorganisms between patients, visitors and staff.


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contact with the patient, or touch surfaces or objects in the theatre which came into contact with the patient;

- recovering patient in the theatre or a separate isolated area of the Post Anesthetic Care Unit (PACU);

- terminal cleaning of the theatre after case; and

- ensure the patient health record does not have contact with the bed linen during the transport of the patient.

It is important to remember that these resistant microorganisms can survive on surfaces for an extended period of time. (PIDAC December 8, 2009 p. 21 - 22) have a table which shows VRE up to 58 days on counter tops; MRSA – 9 weeks after drying; gram positive & cocci 25 days and gram negative 60 days on hospital fabrics and plastics; and entercocci/staphylococci up to 90 days. Cleaning with appropriate hospital grade disinfectants will control the microorganisms thereby protecting other patients, staff and the aseptic environment.

REFERENCES Association of PeriOperative Registered Nurses. (2010). Perioperative Standard and Recommended Practices. Denver: AORN. Canada Communicable Disease Report. (1999) ISSN-4169, Vol. 25S4, 42. Provincial Infectious Diseases Advisory Committee PIDAC, (December 8, 2009) Best Practices for Environment Cleaning for Infection Prevention and Control in Health Care Settings. Ontario. Siegel, J., Rhinehart, E., Jackson, M., & Chiarello, L., the Healthcare Infection Control Practices Advisory Committee, (2007). Guidelines for Isolation Precautions: Agents in Healthcare Settings.

BIBLIOGRAPHY

Arpin, Jocelyne (2005). Sars and it’s Effect on Health Care. Canadian Operating Room Nurses Journal, 23(4). Barrow, C. (2009). A patient’s journey through the operating department from an Infection Control perspective.

Journal of Perioperative Practice, 19(3), 94-98. CDC, (2007). Guidelines for isolation precautions: preventing transmission of infectious agents in healthcare

settings, CDC, Atlanta GA. CHICA-Canada, (2008). Position Statement, Hand Hygiene. http://www.chica.ca Canadian Standards Association (2007). CSA Z94.3-F07 Eye and Face Protectors. Toronto: Author. Canadian Standards Association (2009). CSA Z94.3.1-09 Selection, Use and Care of Protective Eyewear. Toronto: Author. Department of Health, (2008). Clean, Safe Care: Reducing Infections and Saving Lives, Dept. of Health. www.dh.gov.uk/publications Freeman, S. (2009). An Evidence-based Process for Evaluating Infection Control Policies. AORN Journal, 89 (3), 489-508.


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Lee, T. C., Carrick, M.M., Scott, B.G., Hodges, J.C. (2007). Incidence and Clinical Characteristics of Methecillin-

resistant Staphylococcus Aureus necrotizing Fasciitis in a Large urban Hospital. Canadian Journal of Surgery, 194, 809-813.

Ott, M. & Wirick, H. (2008). Vancomycin-Resistant Entercocci (VRE) and the role of the healthcare worker. Canadian Operating Room Nursing Journal, 26(1), 21-24, 26-29. Provincial Infectious Diseases Advisory Committee (PIDAC), (December 8, 2009) Best Practices for Environment Cleaning for Infection Prevention and Control in Health Care Settings. Ontario. Siegel, J., Rhinehart, E., Jackson, M., & Chiarello, L., the Healthcare Infection Control Practices Advisory Committee, (2007). Guidelines for Isolation Precautions: Agents in Healthcare Settings. Stopp-Caudell, B. (2008). Gangrene: Recognizing and Treating Cellular Necrosis, Surgical Technologist, 40(12),

547-552. Tanner J (2008). Surgical Hand Antisepsis: The Evidence, Journal of Perioperative Practice, 18 (8), 330-339. Tanner J & Blunsden C (2007). National Survey of Hand Antisepsis Practices, Journal of Perioperative Practice

17(1), 27-37. Tarrac, S. E., (2008). Application of the Updated CDC Isolation Guideline for Healthcare Facilities, AORN, 87(3),

534-545. Weaving P, Cox F, & Melton S (2008). Infection Prevention and Control in the Operating Theatre: reducing the risk

of SSI, Journal of Perioperative Practice, 18(5), 199-204. Valentin Rodriquez, (2008). Necrotizing Fasciitis, Surgical Technologist, 40(7), 305-315.

Classic Creutzfeldt-Jakob Disease (CJD)

CJD Precautions These recommendations summarize those outlined by Health Canada in Infection Control Guideline Classic Creutzfeldt - Jakob disease in Canada. (CCDR, 2002; 28S5, p.1-84) and include updates from the Infection Control Guidelines Creutzfeldt-Jakob Disease in Canada Quick Reference Guide 2007. They apply to all forms of classic CJD (sporadic, familial and iatrogenic), and to Gerstmann-Straussler-Scheinker syndrome (GSS) and Fatal Familial Insomnia (FFI). The Public Health Agency of Canada guidelines should be consulted for detailed information regarding the management of CJD. www.phac-aspc.gc.ca/publicat/ccdr-rmtc/02vol28/28s5/index.html. Updates and Quick Reference Logarithm can also be accessed from The Public Health Agency of Canada Agency Guidelines, 2007 http://www.phac-aspc.gc.ca/nois-sinp/cjd/cjd-eng.php At this time, variant CJD is excluded from Health Canada’s recommendations. 2.1 Implementing CJD Precautions CJD precautions shall be implemented when warranted, after completing an assessment of the combination of patient risk and tissue risk. Refer to Appendix A, p.102 for an example of a patient risk assessment tool.


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The following table summarizes the situations when CJD precautions are required.

Tissue Contact During Surgery

High Risk Patient i.e. CJD diagnosed or

suspected

Low Risk Patient i.e. Recipients of high infectivity tissue grafts

or injections, or members of families

with familial CJD

No Risk Patient

All other patients

High Infectivity Tissue Brain, spinal cord & spinal ganglia, trigeminal ganglia. cerebrospinal fluid (CSF), dura mater, pituitary, and posterior eye (including retina and optic nerve)

YES NO NO

Low Infectivity Tissue Kidney, liver, lung, lymph nodes, spleen, placenta, cornea

YES NO NO

No Detected Infectivity Tissue All other tissue including blood, body fluids (except CSF).

NO NO NO

2.2 CJD Precautions PRACTICE RATIONALE

When CJD is identified prior to surgery, the CJD protocol shall include the following:

2.2.1 Notify OR and other affected departments

(i.e. central processing and laboratory) in advance.

2.2.2 Remove unnecessary supplies and equipment from the theatre.

2.2.3 Use single use items (including drapes and gowns) whenever possible.

2.2.4 Protect fixed surfaces and equipment with water resistant drapes and covers.


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PRACTICE RATIONALE

2.2.5 Do not use difficult to clean items e.g. power equipment, flexible scopes, or stereotactic equipment.

These items would be destroyed by CJD reprocessing protocol.

2.2.6 When possible, schedule these surgical procedures as the last case of the day in a specific theatre.

This will reduce delays and potential patient cancellations that would result from the extensive cleaning protocols required for CJD.

2.2.7 Limit the number of staff in the room.

2.2.8 Wear personal protective equipment as per Routine Practices. Refer to Section 1 page 92 for further information.

2.2.9 Once the “contaminated” part of procedure has begun, no items shall leave the room until the completion of the surgical procedure.

“Contaminated” refers to the part of the procedure that begins when contact is made with infective tissue as described in the preceding table.

2.2.10 Specimens shall be sealed and clearly labeled “Infectious, Biohazardous and CJD”.

2.2.11 Ensure that instruments sent to the reprocessing area are sealed in a biohazardous container and clearly labeled as “CJD Protocol Required”.

2.2.12 Instruments that will not be incinerated shall be kept moist in a closed container during transport to the reprocessing area.

2.2.13 Whenever possible, incinerate used instruments following surgery.

Disposable brain biopsy sets are available. Incineration of biohazardous materials is provincially regulated.

2.2.14 Immediately after the completion of surgery, all personnel shall wear appropriate personal protective equipment to clean the theatre, and will follow the “CJD Hard Surface Decontamination” (CCDR, CJD, 2002) protocol:

- Remove visible soil. - Flood soiled area(s) with freshly prepared

sodium hydroxide 1 N solution or sodium hypochlorite (bleach) solution (20,000 ppm) for 1 hour of contact time.

- Rinse well.

Full strength sodium hypochlorite (bleach) is usually ~ 5% or 50,000 ppm. 20,000 ppm is about half strength. Sodium hydroxide remains active for only a short period of time (approximately 20 min).

2.2.15 Garbage and solid wastes shall be sealed in a leak-proof, puncture-resistant container, labeled “Infectious, Biohazardous and CJD”, and sent for incineration.


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PRACTICE RATIONALE

2.2.16 Suctioned liquids shall be solidified, sealed in a leak-proof, puncture-resistant container, labeled “Infectious, Biohazardous and CJD”, and sent for incineration

2.2.17 Liquids for cleaning can be flushed down the drain.

Postoperative Instrument Containment

Following surgery, the procedure for processing contaminated instruments that will not be incinerated shall include the following: 2.2.18 Process in a specially designated area,

preferably within the Decontamination area. Protect the separate area with disposable, waterproof covers.

Processing in a separate area limits the potential for cross-contamination.

2.2.19 Reprocess instruments following the CJD Decontamination protocol (Public health Agency, 2007): - Manually clean instruments using

detergent. - Rinse well. - Immerse in fresh sodium hydroxide

(1N) or sodium hypochlorite (bleach) (20,000 ppm) solution for 1 hour.

Cover container during immersion. - Rinse well. - Sterilize:

- Position instruments in a mesh bottomed instrument pan and steam sterilize in a Prevac cycle @ 134ºC for 1 hr

- Reprocess through a washer decontaminator/disinfector using standard methods.

Following washer decontaminator/ disinfector reprocessing, run one empty cycle before further use.

A detailed inspection of a complex or fragile piece of a reusable device may reveal that the item can be dismantled more thoroughly than anticipated. Various parts of the device may tolerate the CJD decontamination process safely. By completing this process, far less of the device may need to be incinerated. If necessary, the manufacturer should be contacted for assistance. CAUTION: Highly alkaline detergents should not be used when manually cleaning as they pose a safety risk to staff. Recent research indicates promising results regarding prion inactivation using highly alkaline detergents in combinations with various sterilization methods. (Yan, et.al, 2004 and Fichet, et.al, 2004) Because the final rinse water of one cycle is often used as the pre-rinse water of the next cycle, running an empty cycle removes all saved water.

2.2.20 Incinerate solid waste and cleaning supplies.

2.2.21 Cleaning liquids may go down the drain.

Infective Tissue or Fluid Spill protocol shall include the following: 2.2.22 Flood area of spill with full strength bleach.

Let stand 10 minutes.


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PRACTICE RATIONALE

2.2.23 Apply absorbent material.

2.2.24 Follow “CJD Hard Surface Decontamination” protocol outlined in 2.1.14.

2.2.25 Incinerate clean-up materials.

Quarantine for Suspected CJD protocol shall include the following: Some facilities may choose to quarantine used instruments until a diagnosis of CJD is confirmed. If instruments are quarantined, the following measures shall be taken:

2.2.26 Clean instruments. Scrub nurse shall

remove gross soil.

2.2.27 Separate in reprocessing of instruments and quarantine.

2.2.28 Store in a sealed container that is: dated; leak-proof; puncture-resistant; and labeled “Infectious, Biohazardous, and

CJD Protocol”.

2.2.29 Monitor in a secure area.

2.2.30 When diagnosis is confirmed: If positive—incinerate or reprocess

following “CJD Instrument Decontamination” protocol.

If negative—reprocess using standard (usual) methods.

The protocol for CJD Risk identified after procedure completion shall include the following: 2.2.31 Implement CJD precautions as required.

Refer to clause 2.2 of this section.

2.2.32 Identify all reusable instruments used on patient prior to the risk being identified.

2.2.33 If unable to identify specific instruments

used, follow recommendations for High Risk patients managed Retrospectively (Public Health Agency, 2007) and the healthcare facility policy.

A method for tracking instruments used in high-risk procedures facilitates quarantine.


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Appendix A Source: (Risk Assessment tool Recommendations for managing instruments used on CJD patients. Decision algorithm-graphic version), Public Health Agency of Canada, (2007) Reproduced with the permission of the Minister of Public Works and Government Services Canada, 2009.


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REFERENCES Adapted from Canada Communicable Disease Report - Infection Guidelines, Classic Creutzfeldt-Jakob Disease in

Canada, Volume 28S5, November 2002, and Health Canada. Accessed April 26, 2009 at www.phac-aspc.gc.ca/publicat/ccdr-rmtc/02vol28/28s5/index.html. Reproduced with the permission of the Minister of Public Works and Government Services Canada. Health Canada assumes no responsibility for any errors or omissions, which may have occurred in the adaptation of its material.

Fichet, G., Comoy, E., Duval, C., Antloga, K., Deher, C., Charbonnier, A., et al. (2004). Novel methods for

disinfection of prion contaminated medical devices. Lancet, 364, 521-526. Public Health Agency of Canada (2007). Infection Control Guidelines: Classic Creutzfeldt-Jakob disease in Canada,

Quick Reference Guide. Accessed on April 26, 2009 at http://www.phac-aspc.gc.ca/nois-sinp/cjd/cjd-eng.php

Yan, Z., Stitz, L., Heeg, P., Pfaff, E., & Roth, K. (2004) Infectivity of prion protein bound to stainless steel wires: A

model for testing decontamination procedures for transmissible spongiform encephalopathies. Infection Control and Hospital Epidemiology, 25(4), 280-283.

BIBLIOGRAPHY Advisory Committee on Dangerous Pathogens Spongiform Encephalopathy. (1998). Advisory Committee

Transmissible spongiform encephalopathy agents: safe working and the prevention of infection. London, England: The Stationary Office.

Barnett, F., McLean, G. (2005). Care management of Creutzfeldt-Jakob disease within the United Kingdom. Journal of Nursing Management. 13(2), 111-8.

Beesley, J. (2003). Creutzfeldt-Jakob Disease. British Journal of Perioperative Nursing, 13(1), 21-2. Belkin, N. (2003). Creutzfeldt-Jakob disease: Identifying prions and carriers. AORN Journal, 78(2), 204-208, 210. Farling, P. & Smith, G. (2003). Anesthesia for patients with CJD: A practical guide. Anesthesia, 58(7), 627-629. International Association Healthcare Central Services Material Management (2007) Central Services

Technical Manual. Author. http://iahcsmm.org/ Knight, R. (2006) Creutzfeldt-Jakob Disease: A rare cause of dementia in elderly persons. Clinical Infectious

Diseases, 43(3), 340-346. McNeil, B. (2004). Management of a CJD Case: Part 2-The patient with CJD in the operating theatre. British Journal

of Perioperative Nursing, 14(5), 223-226. Scicchitano, L. (2004). Bovine spongiform encephalopathy and CJD: Background & implications for nursing

practice. Insight. 29(4), 17, 19-21. World Health Organization. Variant Creutzfeldt-Jakob disease. Retrieved April 26, 2009 from

www.who.int/mediacentre/factsheets/fs180/en/


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Environmental Cleaning/Sanitation

Principles:

1. Only essential equipment should be maintained within the operating room.

2. Open shelving shall not be used in the patient operating room to store sterile supplies.

3. All cupboards should have doors

preferably with glass. 4. Positioning equipment components should

be stored within a cupboard with door

5. OR doors shall remain closed at all times, including during cleaning.

The less equipment in the room the less cleaning is necessary and a reduced number of areas are available for dust to harbour organisms.

Bioburden may be increased by microbial laden aerosols and dust may land on the sterile packages. Sterile goods should be protected from high traffic. Sterile packages may be at risk with routine cleaning agents and activities. Bacterial growth is impeded by fluorescent lighting. Bioburden may be increased by microbial laden aerosols and dust may land on the components. Closed doors are essential to maintain the positive room pressure and preventing air from potentially contaminated corridors entering the room.

PRACTICE RATIONALE

3.1 General Practices

3.1.1 All surgical procedures shall be considered

potentially infectious and environmental cleaning protocols shall be documented and implemented for all procedures with additional precautions required for specific patient conditions as outlined in Routine Practices, Section 2. All surgical patients shall be provided with a clean, safe environment, which is free from dust, debris and bioburden. The perioperative nursing team, lead by the Registered Nurse circulator share the responsibility and accountability for ensuring a clean environment for each patient. It is essential that doors to the rooms be kept closed, except for entry/exit, including during cleaning procedures to ensure positive pressure is maintained.

A clean OR environment ensures minimal microbial growth, which is essential to the reduction of infections and well-being of patients and personnel. The surgical suite can become heavily contaminated with microbes, becoming a risk for patients, unless it is properly cleaned and disinfected. Positive pressure is easily lost with open doors, which allow air currents from corridors, and surrounding rooms that may be laden with organisms and dust entering the clean/sterile areas.

3.1.2 Procedures shall be available for the Additional precautions are available in addition to


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PRACTICE RATIONALE

containment and control of antibiotic- resistant organisms (AROs) and emerging diseases according to the health care facility’s infection control protocol.

Routine Practices for such contaminants as antibiotic-resistant organisms (AROs), drug resistant gram-negative organisms, tuberculosis and Creutzfeldt-Jakob disease. (See specific sections). AROs can be found on surfaces many days to weeks after improper/ incomplete cleaning Studies show that microorganisms can survive after inoculation onto items/surfaces and/or can be cultured from the environment in healthcare settings; and/or can proliferate in or on items/surfaces in the environment (Best Practices for Environment Cleaning for Infection Prevention and Control in Health Care Settings, December 8, 2009 p. 21).

3.1.3 The theatre's environment shall be designed so that it can be easily cleaned: - floors should be smooth, seamless, and

easy to clean - finishes on all walls and ceiling surface

materials should be hard, non-porous, fire-resistant, waterproof, stain-proof, seamless, non-reflective, and easy to clean (CSA Z314.8-08; CSA Z314.3-09; Phillips, 2007; Rothrock, 2011);

- wall finishes should be free of fissures, open joints, or crevices;

- room furnishings and equipment shall be easily washable/wipeable;

- shelving and cabinets should be of a material and design that is easily cleaned; and

- minimal supplies and equipment should be stored inside the theatre.

Debris could become lodged in cracks and uneven surfaces. Spaces or crevices may retain or permit passage of soil particles. Supplies and equipment stored in the operating room make it difficult to maintain a clean environment. Sterile supplies become laden with dust, microbes over time.

3.1.4 Intraoperative, between - case, terminal, daily, weekly, monthly cleaning schedules shall be documented and available to all involved team members. Environmental sanitation practices shall be performed by trained personnel according to health care facility protocol.

Documentation of cleaning provides a means of tracking for Quality Assurance purposes...

3.1.5 Cleaning solutions, equipment, and supplies utilized for sanitation shall be approved by the Infection Prevention and Control Committee. Selection of above items shall be supported by current evidence.

Ensures that appropriate solutions, equipment and supplies are utilized to reduce microbial contamination of the environment.


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PRACTICE RATIONALE

3.2 Preliminary Cleaning 3.2.1 The perioperative Registered nurse is

responsible for ensuring all team members take an active role in facilitating a clean surgical environment.

A clean surgical environment will reduce the number of microbial flora present. Staphylococcus aureus is the most common microbe causing surgical wound infections. The microbes are transferred by lint, dust, air currents and hands.

3.2.2 All horizontal surfaces within the theatre (e.g., furniture, tops of surgical lights, and equipment) shall be damp-dusted. Damp dusting is done with a clean, lint-free cloth moistened with a hospital approved low-level disinfectant. Start dusting at higher surfaces and work down to lower levels.

Dust with a solution approved by the facility IPC Committee and validated by the manufacturer for the intended purpose. Electronic equipment (i.e. monitors) shall be cleaned as per manufacturer’s instructions.

The team shall be vigilant in checking the reflective surface of the surgical lights for blood splatters. The reflective portion of the surgical lights shall be wiped between cases and as needed.

Proper cleaning of the theatre reduces the amount of exogenous microorganisms, dust, debris and bioburden in surgical environments. It also helps to reduce airborne contaminants that may travel on dust and lint and settle on surfaces. Ensures the product being used meets the required standards. Inappropriate use of liquids on electronic medical equipment may result in fires and other damage, equipment malfunctions and health care provider burns (Best Practices for Environment Cleaning for Infection Prevention and Control in Health Care Settings, December 8, 2009 p. 81).

3.2.3 Equipment from other areas such as X-ray machines, compressed gas tanks, etc., shall be damp-dusted before being brought into the operating room and prior to leaving.

Damp dusting reduces viable microbial contamination from air and other sources.

3.3 Intraoperative Cleaning

3.3.1 During the procedure, all contaminated items and spills shall be contained and/or promptly cleaned up using a facility approved disinfectant.

Prompt cleaning prevents spreading of microorganisms.

3.3.2 Equipment leaving the theatre shall first be wiped down with a hospital approved disinfectant prior to being stored.

Prevent cross contamination.


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PRACTICE RATIONALE

3.4 End of Procedure Cleaning (Between Cases) 3.4.1 Any surface and equipment that comes in

direct or indirect contact with the patient or body fluids, are considered contaminated and shall be cleaned with a hospital-grade disinfectant approved by Infection Prevention and Control. Clean up for surfaces and equipment shall proceed from the least contaminated to the most contaminated area

3.4.2 Regulated Medical Waste (RMW) shall be handled as little as possible and disposed of according to municipal/provincial/federal legislation and/or health care facility policies and procedures.

Prevents leakage and cross-contamination.

3.4.3 After removal of trash, linen and instruments, the floor area to within a 1 to

1.5m (3 to 4 ft) perimeter around the operative area should be cleaned if visibly soiled. The area cleaned shall be extended as required to encompass visibly soiled areas. (CSA Z314.8-08 p 23)

The extent of cleaning is case-specific depending on the amount of contamination.

3.4.4 Mop heads shall be changed after each use.If a bucket of hospital grade disinfectant solution is prepared for multiple uses, used mops shall not be reintroduced into the bucket (AORN, 2008).

A minor cleaning with a wet mop immediately around the OR table (without moving the OR table) is adequate after a minor case with no spillage.

3.4.5 Suction containers/liners should be disposable and wherever possible solidifiers should be used. Containers shall be disposed of as per facility waste management policies

Use of solidifiers will prevent splashing and aerosolization of blood, body fluids and microorganisms.

3.4.6 Reusable suction containers should not be used (AORN, 2008).

Risk of splashing and aerosolization are a high risk to personnel

3.4.7 Suction tubing shall be disposable. The lumen of suction tubing cannot be cleaned effectively.


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3.5 Terminal Cleaning 3.5.1 After the day’s schedule each theatre, scrub

area, corridor, furnishings, and equipment shall be terminally cleaned. This includes: - lights and ceiling-mounted tracks; - door handles and push plates; - light switches and controls; - telephones and computer keyboards; - spot-checking walls for cleanliness; - the exterior surfaces of all machines and

equipment (allow adequate drying time –as per manufacturer’s instructions –before storage);

- all furniture, including wheels/casters; - all horizontal surfaces; - scrub sinks and surrounding walls; - floors should be mopped with a

sufficient amount of disinfectant/ detergent to ensure that the floor remains wet for 5 minutes. Each floor shall be thoroughly cleaned using fresh solution and a fresh mop/mop head; and

- floors should be power scrubbed at regular intervals according to established protocols.

To reduce the number of infectious agents/microorganisms present. Moisture encourages microbial growth.

3.5.2 Refillable liquid soap dispensers should not be used. If refillable soap dispensers must be used, they shall be disassembled, cleaned and terminally disinfected before refilling with antiseptic solutions. Dispensers shall not be topped up (Health

Canada, 2004).

Refillable dispensers may become contaminated and act as a reservoir for microbial growth (Health Canada, 2004; AORN, 2010).

3.6 Weekly and/or Monthly Cleaning 3.6.1 Cleaning protocols and schedules for all

areas of the surgical suite shall be documented and assigned to specific personnel.

Effective sanitation techniques reduce the possibility of cross-contamination of patients and decrease risks to personnel. Promotes effective collaborative practice. A means to confirm that cleaning has been done is essential for infection control audit purposes. i.e. signed checklists.

3.6.2 Items/areas scheduled to be cleaned should include, but are not limited to: - walls; - floors - air-conditioning and ventilation

Effective sanitation techniques reduce the possibility of cross-contamination of patients and decrease risks to personnel.


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grills/vents; - light fixtures, sprinkler heads and other

fixtures - ducts and filters; - sterilizers; - cabinets, closets, shelves; - warming cupboards; - theatre walls and ceilings; - recessed ceiling tracks; - store rooms; - offices and lounges; - pre-op holding area - refrigerators, ice machines; and - washrooms and locker rooms

REFERENCES

Association of PeriOperative Registered Nurses. (2010). Perioperative standards and recommended practices. Denver: Author. Canadian Standards Association. (2009). Z314.3-09. CAN/CSA. Effective sterilization in health care facilities by the steam process. Toronto: Author. Canadian Standards Association. (2008). Z314.08-08. CAN/CSA. Decontamination of reusable medical devices. Toronto: Author. Health Canada (2004). Drugs and Health Products. Retrieved April 1, 2009 from www.hc-sc.gc.ca Phillips, N. (2007). Berry & Kohn’s operating room technique. (11th ed.). Toronto: Mosby. Provincial Infectious Diseases Advisory Committee (PIDAC), (December 8, 2009) Best Practices for Environment Cleaning for Infection Prevention and Control in Health Care Settings. Ontario. Rothrock, J. (2011). Alexander’s Care of the Patient in Surgery. (14th ed.). St. Louis: Mosby. Woodhead, K. and Wicker, P. (2005). Textbook of Perioperative Care. Toronto: Elsevier.

BIBLIOGRAPHY

Nelson , Jason., et al. (2006). Microbial Flora on operating Room Telephones, AORN Journal, 83(3), 607-626. Walsh, Eric F., et al. (2006). Microbial Colonization of Tourniquets Used in Orthopedic Surgery, Orthopedics, 29(8), 709-713. www.ORTHOSuperSite.com

Traffic Control

PRACTICE RATIONALE

4.1 General Practice

The surgical suite shall have three (3) levels of increasingly restricted access.

4.1.1 Unrestricted Areas

- street clothes are permitted;

Microbial load is reduced with progression of area restrictions.


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- includes a control point or desk to monitor and direct further access; and

- depending on facility policy, may also include pre-op holding area, staff lounge, booking office and/or manager’s office.

4.1.2 Semi-restricted Areas

- personnel are required to wear appropriate surgical attire and cover head and facial hair; and

- includes peripheral support areas, i.e. clean and sterile supplies, work areas for storage, scrub sink areas, corridors leading to restricted areas.

4.1.3 Restricted Areas

- surgical attire and facemask required; and

- includes any area where scrub personnel are present such as the operating room and/or any area where sterile supplies are opened.

Identified in CDC requirements for infection control in perioperative settings (Gruendemann,1999).

4.2 People 4.2.1 All visitors shall report to, or communicate

with, the reception desk and receive authorization and directions as to traffic flow and dress protocol.

All visitors and staff shall wear identification while in the surgical suite and adhere to specific hospital policy.

Control and identification of persons entering the surgical suite is essential for patient confidentiality, infection control, and evacuation in the event of a fire or other disaster.

4.2.2 The number of personnel in the theatre should be kept to a minimum.

The potential for microbial contamination within the theatre increases significantly as the number of people and movement in the theatre increases, as this increases the shedding and air turbulence that carries microbes to the wound (Phillips, 2007, p. 257).

4.2.3 Doors to an operating room should be kept closed except when moving patients, supplies and equipment in or out. Doors to an operating room should be kept closed during cleaning procedures.

Disrupted pressurization mixes the clean air of the OR with the corridor air, which has a higher microbial count (Phillips, 2007, p. 257). Pressure in room is lost just prior to sterile set up when left open during cleaning.


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4.3 Supplies and Equipment

4.3.1 Cupboard doors shall be kept closed.

Reduces environmental dust, which is laden with microorganisms, from settling on shelves and packages. The presence of this dust can increase the risk of contamination when opening sterile packages.Prevents inadvertent splash contamination during procedures or cleaning.

4.3.2 All movement of clean and sterile supplies and equipment shall be separated from the movement of soiled equipment and waste. Where there is a clean core items should be moved from the clean core through the operating room to the peripheral core.

In suites where there are peripheral corridors, clean items such as equipment should be moved through the corridor and not through sterile storage areas.

Direct contamination from soiled to clean items is reduced when routes are separated.

4.3.3 Soiled equipment/items shall be covered/contained when being transported.

Soiled supplies, instruments and equipment should not enter the clean core area, but should be covered/contained and transported to a designated soiled area through a corridor.

Spillage presents risk to personnel and the environment.

4.3.4 Exterior packing containers and/or corrugated cardboard shall be removed in an unrestricted area before goods enter a restricted or semi-restricted area. Corrugated cardboard shall not be used for storage in the Surgical Suite.

Gross soil and organisms are prevented from entering the surgical suite when exterior packing/shipping containers are removed prior to entry. During transport, corrugated cardboard may carry dust, shavings, debris, insect larvae, and insects (Phillips, 2007). Corrugated cardboard, can harbor moisture and attract potentially pathogenic microorganisms and spores (PLUS 1112 March 2004 p61).

4.3.5 Sterile and clean supplies shall be transported to the theatre or the semi- restricted storage area in clean containers or covered carts selected to protect the integrity of the sterile packages.

Covered or contained carts protect the clean and sterile supplies from environment contamination via aerosols, air contaminants, dust and excess handling.

REFERENCES

Canadian Standards Association (March 2004). PLUS 1112, (2nd ed.) Infection prevention control in office-based health care and allied services. Phillips, N. (2007). Berry & Kohn’s operating room technique. (11th ed.) Toronto: Mosby.


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Dress Code

PRACTICE

RATIONALE

5.1 Patients 5.1.1 The majority of patients should be required

to remove all clothing prior to surgery. Exceptions: see Section 3: “Gathering Medico-legal Evidence in the Surgical Suite”

The amount of clothing removed will depend on the type of surgery and the patient’s individual needs. Underpants may be worn if it does not interfere with the surgical procedure. Consider clothing removal to reduce a potential source of microbial contamination.

5.1.2 Patients should wear a clean gown, hair covering and be covered with clean linen.

Clean gown, hair covering and linen minimize contamination from shedding.

5.1.3 Patients are not required to wear a mask in the surgical suite unless immuno-compromised or under airborne precautions.

5.1.4 For outpatient surgery, the patient may wear some of their own clothing, especially if the clothing does not interfere with the procedure and the procedure is of short duration (e.g., cataract surgery). However, the patient should still wear a clean gown, have their hair covered and be covered with clean linens (AORN, 2010).

Recommendations from AORN, 2010 do not specifically state that outpatients must remove all clothing. If it is judged by the health care worker that more clothing needs to be removed, that can be accommodated on a patient-by-patient basis. The matter of attire for outpatients is a facility decision.

5.1.5 All jewellery, including items contained within body piercings, shall be removed.

Jewellery carries microorganisms into the theatre. Failure to remove jewellery is an issue related to patient safety, as there is a potential for injury from burns, tears, infection or inability to access areas required for interventions during the surgical procedure. (i.e. endotracheal intubation, catheterization etc.)

5.2 Visitors

5.2.1 Visitors requiring limited time in the OR, such as, parents accompanying children, law enforcement officers and/or biomedical engineers may don one piece coverall or cover gowns along with head and facial hair coverings. Visitors who will remain in the theatre for any extended period of time will follow the staff section of the dress code standards. Shoe covers are not required.


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5.3 Staff 5.3.1 All personnel who enter the semi-restricted

and restricted areas of the surgical suite shall wear appropriate surgical attire and adhere to the health care facility's dress code policy.

Surgical attire minimizes patient exposure to microorganisms from the skin, mucous membranes, or hair of surgical team members. Surgical attire may also be considered personal protective equipment and worn to prevent the spread of contamination from the patient.

5.3.2 The top of a two piece scrub suit should be tucked inside the pants.

5.3.3 Scrubs that are worn into the institution or

between institutions, where outside access is required, must be changed before entering the semi-restricted and restricted areas.

The uniform should confine skin cell and microbe shedding and promote infection control. Shedding is increased by movement and friction. Pants confine bacterial shedding.

5.3.4 Within restricted and semi-restricted areas, non-scrubbed personnel should wear a long sleeved jacket. Jackets shall be buttoned or snapped closed during wear. Jackets shall be changed daily and laundered after each use.

5.3.5 Personal clothing (i.e. long sleeve undershirt) that cannot be completely covered by surgical attire should not be worn.

Long-sleeved attire prevents shedding from bare arms. Loose-fitting jackets may cause accidental contamination of the sterile field. Potential to contaminate surgical environment with “outside” organisms.

5.3.6 The use of cover-up attire (e.g. lab coats) should be determined by the practice setting.

The value of cover gowns within the institution has not been substantiated.

5.3.7 All members of the health care team shall don freshly laundered scrub attire upon entryto the unit. If surgical attire is worn outside the facility, it is removed and new attire is donned before entering any semi-restricted or restricted area. Surgical attire should be changed daily, and whenever it becomes visibly soiled, contaminated, or wet. Upon removal of surgical attire, it is placed in a designated container for washing or disposal. Surgical attire is not hung in a locker to be worn later.

Reusable surgical attire shall be laundered by the laundry facilities used by the health care facility for other surgical textiles (Best Practices for Environment Cleaning for Infection Prevention and Control in Health

Soiled clothing increases the risk of cross-contamination to patients, staff, and the public. Approved laundering facilities use recommended detergent and temperature settings to launder linen.


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Care Settings. (December p. 16)). 5.3.8 Footwear for the surgical suite should meet

provincial labour codes. Shoes that can be easily cleaned and have enclosed toes and heels are recommended. Shoe covers should be worn when splash and spills of body fluids are anticipated. Shoe covers shall be removed or changed when soiled, or when leaving the department.

The literature indicates there is no significant difference in relation to the amount of bacteria tracked regardless of the type of footwear (street shoes, clinic shoes, or shoe covers) worn in the surgical suite; and there is no clinically significant airborne bacterial dispersion caused by foot movement. There have been no controlled clinical studies to evaluate the role of covers in preventing or reducing surgical site infections (SSI). Handling soiled shoes may be a hazard to team members. Depending on the extent of soiling, gloving or good hand washing is required. Shoe covers provide personal protection and prevent environmental contamination outside the theatre.

All hair (including facial hair) shall be completely confined by a clean hood or hat.

Shedding of squamous cells and hair has been shown to affect surgical wound infection; therefore, complete coverage is necessary.

5.3.9 Fingernails shall be clean, short, natural and appear healthy.

Natural nail tips should be less than .6 cm (1/4 in.) long (CDC, 2002, p. 33). Artificial nails, extenders or artificial enhancers shall not be worn. Each health care facility’s infection control policy should dictate the use of nail polish.

The subungual region harbors the majority of microorganisms on the hand. Damaged nails, chipped or peeling polish may provide a harbor for microorganisms (Phillips, 2007, p. 269). Long nails, natural and/or artificial can tear gloves. Artificial nails and tips harbour higher numbers of organisms, Artificial nails are known to promote the growth of Staphylococcus aureus, gram negative bacilli and yeast as moisture becomes trapped between the natural and artificial nail. Surgical conscience must be foremost in the minds of those individuals who choose to wear nail polish.

5.3.10 All jewellery should be removed.

Jewellery harbours microorganisms and could result in a glove tear. Several studies have demonstrated that skin underneath rings is more heavily colonized than skin on fingers without rings (Thurston, 2007). Necklaces and earrings may fall on the outside of the sterile scrub gown into the sterile field or wound.

5.3.11 Health care workers must wear protective eyewear if splash is anticipated. Reusable eyewear shall be cleaned after use.

Protective eyewear that includes side shields and face shields is worn to reduce the incidence of contamination of mucous membranes of the eyes. Contaminated eyewear that is not immediately cleaned may result in contamination to the wearer.


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5.3.12 All personnel shall wear a single surgical mask during procedures and/or in the presence of open sterile supplies (Thurston, 2007). The type of mask that offers the most appropriate protection for the specific circumstances shall be worn e.g., laser masks. Special N95 or equivalent respirator/masks shall be available when airborne infection is suspected or confirmed. These respirator/masks shall be fit tested. Masks shall cover the nose and mouth and be adjusted for proper fit to prevent venting. Masks should not hang around the neck or be stored in pockets. Masks should be changed between procedures, or immediately if they become soiled. Masks should be removed by handling ties only and discarded. Hands should be washed.

Masks should be considered both a patient and personal protection item. Laser masks give protection when there is exposure to aerosolized particles such as laser or electrosurgical plume, or from power instruments. Two masks act as a barrier rather than a filter and create side-venting because of the increased effort to breathe. Occlusive fitting 0.1 micron filter masks provide personal protection in cases where airborne infection is suspected or confirmed. Used masks contain a large number of microorganisms, which are transferred to the hands during inappropriate handling. Hand washing protects the health care worker and the patient from the possible spread of infection.

REFERENCES

Association of PeriOperative Registered Nurses. (2010). Perioperative standards and recommended practices. Denver: Author. Center for Disease Control and Prevention. (2002). Guideline for hand hygiene in healthcare settings.

Atlanta: Author. Phillips, N. (2007). Berry & Kohn’s operating room technique. (11th ed.). Toronto: Mosby. Thurston, A. J. (2007). Sources of infection in the operating theater in Limb, D. & Hay, S. (editors). The Evidence for Orthopaedic Surgery. Shewsbury, UK: tfm Publishing.

BIBLIOGRAPHY

Community and Hospital Infection Control Association (CHICA) Information about Hand Hygiene retrieved April 24, 2009 from www.chica.org/links_handhygiene.html#STANDARDS Lipp Allyson & Peggy Edwards (2005). Disposable surgical masks: A Systemic Review. Canadian Operating Room Nurses Journal, 23(3).


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Nathan L Belkin, (2006). Opinion Masks, Barriers, Laundering, Gloving Where the Evidence is? AORN Journal, 84(4), 655-664.

Rothrock, J. (2011). Alexander’s Care of the Patient in Surgery. (14th ed.). St. Louis: Mosby. Roxburgh M, Gall P, & Lee K (2006). A cover up? Potential risks of wearing theatre clothing outside theatre,

Journal of Perioperative Practice, 16(1), 30-41. Thurston, A.J. (2007). Sources of infection in the operating theatre in the Evidence for Orthopaedic Surgery. Edited by David Limb and Stuart M Hay. Shewsbury, UK: tfm Publishing Limited.

Scrubbing, Gowning, Gloving

PRACTICE RATIONALE

6.1 Scrubbing 6.1.1 Health care workers should practice general

hand hygiene including;

- hand hygiene immediately before and after patient contact

- after removing gloves, and any time when there is possibility of blood

or other infectious material contact.

Gloves do not provide complete protection against hand contamination (CSA Z314.8-08 p. 35).

6.1.2 Masks and protective eyewear shall be adjusted for proper fit prior to beginning a surgical hand scrub.

To be effective, a mask filters inhalations and exhalations. Therefore, it is worn over both the nose and the mouth. To be effective, air must pass only through the filtering system; thus, the mask needs to conform to facial contours to prevent leakage of expired air (Phillips, 2007, p. 270).

6.1.3 The skin of the hands and arms shall be free of open lesions and have no breaks in skin integrity.

Cuts, abrasions, burns and dermatitis are sources of infection and pose a risk to patients and personnel.

6.1.4 Members of the scrub team shall be free of respiratory infections.

Reduces the spread of possible infections to the patient and other members of the surgical team.

6.1.5 A surgical hand antiseptic/scrub agent approved by infection control shall be used.

Each surgical hand antisepsis/scrub procedure (water or waterless) should follow a standardized protocol established and approved by the health care facility and the manufacturers’ written instructions for use.

A broad spectrum surgical hand antiseptic/scrub agent should have the ability to kill organisms immediately upon application, provide antimicrobial persistence to reduce regrowth of microorganisms and have a cumulative effect over time. The manufacturer's written instructions should prevail because scrub procedures may differ.

6.1.6 Scrub personnel who have an identified allergy or sensitivity to antimicrobial agents


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should be directed by Occupational Health and Infection Control staff regarding appropriate hand scrub antiseptic agents.

6.1.7 Special attention should be given to nails,

subungual areas, between fingers and between thumb and index finger. Cleaning under each fingernail shall be done before performing the first scrub of the day. Nail cleaners shall be used to remove soil from nails.

The majority of flora on the hands is found under and around the fingernails

8 When using water facilitated scrub methods, hands shall be held above the elbows and away from surgical attire at all times during the surgical hand scrub and while drying the hands and arms with a sterile towel. The direction of the scrubbing procedure is from the hands to the elbows, without returning to the cleaned hands.

To allow the flow of water to run from clean to least clean. Applies the principle of “clean” to “dirty”.

6.1.9 Open the scrub nurse's towel, gown, and gloves on a separate sterile field, away from the back table and operative area.

Reduces the chance of contamination of the instrument table.

6.1.10 When using water facilitated scrub methods hands and arms shall be dried with a sterile towel prior to gowning. When using a waterless facilitated scrub method, hands and arms shall be dry. Sterile glove liners, if used, are put on prior to gowning. Once donned, glove liners are not considered sterile.

Residual moisture increases the risk of strike-through, which contaminates the gown and surgical field.

6.2 Gowning

6.2.1 Sterile gowns shall be made of materials that are resistant to penetration by blood and other body fluids as necessitated by their intended use and compliant with CSAZ314.10.

6.2.2 Gowns should be resistant to tears,

punctures and abrasions.

Protective barriers reduce the risk of exposure to blood, body fluids, or other liquids that may contain potentially infectious agents. Barrier selection may be determined by the complexity and length of the planned procedure, increased potential for exposure to blood borne pathogens may require selection of a gown with greater barrier capability. The inability to withstand tears, punctures and abrasions may allow for passage of microorganisms, particulates and fluids between sterile and nonsterile areas and expose patients to exogenous organisms (AORN, 2010 p. 392).


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PRACTICE RATIONALE

6.2.3 Surgical gowns should be large enough to adequately cover the scrubbed person.

Wrap-around gowns shall be turned by another sterile person or use of a sterile item by the circulating perioperative Registered Nurse.

6.2.4 Sterile gowns shall be considered sterile only in front, from the chest to the level of the sterile field, and sleeves from 5 cm (2 in.) above the elbow to cuff.

The neckline, shoulders, under the arms, sleeve cuffs, and the back are considered unsterile.

Stockinette cuffs of the sterile gown shall be enclosed under the sterile gloves.

These are friction areas and collect moisture. Stockinette is permeable, absorbent and retains moisture, and therefore, does not provide a microbial barrier. Sleeve cuffs become contaminated when the scrubbed person’s hands pass through the cuff (AORN, 2010).

6.3 Gloving

6.3.1 The closed-gloving method shall be used during set-up.

Risk of contamination is significantly reduced when hands are covered during gloving.

6.3.2 A gowned and gloved scrub person should assist the surgical team members in donning their sterile gowns and gloves. Once the incision is made, anyone requiring gowning will do so independently from a separate table. The scrub nurse may glove them but will use caution when gloving to avoid contaminating the inner surface of the glove.

6.3.3 Sterile surgical gloves should be inspected

immediately upon application and prior to contact with sterile supplies or tissue. Gloves, both latex and nonlatex, should be checked frequently for perforations/tears.

6.3.4 Scrubbed personnel should wear double gloves during invasive procedures

Glove barriers become compromised with use. Each operation should be assessed for risk. Operations involving bone, metal work, deep cavities, confined space and lasting more than one hour have a higher incidence of perforation. Double gloving for invasive procedures is supported by the American Academy of Orthopedic Surgeons, the American College of Surgeons, and the Centers for Disease Control and Prevention (AORN, 2010, p. 279).


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PRACTICE RATIONALE

6.3.5 Sterile surgical gloves should be changed:

- after each patient contact; - when a defect is noted; - following suspected or actual

contamination; - when perforation from a needle, suture,

or other event occurs; - immediately following the use of

methyl methacrylate; - if unintentional electric shock from the

electocautery device is received; - when gloves swell or become loose; and- according to hospital policy.

Users should refer to glove manufacturer’s written instruction for use with certain chemicals.

6.3.6 The recommended procedure for changing a glove during a procedure is as follows: - the non-sterile person (wearing

appropriate PPE/gloves) removes the contaminated glove touching only the glove, not the gown;

- the gown cuff shall remain at the wrist level;

- the correct method for regloving is for one member of the sterile team to glove the other; and

- the closed-glove method shall not be used for regloving unless both the gown and gloves are changed.

6.3.7 Health care workers should be familiar with

the intended use and limitations of each glove material.

Removal of Contaminated Gown and Gloves

Surgical glove materials have specific characteristics that affect the performance and use of the glove.

6.4.1 If the gown becomes contaminated, it shall be changed as soon as possible. The team member steps away from the field, and the circulator unfastens the neck and waist ties of the soiled gown. The contaminated person grasps the front of the gown at the shoulders below the neckline. The gown is pulled off inside out by the wearer and rolled off away from the body. The gloves are removed using a glove-to-glove and then skin-to-skin technique. (Phillips, 2007, p. 281) and discarded immediately.

The scrub perioperative Registered Nurse

Careful handling of used gowns and gloves prevents contamination. Regowning from the sterile back or instrument table


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regowns and regloves self, using closed-glove technique (from another table, not the back or instrument table).

brings unsterile scrub attire too close to the sterile field. Reaching over the sterile set-up may also occur and breaches aseptic technique.

6.4.2 At the completion of the case, the same technique for removal of contaminated gown and gloves shall be used.

6.4.3 Hands shall be washed as soon as gloves are removed.

Hand perspiration contains high levels of microorganisms. Hands may be contaminated from hole(s) in the gloves. Washing hands immediately may decrease the risk of latex allergy.

REFERENCES Association of PeriOperative Registered Nurses. (2010). Perioperative standards and recommended practices. Denver: Author. Canadian Standards Association. (2010). Z314.10.1 CAN/CSA, Selection and use, of gowns, drapes, and wrappers in health care facilities... Toronto: Author. Canadian Standards Association. (2010). Z314.10.2 CAN/CSA, Laundry, maintenance and preparation of multi-use gowns, drapes and wrappers in health care facilities... Toronto: Author. Canadian Standards Association (March 2008). CSA Z314.8.08 Decontamination of reusable medical devices. Mississauga, Ontario Gruendemann, B. & Mangum, S. (2001). Infection prevention in surgical settings. Toronto: W.B. Saunders. Korniewicz, D.M., Garzon, L., Seltzer, J., & Feinleib, M. (2004). Failure rates in non-latex surgical gloves.

American Journal of Infection Control, 32(5), 268-273. Phillips, N. (2007). Berry & Kohn’s operating room technique. (11th ed.) Toronto: Mosby.

BIBLIOGRAPHY

Kelsell, N.K.R. (2006). Should finger rings be removed prior to scrubbing for theatre. Journal of Hospital Infection, 62, 450-452. Marchand, R., Theoret, S., Dion, D. & Pellerin M. (2008). Clinical Implementation of a Scrubless

Chlorhexidin/ethanol Pre-operative surgical Hand Rub, Canadian Operating Room Nurses Journal, 26 (2). Public Health Agency of Canada.(2009) . Stop Clean Your Hands. retrieved April 26, 2009. http://cpsi.discoverycampus.com/courses/cps002/cps002.html Tanner J & Parkinson H (2007). Surgical Glove practice: the evidence, Journal of Perioperative Practice, 17(5),

216-225.


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Aseptic Technique

PRACTICE

RATIONALE

7.1 Establishing an Aseptic Environment 7.1.1 An aseptic environment must be established

and maintained in order to create a sterile field 7.1.2 All OR doors shall remain closed at all times except to allow for the procurement of

supplies, receiving patients and admittance of personnel.

7.1.3 Traffic shall be kept to a minimum. 7.1.4 The number of air exchanges must adhere to

the provincial building code. This rate is dependent on the ratio of fresh air to recirculated air exchanges.

7.1.5 The ambient temperature should be maintained between 20°C - 23°C (68° F- 73° F).

The humidity should be maintained between 30% and 60 % (Rothrock, 2011 p. 67; CSA Z314.8- 08)

7.2 Establishing the Sterile Field 7.2.1 All flat surfaces shall be dry and dust-free

prior to the placement of a sterile bundle or drape.

An aseptic environment requires control of the parameters of air exchange and air currents, dust control, temperature and humidity in order to keep microbial growth to a minimum. An aseptic environment is enhanced by positive pressure in the room moving the air out into the corridor and taking any particulate matter with it. Traffic into and out of the room increases the potential of contamination from increased air turbulence in the room. Microbial growth and static electricity are reduced if temperature and humidity are kept within acceptable parameters. Moisture may cause strike-through and contaminate the sterile field. Dry, clean surfaces reduce the risk of strike-through.

7.2.2 Sterile drapes used to establish a sterile field shall be impermeable to liquids including blood and body fluids.

Sterile impermeable drapes establish an aseptic barrier.

7.2.3 Only the working surface of a draped area shall be considered sterile.

The drape below the working surface is not under direct vision of the surgical team and is not considered sterile. The table top serves as a demarcation line between sterile and non-sterile.

7.3 Dispensing Sterile Supplies


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7.3.1 Supplies shall be opened as close as possible to the surgical start time

The potential for contamination increases with time. Dust and other particles, stirred up by movement of personnel, can settle on horizontal surfaces (AORN, 2010, p. 94).

7.3.2 All items added to the sterile field shall be assessed prior to opening for sterility by checking for wrapper integrity, and changed chemical indicators (external and internal). The contents of packages with questionable wrappers or indicators shall be considered unsterile.

If there is any doubt about the sterility of an item it shall be considered contaminated. Indicator tape assures personnel that the item has been exposed to the sterilization process, it does not guarantee sterility.

7.3.3 Items which display a manufacturer's expiry date shall be considered unsafe for use after that date.

Frequently expiry dates refer to the degradation of the product or a component of the product after the specified date.

7.3.4 Peel-packages shall be opened carefully to prevent tearing the package. The sterile boundary of a peel-open package is the inner edge.

Only the inner border of the heat seal is considered sterile. Torn packages are considered unsterile.

7.3.5 Large bundles or packages shall be opened on a flat surface.

Large and/or heavy items are difficult to open aseptically while being held in the circulator’s hand.

7.3.6 Sterility and integrity shall be maintained whenopening, dispensing and transferring items to the sterile field. Methods of transfer include, but are not limited to the following: - place the item on the edge of the sterile

instrument table with the inside of the wrapper everted and secured over your hand. Never reach over the sterile field and shake an item from its package;

- expose the contents so the scrub person can remove the item from the wrapper or package by using a forcep or by grasping the item; and

- items shall not be flipped.

Protects the sterile field from potential contamination Flipping creates air turbulence. It also creates the potential for device contamination or damage (Phillips, 2007).

7.3.7 Sterile supplies shall be handled as little as possible.

Increased handling increases the potential for contamination and prolongs set-up time.

7.3.8 Items that have been dropped on the floor or that are compressed, torn, or wet shall be considered to be contaminated and they shall

Dropping items wrapped in woven materials and paper could force air and contaminants through the wrapper; therefore such dropped items shall not be


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be repackaged and reprocessed or discarded (CSA Z314.3-09).

used. (IAHSCMM, 2007). Paper has not been shown to have greater strike-though resistance than fabric.

7.3.9 Once a patient has entered the theatre where sterile supplies have been opened, those supplies shall be discarded/dismantled in the event that surgery is cancelled.

Potential for cross-contamination will be prevented.

7.3.10 When a bottle of sterile solution is opened, the contents of the bottle shall be dispensed and the remainder discarded.

Re-application of sterile caps is a questionable technique as the pour spout and cap may have been contaminated. The edge of a container is considered contaminated after the contents have been poured; therefore, the sterility of the contents cannot be ensured if the cap is replaced (AORN, 2010, p.94).

7.3.11 When pouring solutions, care shall be taken to avoid splashing. The solution should be poured in a slow steady stream. The scrub nurse should hold the receptacle away from the table or set it near the edge of the table. The circulating Registered Nurse shall not reach over the sterile field when pouring.

Droplets, which have splashed on unsterile areas, may roll back on to the sterile field.

7.4 Maintaining the Sterile Field 7.4.1 Opened sterile supplies/set-up shall not be left

unattended. They shall be continuously monitored for possible contamination.

Sterility of unattended items cannot be ensured without direct observation. Event-related sources of possible contamination can occur at any time. These include personnel, airborne contaminants, liquids and insects.

7.4.2 Unsterile persons shall not reach over the sterile field.

Invisible shedding of skin laden with microorganisms may contaminate the field.

7.4.3 Sterile persons shall not reach over unsterile areas.

Contamination of the sterile gown or gloves may occur.

7.4.4 Sterile persons shall stay within the sterile field. Sterile persons shall not walk around or go outside the theatre.

7.4.5 The scrub team should remain close to, and face the sterile field. Movement shall be between sterile areas only. If position changes are necessary, scrubbed personnel shall pass face to face or back to back. When changing positions, the scrub personnel should avoid changing levels; they either sit or stand. Hands shall be kept above waist level.

The back of the sterile gown is considered unsterile. To maintain sterility, scrub persons should not allow their hands or any sterile item to fall below the level of the sterile field (Rothrock, 2011, p. 86).


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7.4.6 Talking should be kept to a minimum.

Talking increases droplet formation and forces moisture droplets to be dispersed into the air. Talking also causes friction between the mask and the skin increasing shedding.

7.4.7 Unsterile health care team members shall remain at least 30cm (1 ft.) from the sterile field.

Movement is from unsterile to unsterile areas. They should not pass between sterile fields.

Protection of the sterile field is enhanced by limited activity and direct vision.

7.4.8 The sterile set-up shall not be covered. Removing a table cover without contaminating the sterile area cannot be done because the drape below the level of the tabletop is considered contaminated, and the cover would touch the sterile tabletop during removal (Phillips, 2007).

7.4.9 Cover unsterile equipment with sterile barriers before placing them over or in the sterile field.

7.4.10 Breaks in aseptic technique shall be monitored, documented and corrective action taken as soon as safely possible.

The documentation indicates to infection control what may have been a potential source of a surgical site infection, and allows them to follow the patient postoperatively.

7.5 Sterile Storage 7.5.1 Sterile supplies shall be stored in a separate

protected area.

Dust, traffic, excess handling, and exposure to water sources increase the risk of contamination.

7.5.2 Separate and protected areas for sterile supplies shall be:

- on open or closed shelves (shelves being at least 20 - 25 cm [8 - 10 in.] from the floor and at least 45 cm [18 in.] from the ceiling);

- controlled for humidity, temperature and ventilation ( See Establishing an Aseptic Environment Section 2, 7.1.4 – 7.1.5); and

- traffic restricted (CSA Z314.3-09).

7.5.3 An item shall be considered contaminated if there is any doubt about its sterility.

Sterility is event related rather than time related. Event related sterility is multifactorial including, but not limited to: - type of wrapper used;

- the number of times a package is handled; and

- the use of dust covers. 7.5.4 Manufacturer's recommendations and

suggested expiration dates shall be followed. The manufacturer’s expiration date printed on the

package indicates the maximum time the


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7.5.5 Sterile supplies shall be rotated on a first in first out system (FIFO). For example, stock to the right, take from the left or stock to the back, take from the front).

Rotation of sterile goods reduces the number of handlings and facilitates the practice that the older product is used first. Dates shall be used as a method to rotate materials.

7.6. Storing and Transporting Clean and Sterile Surgical/Medical Devices 7.6.1 The perioperative Registered Nurse Local, provincial, and national

shall ensure the storage and transportation of clean regulatory bodies recognize and sterile surgical/medical devices is in support the use of CSA Standards. compliance with CSA Z314.15-10

REFERENCES

Association of PeriOperative Registered Nurses. (2010). Perioperative standards and recommended practices. Denver: Author. Canadian Standards Association. (2009). Z314.3-09. CAN/CSA Effective sterilization in health care facilities by the steam process. Toronto: Author. Canadian Standards Association (2009) Gruendemann, B. & Mangum, S. (2001). Infection prevention in surgical settings. Toronto: W.B. Saunders. International Association Healthcare Central Services Material Management (2007). Central Services Technical Manual. Author. http://iahcsmm.org/ Phillips, N. (2007). Berry & Kohn’s operating room technique. (11th ed.) Toronto: Mosby. Rothrock, J. (2011). Alexander’s Care of the Patient in Surgery. (14th ed.). St. Louis: Mosby.

BIBLIOGRAPHY

Fry , Donald E., Fry, Rosemary V. (2007). SSI: the Host Factor. AORN Journal, 86(5), 801-814.

McBride, Tara., Beamer, Jennifer. (2007). Pre-operative patient preparations in the prevention of surgical site infections. Canadian Operating Room Nurses Journal, 25(4).


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Instrument Management and Reprocessing

Note: users shall follow the medical device manufacturer’s instructions related to reprocessing (CSA Z314.8-08) PRACTICE

RATIONALE

8.1 Intra-operative Instrument Care 8.1.1 Each health care facility shall have copies

of the current and relevant CSA Standards readily available.

For review or reference.

8.1.2 All reusable instruments that have been opened for use shall be decontaminated prior to resterilization.

8.1.3 Instruments shall be handled gently and in small groups. Delicate instruments should be handled individually (IAHCSMM, 2007).

Instrument tips may be damaged by rough or careless handling.

The perioperative scrub nurse is responsible for keeping instruments clean throughout the procedure by using sterile water. Saline is never used to soak or clean instruments.

Blood, body fluids and saline can cause pitting and damage to instruments.

8.1.4 The scrub nurse shall prepare instruments for reprocessing. This includes, but is not limited to: - separating delicate/sharp instruments

from others; - protecting tips of fine/sharp

instruments; - placing heavy instruments in the

bottom of the pan; - opening/disassembling instruments to

expose jaws and box locks; and - flushing/soaking soiled lumens with

sterile water. Special attention is required to ensure all single-use sharps, e.g. blades, needles, etc. have been removed and safely disposed of by the scrub perioperative nurse.

The cleaning process and protection of instruments is facilitated by organized sorting and careful placement. Reduces the potential for injury among health care workers. Protecting instrument tips in towels, silicone mats or foam wrappers, or using tip protectors or special protective boxes/pans prevent damage to the instruments and injury to personnel. Irrigating cannulated or lumened instruments with sterile water during the procedure helps to remove residue. Injury from contaminated sharps for unsuspecting members of the health care team is a common and high risk occurrence.

8.1.5 Contaminated instruments and/or supplies shall be transported to the decontamination area in a closed container or covered cart. Instruments should be promptly and thoroughly cleaned following the

Thorough decontamination facilitates the sterilization process. Prompt removal of proteinaceous soil prevents drying and facilitates thorough cleaning.


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established procedure and according to the manufacturer's recommendations.

8.2 Reprocessing Surgical Instruments 8.2.1 Staff trained in a recognized program and

certified in reprocessing techniques, shall be assigned to instrument reprocessing.

8.2.2 Surgical instrument reprocessing practices shall be based on current CSA Standards. These include but are not limited to: - Decontamination of Reusable Medical

Devices Z314.8; - Effective Sterilization in Health Care

Facilities by the Steam Process Z314.3 - Effective Sterilization in Health Care

Facilities by the Ethylene Oxide Process Z314.2

Following CSA Standards will minimize the risk to patient safety. The CSA Standards are also endorsed by Health Canada.

8.2.3 All items being reprocessed shall first be thoroughly cleaned: - cleaning should be done in a dedicated

"decontamination" area. Cleaning shall not be done at a surgical suite scrub sink;

- cleaning staff shall wear appropriate

personal protective equipment (i.e. water resistant gown, durable gloves and a face shield and/ or mask and goggles);

- clean water, detergent and friction should be used to remove soil;

- cleaning may be completed manually or by machine (mechanically);

- items shall be completely disassembled

for cleaning; and - items shall be thoroughly rinsed

following cleaning.

Failure to remove soil, organic material, and microorganisms from an object will render disinfection or sterilization ineffective. Inadequate pre-cleaning can be hazardous and will pose serious risks of infection to both the patient and staff. Contaminated medical devices are a source of micro-organisms that can infect personnel through nicks, cuts, or abrasions in skin or through contact with the mucus membranes of the eyes, nose, or mouth. Appropriate attire minimizes the potential for exposure to blood-borne and other disease producing organism (CSA Z314.8-08 p. 35). Mechanical cleaning is preferable to manual cleaning as the process is standardized and confines potentially contaminated aerosols and thus protects staff.

8.2.4 Between uses, items should be inspected to ensure that they are:

Inspection confirms all debris has been removed, the instrument is not damaged, and is functioning


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-clean; -complete; -and functional e.g., sharp, aligned, tight, and/or free of burrs/chips/gouges/corrosion.

8.2.5 Damaged or poorly functioning instruments

shall be removed from circulation, labeled and sent for repair or replacement.

appropriately.

8.2.6 Further reprocessing shall be based on the Spaulding classification system: - Critical items (contact normally sterile

body tissue or vascular system) shall be sterilized between uses;

- Semi-critical items (contact mucous membranes or broken skin) shall, at a minimum, be high level disinfected (HLD);

- Non-critical items (contact intact skin or do not make direct contact with a patient or staff member) must, at a minimum, be thoroughly cleaned and disinfected (CDC, 2008).

The Spaulding classification system separates items into categories according to the nature of the item, the manner in which it is used and the degree of risk of infection during use (Gruendemann & Mangum, 2001, p. 160).

8.2.7 All instruments shall be opened and disassembled for sterilization (CSA Z314.8).

Allows sterilizing agent to contact all surfaces.

8.2.8 Additional preparation of items shall depend on the method of sterilization used e.g., narrow lumens being steam sterilized will first require irrigation with distilled water; very long or narrow lumens being sterilized in a Sterrad® (hydrogen peroxide plasma) system may require a "booster" device. Sterilizer manufacturer recommended guidelines and CSA Standards shall be followed.

8.2.9 Clean Instruments shall be dry prior to storage (CSA Z314.8).

To prevent microbial growth.


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8.3 Loaned and Leased Surgical/Medical Equipment 8.3.1 The perioperative Registered Nurse shall be

aware of the policies and procedures associated with the use of loaned, leased or shared surgical/medical devices.

8.4 Packaging for Sterilization

Local, provincial, and national regulatory bodies support the use of CSA Standards (CSA Z314.22-04)

8.4.1 Packaging material and design shall protect the sterility of package contents during sterilization, normal handling and storage.

Packaging material shall: - be compatible with the sterilization

process, allowing both sterilant penetration and removal without damage to the barrier capability;

- provide a barrier to microbes, particulate matter and fluids;

- be tear and puncture resistant; - not leach toxic substances or contain

non-fast dyes; - be lint free or low linting; - protect the contents from physical

damage; - be economical; - allow for aseptic removal of contents;

and - be flexible and memory free (pouches

and wrappers) (CSA Z314.3-09).

Packaging materials shall be selected that: - remain sealed during the sterilization

process and intact until time of opening;

- preclude open pockets or flaps where dust can collect e.g. chevron opening on peel pouches;

- ensure tape or adhesive labels remain intact through all processes; and

- allow a visual indicator that the item has in fact been exposed to a sterilization process.

Packaging material currently in use include:- reusable fabrics: cotton or synthetic,

woven or non-woven; - single use fabrics: paper or synthetic;


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- peel pouches: paper or Tyvek® backed; and

- rigid sterilization containers. 8.4.2 Woven packaging materials shall be

laundered between uses (CSA Z314.10). Laundering rehydrates fibres. Non laundered fabrics

may lead to superheating, damage to fibres and potential sterilization failure (AORN, 2010).

8.4.3 An internal chemical indicator/integrator shall be placed inside each package in the area of the package that is least accessible to the sterilant (CSA Z314.3-09).

There are currently 6 different classes of chemical indicators/integrators/emulators available in Canada. The indicator/integrator/emulator monitors the physical parameters of the sterilization process, e.g. time, temperature, air evacuation and sterilant contact.

8.4.4 Each package shall be assembled, handled and wrapped in a manner that provides for an aseptic presentation of package contents.

Standard (square and envelope style) wrapping techniques are described in CSA Z314.3-09 p.29 and 30. Note: Air pockets, unless evacuated, are often not penetrated by steam leaving unsterilized areas within the package.

8.4.5 Prior to sterilization, a tamper evident device shall be applied to each package (CSA Z114.3-09). i.e. Self-sealing pouches/ heat sealed packages or using external autoclave tape

8.4.6 Each package shall be labeled with: -an external chemical indicator; -the name of the item; -the date of sterilization; -identification for recall purposes; and -the initial of the person preparing the item or set shall be included. When writing on the paper-plastic pouch, only a permanent, soft tip marker that has been validated for this purpose shall be used. Neither pens nor pencils shall be used. There shall be no writing on the paper side of a paper-plastic pouch (CSA Z314.3-09 p38).

The purpose of an external indicator is to differentiate processed goods from unprocessed goods. An external indicator does not indicate device sterility. Ink markers can soak through the material onto the package contents as well as destroy the integrity of manufactured materials. This renders the item of questionable sterility, therefore requiring the item be discarded or reprocessed. Pens and pencils tend to perforate packaging materials allowing entry for microorganisms. Writing on the paper side of the pouch within the sealed area can result in ink penetration or puncturing of the pouch (CSA Z314.3-09 p38).

8.5 Rigid Sterilization Containers


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8.5.1 Rigid sterilization containers shall be compatible with the sterilization method chosen and the goods to be sterilized.

The health care facility shall require the container manufacturer to provide documentation describing: -the container’s compatibility with various sterilizing methods including the aeration protocol to be used following ETO sterilization; (CSA Z314.2-09); - a decontamination protocol; - maximum weight and density of instrument sets that will be held in the container; - sterilizer loading procedure; and - sterilizing exposure and dry times (CSA Z314.3-09, p. 12).

8.5.2 The combined weight of the instrument set and the rigid sterilization container shall be limited to ensure that: - occupational health and safety

guidelines related to lifting are met; - total metal mass of the set is evenly

distributed; and - metal mass is limited to facilitate

heating, cooling and drying.

For safety of personnel, it is generally accepted that instruments in a pack/pan should not exceed 7kg (16 lb); and the combined weight of the instruments and their container should not exceed 10kg (22 lb) (CSA Z314.3-09). Large weight of metal mass heats and cools more slowly than the container resulting in condensation and water droplets within the container, which will present doubts as to its sterility.

8.5.3 Containers shall be cleaned between uses according to the manufacturer’s instructions.

See CSA Z314.14-04

8.5.4 Each container shall be checked thoroughly before reuse for:

- cleanliness, dryness and - functionality of the following: - sealing edges; - filter retention devices; - latches; and - valves, if present (CSA Z314.14).

Damage to seals and container edges frequently occurs and if not corrected interferes with the integrity of the sterile product, a risk often unknown by the users. In addition, a routine inspection plan by qualified personnel needs to be a part of the preventative maintenance program to ensure rigid sterilization containers are in proper working order.

8.5.5 Disposable or reusable filters in rigid containers shall be used according to manufacturer’s instructions.

8.5.6 Internal pouches, wraps, towels, gauze, baskets or trays shall not be added to a container system unless such addition(s) have been designed and tested for the intended configuration, and validated by the manufacturer.

Internal packages, gauze and towels create additional resistance to sterilant penetration. This may compromise sterility of the devices within the internal packages.


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8.5.7 When opening a sterilization container in the OR, the circulating nurse shall ensure aseptic presentation and shall: - inspect the integrity of the tamper-

evident device prior to disengaging it/them (following manufacturer's instructions);

- completely and simultaneously open the lid latches;

- inspect the integrity of the filter or valve, the gasket, and the chemical indicator;

- check the alignment of the filter system or valve according to the manufacturer's instructions; and

- inspect for moisture within the container (CSA Z314.14).

8.5.8 Each facility shall develop a policy to address the situation of condensate within the container following steam sterilization.

Condensate within a container can compromise sterility if the moisture is able to come in contact with outside contaminants (CSA Z314.14 -4 p.18).

8.5.9 A sterile instrument container that has been opened shall not be used to receive other sterile items (CSA Z314.14- 4 p.18).

Sterile items may be contaminated by contact with the non-sterile outer rim of the external container. One principle of asepsis is that the edge of a sterile package/container is considered contaminated.

8.5.10 Rigid containers shall not be used for emergency flash sterilization unless validated by the manufacturer.

Special emergency flash sterilization rigid containers are available.

8.6 Sterilization

8.6.1 Instruments shall not be sterilized within a drape bundle (CSA Z 314.3-09).

Instruments in drape bundles cool at a much slower rate, resulting in condensation, re-wetting and potential contamination.

8.6.2 When sterilizing any item, follow device manufacturer's directions for method and parameters of sterilization. CSA Z314.3 guidelines shall be followed.

Instrument manufacturers /vendors are required to provide validated reprocessing instructions. More complex instrument sets may require parameters that differ from routine hospital cycles.

8.6.3 Sterilizers shall have preventative/planned maintenance. All sterilizers shall have preventative maintenance and repairs documented.

Documentation provides a history of the maintenance and repairs to the sterilizer(s).

8.6.4 The efficacy of each sterilizer shall be monitored according to CSA Z314.3 and CSA Z314.2 to include:


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- a mechanical or digital display visible during each cycle.

- a permanent graph, printout or electronic record documenting cycle parameters that shall be retained for quality assurance purposes as per healthcare facility policy;

- an external chemical indicator (e.g. autoclave tape) affixed to the outside of each package;

- an internal chemical indicator within each package. The internal chemical indicator shall be placed in the part of the package that is least accessible to the sterilant;

- an air-removal test performed on all "vacuum air removal" type steam sterilizers each day prior to use;

- a biological test performed each day that the sterilizer is used. Each type of cycle that will be run on the sterilizer shall be tested i.e., if a steam sterilizer can operate by either "gravity" or "vacuum air removal" method, and both will be used during the day, then both cycles shall be tested;

- a biological indicator (BI) validated for its intended use e.g. flash sterilization (unwrapped); gravity (wrapped) sterilization or vacuum (wrapped) sterilization; and

- a biological indicator included in each load containing implants. Sterilized implants should not be released until the results of the biological indicator are known.

Visual checks assist in sterilizer efficacy.

8.6.5 A recall procedure shall be established by the health care facility and shall: - be in writing; - outline the circumstances for issuing a

recall order; - designate the personnel authorized to

issue a recall order; - outline the procedure to be followed when a recall is necessary; - designate the personnel responsible for reporting on the execution of a recall order - implement and document all activities related to the recall order.

The recall protocol will assist with mechanical failure tracking and infection control investigations to promote patient safety. See CSA Z314.3-09, p. 59


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8.7 Emergency (Flash) Sterilization

8.7.1 Flash sterilization shall not be used for Although the process itself can be routine sterilization. similar, the lack of pre and post sterilization

precautions introduces additional risks to the use 8.7.2 Flash sterilization shall not be used to of flashed devices (CSA Z314.3-09 p. 62).

compensate for inadequate inventory or scheduling problems. If flash sterilization is included in emergency plans, it shall only be as a last resort (CSA Z314.3-09 p. 62). 8.7.3 Flash sterilization shall not be used to Flash sterilization is prone to numerous errors, sterilize implants. any one of which could cause a sterilization failure.

Note: Implants include but are not limited to: - ligating clips; - gastric staples; - orthopedic internal fixation devices such as

- Screws; - Staples and - Wires;

- joint replacement prostheses; and - Cardiac valves (CSA Z314.3-09, p. 62).

8.7.4 Flash sterilization shall not be used on complete sets or trays of instruments (CSA Z314.3-09 p. 62).

8.7.5 All staff performing flash sterilization shall

be appropriately trained (CSA Z314.3-09; CSA Z314.8-08).

8.7.6 Items for flash sterilization shall be prepared as per the manufacturer’s instructions. Steps of preparation: - disassemble; - decontaminate; - reassemble - inspect; - disassemble; - arrange in container; - include chemical indicator; - package (if used); - load the sterilizer; and - transfer from the sterilizer to the sterile

field in an aseptic manner.

Inclusion of a chemical indicator with the device provides the scrub nurse with the visual confirmation that the device has been processed.


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8.7.7 Sterilization parameters shall comply with the sterilizer manufacturer, the equipment manufacturer, and the biological indicator manufacturer’s instructions.

8.7.8 A closed container specifically designed for flash sterilization shall be used to protect sterile items during transfer from the sterilizer to the sterile field. Follow the manufacturer's guidelines regarding: - exposure time and temperature; - maintenance and cleaning procedures;

and - length of sterility in container after

sterilization.

8.7.9 On completion of a flash sterilization cycle, the printout/chart shall be checked for correct sterilization conditions. For steam sterilization, those conditions are: time and temperature (CSA Z314.3-09).

8.7.10 The flash sterilization process shall be documented in a manner that will correlate the flashed items with: - the patient; - the surgeon - the results of the biological and

chemical monitoring; - the cycle printout (time and

temperature), and; - the staff responsible for the processing

of that item. 8.7.11 Further information on Chemical Indicators

may be obtained by referencing CLASSES OF CHEMICAL INDICATORS (CIs) in CAN/CSA-Z11140-1-98.

Records to be kept as per facility policy and CSA recommendations.

8.8 High Level Disinfection 8.8.1 As a minimum, all semi-critical devices

shall be high level disinfected (HLD) between patient uses.

The selection of an HLD solution should be based on the :

-type of devices to be processed; -efficacy of the chemical; -safety of the product; and -its in-use characteristics.


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8.8.2 The use of a specific HLD shall be consistent with the manufacturer’s recommendations and the accepted infection control practices of the health care facility.

8.8.3 Disinfectant manufacturers' instructions for use shall be followed.

8.8.4 HLD may be performed manually or via an automated process complying with device manufacturer’s instructions and occupation health and safety standards

8.8.5 Occupational Health and Safety and

WHMIS guidelines regarding personal protection shall be followed. This may include: -choosing the least toxic chemical; -environmental controls such as:

-covered containers; -automatic endoscope reprocessors; -area ventilation; and -personal protective equipment.

Spill management protocols need to be in place and reviewed regularly with personnel.

Health risks to personnel may result from improper use, ventilation, and/or disposal. Chemical disinfectant vapours may be harmful, even those scented for aesthetic reasons.

8.8.6 Reusable solutions shall be dated when initially opened and used. The minimum effective concentration (MEC) of a reusable HLD shall be tested and recorded at the beginning of the day that the solution is used (CSA Z314.8-08 p. 41). Solutions shall be discarded when they fall below the MEC or the maximum “in-use” date has been reached, whichever comes first

Follow the disinfectant and test strip manufacturer’s instructions.

Chemical disinfectants are effective for a specific limited time. Confirmating that the MEC is within levels specified by the manufacturer ensures that the efficacy has not deteriorated due to dilution from water or by contamination from biological matter.

8.8.7 Devices shall be thoroughly cleaned and rinsed prior to HLD. Excess rinse water shall be removed.

If proteinaceous soil remains on devices during HLD, the proteinaceous soil may inactivate the HLD and/or coagulate, forming a protective barrier that may allow pathogens to survive the HLD process. Cleaning and decontamination are the initial and most critical steps in breaking the chain of disease transmission. Debris, blood, and tissue will interfere with the action of the disinfectant and sterilization methods. Rinsing removes residual detergent from the instruments and equipment.


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Drying prevents dilution of the disinfecting agent when instruments are placed in the solution. (CSA Z314.8-08)

8.8.8 The manufacturer recommended chemical concentration and contact time shall be maintained during HLD.

All lumens shall be flushed and filled with solution. When rinsing a lumen, it shall be flushed with a volume of water at least three times the volume of a lumen (CSA Z314.8-08)

Liquid HLDs only disinfect those areas that they contact directly. Therefore, all air bubbles and other barriers to contact must be removed before timing begins.

8.8.9 All devices shall be completely immersed in the HLD solution (unless being processed in an automatic endoscope reprocessor that has been otherwise validated). To ensure complete contact and removal of air:

- completely disassemble the device following manufacturer’s instructions;

- fill all lumens with disinfecting solution and ensure fluid flows from the distal ends;

- position the device to allow trapped air to escape; and,

- weigh down items that may float (CSA Z314.8-08 p. 42).

8.8.10 Each device shall be thoroughly rinsed following chemical HLD. Devices that have been treated with liquid chemicals to provide sterilization and rinsed with sterile water should be used immediately and not dried. If not used immediately and drying is necessary, drying should be performed with medical air or HEPA-filtered air to ensure no particulates or organisms re-contaminate the device by drying. Drying of non-critical devices may be done by air-drying or other methods. (CSA Z314.8-08 p. 43)

Many chemical manufacturers currently define thorough rinsing as a triple (3 separate) rinse using copious amounts (8 litres/2gallons in each rinse for a flexible endoscope) of fresh water. The quality of the water e.g. potable, filtered or sterile will depend on the intended use of the device. Hard water ions can cause deposits or scale formation. Free rinsing is necessary to prevent residues of cleaning chemicals from remaining on instruments. (IAHCSMM, 2007)

8.8.11 Unless a device will be used immediately, it shall be thoroughly dried. Special care shall be taken to ensure all lumens are completely dry.

If devices, and especially lumens, are stored, wet, microbial overgrowth can occur in the moist environment during storage. Nosocomial infections can occur.


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8.8.12 Disposal of HLDs shall follow written

federal, provincial, and local government regulations and health care facility specific procedures.

8.8.13 If flexible endoscopy is performed in the surgical suite, the Society of Gastroenterology Nurses and Associates (SGNA) guidelines for reprocessing of flexible endoscopes and the scope's manufacturers instructions for use shall be followed.

SGNA guidelines are available on the web at www.sgna.org

8.8.14 Document and maintain records of the high level disinfection process that include but are not limited to: - date solution was opened - date solution was dispensed from

original container - date test strip expire - test date - location - test results - the staff responsible for testing - serial number of instrument - contact time - temperature of the solution - concentration

Tracking or traceability of item such as scope to a specific patient is recommended. Solution testing will indicate diluted solution and reduced efficacy.

REFERENCES

Association of PeriOperative Registered Nurses. (2010). Perioperative standards and recommended practices. Denver: Author. Center for Disease Control (CD). (2008). Guidelines for disinfection and Sterilization in Healthcare Facilities. Atlanta: Author. Canadian Standards Association (2008). CSA Z314.8-08 Decontamination of Reusable Medical Devices. Toronto: Author. Canadian Standards Association (2009). CSA Z314.3-09 Effective Sterilization in health care facilities by the steam process. Toronto: Author. Canadian Standards Association. (2004). CSA Z314.14 Selection and Use of Rigid Sterilization Containers. Toronto: Author. Canadian Standards Association. (2009). CSA Z314.2 Effective Sterilization in Health Care Facilities by the Ethylene Oxide Process. Toronto: Author.


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International Association Healthcare Central Services Material Management (2007) Central Services Technical Manual. Author. http://iahcsmm.org/ Phillips, N. (2007). Berry & Kohn’s operating room technique. (11th ed.) Toronto: Mosby.

BIBLIOGRAPHY Alberta Public Health, (2008). Standards for Cleaning, Disinfection and Sterilization of Reusable Medical Devices for all Healthcare Facilities and Settings. Edmonton, AB: Author. ANSI/ AAMI ST 79, 2006 & 2008 Comprehensive Guide to Steam sterilization and sterility assurance in healthcare

facilities, AAMI, Arlington VA Basile, Ralph J. (2008). The Rising Tide of Cleaning Standards. Healthcare Sterilization Horizons, 31-36. Bayes, Nola J. (2008). Effective Cleaning: the Fundamental Step of the Decontamination Process. Healthcare Sterilization Horizons, 37-40. Bilyk, Candis. (2008). Don’t Break the Chain: Importance of supply Change Management in the operating Room

Setting. Canadian Operating Room Nurses Journal, 26(3). Bolding, Barbara. (2004). Choosing a Re-processing method. Canadian Operating Room Nurses Journal, 22(2). Cardinal Health. (2006). The Care and Handling of Surgical Instruments, Independent Study Guideline. Cardinal

Health, McGraw Park, IL. Chobin, Nancy. (2008). Are You Up to Speed on Flash Sterilization? Healthcare Sterilization Horizons, 23-26. Crawford, A. (2007). Decontamination and traceability of flexible endoscopes. Journal of Perioperative Practice, 17(6), 257-264. CSA compendium of sterilization standards. Refer to list provided at the back of this publication. Gilmour , Diane. (2008). Instrument integrity and sterility: The perioperative Practioners responsibilities. Journal of

perioperative practice, 18(7), 292-296. Griffiths-Turner , May., Stevenson, Ruth. (2005). Improving Quality of Service in a Sterile Processing and OR

Setting, Canadian Operating Room Nurses Journal,23(4). Healthstream. (2007). Are Your “Sterilized” Instruments Promoting Healthcare Acquired Infections, Independent

Study Guideline. Cardinal Health, McGraw Park, IL. Klacik, Susan. (2008). It’s About “Time”: Extended cycles. Healthcare Sterilization Horizons, 27-30. Meredith SJ, & Sjorgen G (2008). Decontamination: Back to Basics. Journal of perioperative practice, 18(7), 285-

288. Patterson, Pat. (2008). Heavy Instrument Sets Shed Pounds. Healthcare Sterilization Horizons, 17-22. Rothrock, J. (2011). Alexander’s Care of the Patient in Surgery. (14th ed.). St. Louis: Mosby.


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Rutala ,William., Weber, David J. (2008). CDC Guidelines for Disinfection and Sterilization in Healthcare Facilities. The Healthcare Infection Control Practices Advisory Committee, (HICPAC), CDC.

Stewart, Sandra. (2004). Tearing Down the Walls Between OR and SPD. Canadian Operating Room Nurses

Journal, 22(2). Shewchuk, Muriel. (2004). Leader’s Role in Infection Prevention and Control, Canadian Operating Room Nurses

Journal, 22(2). Spry, Cynthia. (2008). Understanding current steam sterilization, Recommendations and Guidelines. AORN Journal,

88(4), 537-552. Spry, Cynthia (2008). BIs and CIs Using Sterilization Monitoring Indicators Appropriately. Healthcare Sterilization

Horizons, 9-15.

Specialized Instruments and Equipment

PRACTICE RATIONALE

9.1 Prosthesis Care and Handling 9.1.1 The manufactuer’s instructions for special

care and handling of prosthesis shall be provided and followed.

9.1.2 Prosthesis shall be meticulously handled to

prevent damage or contamination: - powder shall be wiped from surgical

gloves; - prosthesis shall be inspected for any

defects; - prosthesis shall be placed on a lint-free

surface; - prosthesis shall not contact hard surfaces

such as metal or glass; - unprotected prosthesis shall not be

handled or transferred with any type of forceps; and

- prosthesis shall be handled as little as possible.

Decreases the risk of patient injury and the potential of legal litigation Skin oil, glove powder, lint, and dust particles adhere to prostheses and cause a foreign body reaction.

9.1.3 The sterile prosthesis shall be opened as close to the time of insertion as possible.

Decreases risk of contamination of the prosthesis.

9.1.4 A prosthesis made of one metal should not come into direct contact with a prosthesis made of a different metal.

Direct contact between different metals (i.e., plates and screws) can cause an electrochemical reaction (Phillips, 2007, p. 327).

9.1.5 A prosthesis should be supplied sterile from the manufacturer. Manufacturer’s recommendations shall be followed if the

Manufacturer’s specifications include the appropriate method of sterilization if the prosthesis is supplied unsterile.


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PRACTICE RATIONALE

prosethesis is not supplied sterile. 9.1.6 Every load containing implantable devices

shall be monitored using a biological indicator. Implantable devices should be quarantined until the results of the biological indicator test are available

(CSA Z314.3-09).

9.1.7 The manufacturer's device "identifying" information e.g. serial number, size and quantity, shall be recorded in the patient's record. See Section 3- Nursing documentation. Specific implants require patient registration and communication directly with the vendor for updates, recalls and new information.

In case of a recall, the implanted device must be traceable.

9.2 Power Equipment Care and Handling 9.2.1 When caring for and sterilizing power

equipment, manufacturers' recommendations shall be followed (CSA Z314.8-08; CSA Z314.3-09). Evidence of validation that powered devices can be sterilized using commonly used facility sterilization methods shall be provided by the manufacturer.

Proper care and handling prolongs the life of power equipment and prevents infection.

9.2.2 CSA approval of all motors is required and leakage testing shall be conducted at regular intervals.

9.2.3 All power cords and plugs shall be checked for any cracks or breaks prior to each use.

Faulty cords may result in loss of power during surgery, electrical shorts, and fires.

9.2.4 Equipment shall be tested before being handed to the surgeon: - all blades and attachments shall be seated

securely before activation; - correct pressure in pounds per square

inch (psi) shall be set while the power tool is running or as recommended by the manufacturer and;

- the safety mechanism shall be turned on

before the equipment is handed to the surgeon and/or returned to the scrub nurse.

Advance testing of power equipment ensures proper working conditions, safety for the personnel and patient, and avoids delays after surgery has begun. Excessive psi may damage the powered instrument and/or exert stress on the hose. Under-pressurized equipment may not perform in the designated manner. Passing equipment in the 'safety' mode prevents accidental activation and is recommended by Occupational Health and Safety.


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PRACTICE RATIONALE

9.2.5 During use, the hand piece and attachments should be kept free of gross soil and debris.

Powered instruments should not rest on the patient when not in use.

9.2.6 Attachments, such as blades or burrs, shall be removed from the hand piece at the end of the procedure, and before the items are sent for decontamination.

9.2.7 Hand pieces, power cord and attachments should be cleaned immediately after use. If this is not possible, the items should be kept moist in a transport container by adding a towel moistened in water (not saline) or foam, spray or gel product specifically intended for this use (CSA Z314.8-08).

REFERENCES

Canadian Standards Association (2008). CSA Z314.8-08 Decontamination of Reusable Medical Devices. Toronto: Author. Canadian Standards Association (2009). CSA Z314.3-09 Effective Sterilization in health care facilities by the steam process. Toronto: Author. Phillips, N. (2007). Berry & Kohn’s operating room technique. (11th ed.) Toronto: Mosby. BIBLIOGRAPHY International Association Healthcare Central Services Material Management (2007). Central Services Technical Manual. Author. http://iahcsmm.org/ Rothrock, J. (2011). Alexander’s Care of the Patient in Surgery. (14th ed.) St. Louis: Mosby.

Single Use Medical Devices (SUMeDS)

PRACTICE

RATIONALE

10.1.1 Health care facilities shall not reprocess

medical devices labeled single use. There are primarily three major risks related to this

(reuse) practice. There are primarily three major risks related to this

practice.


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This issue is currently under review at local, provincial and federal levels. The organization prevents the on-site reprocessing of single use devices (SUD). If reprocessing or sterilization of SUDs is done outside the organization i.e. by a recognized third party reprocessor, the organization monitors these processes annually (Accreditation Canada, Infection Control p.18).

First, there can be damage to the device’s functional integrity. The effects of resterilization on the physical and mechanical properties of the device could result in device failure or patient injury. Second, infection or transmission of disease may result from devices exposed to high levels of contamination during first use, build up of toxic residues and ineffective reprocessing. Third, there may be health risks for health care personnel exposed to additional blood and body fluids, or reprocessing chemicals and gases. (Tapp, 2003, p. 18) Health care facilities currently do not have the resources to develop and maintain a comprehensive reprocessing validation program.

First, there can be damage to the device’s functional integrity. The effects of resterilization on the physical and mechanical properties of the device could result in device failure or patient injury. Second, infection, injury or transmission of disease may result from devices exposed to high levels of contamination during first use, build up of toxic residue and ineffective reprocessing. Third, there may be health risks for health care personnel exposed to additional blood and body fluids, or reprocessing chemicals and gases (Tapp, 2003, p.18). Health care facilities currently do not have the resources to develop and maintain a comprehensive reprocessing validation program.

REFERENCES

Tapp, A. (2003). Reuse if single-use medical devices. Canadian Operating Room Nurses Journal. Halifax: Clockworks. Health Canada (2005). Reprocessing and reuse of single-use medical devices April 29, 2005. Retrieved April 25, 2009 from /www.hc-sc.gc.ca/

Selection, Care and Handling of Materials

11.1 Wrappers, Surgical Gowns and Drapes PRACTICE

RATIONALE

11.1.1 Wrappers, drapes and gowns used in a sterile field shall meet the Canadian Standards Association (CSA) and the National Fire Protection Association specifications (CSA Z314.10).

Materials meeting these standards are penetrable by steam under pressure, gas or other sterilizing agents to achieve sterilization and will reduce static charge.

11.1.2 Multiple-use drapes, surgical gowns and wrapper material shall have the following characteristics regardless of temperature or humidity: - adequate barrier to microbes, particulate

matter and fluids; - tear and puncture resistant during use; - flexible;


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- drapable/memory free; - firmly hold a sealing device; - free of noxious odours; - does not lint, pill or shed fibres - maintain protective barrier ability through

multiple reprocessing; - appropriate size (for aseptic technique); - unfrayed edges; and - without joining seams or cross stitching.

11.1.3 Prior to each reprocessing, all multiple-use materials shall be visually inspected over a light table or light bar.

As per CSA Z314.10-03 Standard.

11.1.4 Holes and other defects in multiple-use materials may be patched

according to criteria supplied by the manufacturer.

The patched material shall retain its required barrier and sterilant penetration capability.

The acceptable location, number, shape and size of patches shall be clearly delineated in

written quality standards and repair procedures. The criteria should be developed based on the intended use of the textile, the required barrier properties, and the type of sterilizer used (CSA 314.10-03; 9.2.4 p.21). Patches shall be durable, heat-sealable, made of the same basic material as the item being patched, and allow for sterilant penetration.

Patches shall not be sewn.

As per CSA Z314.10-03 Standard. Holes produced by stitching create breaks in the material and reduces barrier efficacy.

11.1.5 Quality control shall be established to ensurethe effectiveness of the protective barrier for reprocessed materials according to CSA Z314.10.03.

Tracking number of uses and barrier testing are examples of quality control.

11.1.6 All multiple-use drapes, surgical gowns and wrappers shall be freshly

laundered/reconditioned and lint-free before bundles are prepared.

Bioburden is reduced by laundering. Reconditioned/freshly laundered materials are dehydrated and the risk of superheating during sterilization is reduced.

11.1.7 Single-use drapes, surgical gowns and wrapper material shall have the following characteristics regardless of temperature or humidity:

- adequate barrier to microbes, particulate matter and fluids;

- tear and puncture resistant during use; - flexible; - drapable/memory free;


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- moisture repellent; - an appropriate weight for the intended use; - does not lint, pill or shed fibres - antistatic; - flame retardant; and - free of noxious odours

11.2 Multiple-use Bundles 11.2.1 Prior to acceptance of any folding configuration, tests shall be performed using

biological and chemical indicators in multiple layers of the package to ensure effective sterilization (CSA Z314.10-03).

11.2.2 Bundles should be configured place size, shape, and weight from CSA Z314.10-

03 guidelines. 11.2.3 Bundle contents shall be arranged to allow: -effective sterilization (large drapes may need to be fan folded); -aseptic opening; and -items to be used in logical order.

11.2.4 Square or envelope wrapping method shall be used.

Standard wrap techniques are essential for appropriate sterilization as well as protecting sterility.

11.2.5 All bundles shall: - be clearly labeled to identify package

contents; - be dated; - identify the person who prepared the package; and

- have appropriate “load labels” and include information such as sterilization/chemical indicators inside and outside the bundles.

Provides contents and sterilization information, tracking information, and information required for proper inventory rotation, recalls and quality checks.

11.2.6 Pins, staples, string or rubber bands shall not be used to close bundles.

Pins and staples create holes in the bundle. String may cause strike through. Rubber bands do not permit the passage of sterilant.

REFERENCES

Canadian Standards Association (2003). CSA Z314.10-03 Selection, Use, Maintenance & Laundering of Reusable Textile Wrappers, Surgical Gowns and Drapes for Health Care Facilities. Toronto: Author. Canadian Standards Association (2009). CSA Z314.3-09 Effective Sterilization in health care facilities by the steam process. Toronto: Author.


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BIBLIOGRAPHY Sterile Processing University, LLC, (2007). The Basics of Sterile Processing (2nd ed.). Sterile Processing University, LLC, Lebanon, NJ.

Skin Preparation (Prep)

PRACTICE

RATIONALE

12.1.1 The operative site and surrounding areas shall be cleansed before surgical preparation by showering or washing.

Removal of superficial soil and transient flora reduces the risk of wound contamination (AORN, 2010; Thurston, 2007).

12.1.2 All body jewellery that pierces the skin shall be removed and the pierced area cleaned

thoroughly prior to the surgical skin preparation (Gruendemann & Mangum, 2001, p. 259).

12.1.3 Hair shall not be removed unless it will interfere with access to the operative area or fall into the wound. If hair removal is necessary, it should be done: -as close to the time of surgery as possible; -in a room where the procedure will not take place; and -using clippers or a depilatory agent. Clippers with reusable heads shall have the head disinfected between uses.

Hair removal can traumatize skin and provides an opportunity for colonization of microorganisms at the incision site. With increased time between hair removal and surgery comes increased incidence of SSI (SHN!). The dispersal of loose hair has the potential to contaminate the surgical site and surgical field (AORN, 2010 p. 357). Depilatories have caused skin reactions in some individuals causing surgery to be cancelled. To prevent cross contamination

12.1.4 Eyebrows shall not be shaved unless deemed essential by surgeon. . (Fuller, 2005, p.198)

Eyebrows may fail to re-grow or grow abnormally after surgery (Fuller, 2005, p.198). Regrowth is uneven and not complete (Philips 2007 p. 518).

12.1.5 The antiseptic agent used in preparation of the skin should:

- have broad spectrum antimicrobial action and rapidly decrease microbial count;

- be quickly applied and remain effective against micro-organisms;

- be virucidal and active against protozoa and yeast

- be safely used without skin irritation or

Antiseptic agents effectively applied remove many microorganisms from skin. Factors to be considered in skin disinfection are:

-the condition of the involved area; -the number and types of contaminants; -the characteristics of the skin to be disinfected; and

-the general physical condition of the patient (Rothrock, 2011, p.101).


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PRACTICE

RATIONALE

sensitization; - remain active in the presence of alcohol,

organic matter, soap or detergent; and - be non-flammable for use with laser,

electrosurgical or other high energy devices (Phillips, 2007, p. 517).

12.1.6 Prep solutions and irrigations shall not be

warmed unless recommended by the manufacturer.

Heat may change the chemical properties and efficacy of the antiseptic agent.

12.1.7 Exposure of the patient shall be confined to the area being prepped.

The patient's dignity and privacy are maintained.

12.1.8 Antiseptic agents shall be applied by non-scrubbed personnel proceeding from the incision site to the periphery or from clean tosoiled (bioburdened) areas.

The exception is the umbilical area, which shall be prepped first.

A circular pattern moving outward from proposed incision site shall be used. The sponge shall not back track the already prepped area (Phillips, 2007, p.519).

Antiseptic agents effectively applied to the patient’s skin are a method of infection control. Proceeding from cleanest to least clean decreases the risk of microorganisms being brought from the periphery back to the proposed incision site. Prepping the umbilicus first prevents debris from the contaminated site splashing onto the freshly prepped area.

12.1.9 Antiseptic agents shall be applied in a manner that prevents pooling of the agent in skin creases, under the patient, around a tourniquet, ESU dispersive pad site, or near electrodes. Agents shall be allowed to dry prior to placement of sterile drapes. Manufacturer’s instructions shall be followed when using antiseptic agents.

Pooling of antiseptic agents may cause chemical burns. Time for complete evaporation of the antiseptic agent is required before electrosurgery or lasers are used to prevent the possibility of fire or burns (AORN, 2010). To ensure patient and staff safety.

12.1.10 The following situations require additional care during preoperative skin preparation: -when a stoma is involved, a prep sponge soaked with an antiseptic agent is placed over the stoma and removed at completion of the prep, then the stoma is prepped last (Phillips, 2007, p.517; Rothrock, 2011, p. 103); - denuded or traumatized skin should be prepared using normal saline (AORN, 2010,


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PRACTICE

RATIONALE

p.359); and -mucous membranes shall not have chlorhexadine gluconate, alcohol or alcohol based solutions used as a prep solution. If additional procedures are to be performed (e.g. insertion of a Foley catheter), they shall be done prior to the surgical site prep.

12.1.11 Limbs shall be elevated, and prepped in a manner that provides support, safety, and prevents contamination. A full extremity prep may be done in two stages to provide adequate support to joints and to ensure that all areas are prepped (Phillips, 2007, p. 520).

12.1.12 When performing both abdominal and perineal skin prep, the perineal area is prepped first. Preps shall be performed sequentially and not simultaneously, with a new prep kit used for each area (Burlingame, 2005, p. 112).

Avoids potential contamination of the abdomen or aerosolization of prep solution from the perineal area. (Burlingame, 2005, p. 112)

12.1.13 The skin preparation shall be documented on the operative record. The following information shall be included: -condition of the skin at the operative site (if other than healthy and intact); -method of hair removal, if used; -name and concentration of antiseptic agent(s) used; -any skin reaction that occurred ; and -name of person performing skin preparation.

Documentation of preoperative skin preparation assists in quality assurance and in infection control follow-up.

REFERENCES

Association of PeriOperative Registered Nurses. (2010). Perioperative standards and recommended practices. Denver: Author. Burlingame, B. (2005). Clinical issues: Dual procedure prep. AORN, (82), 1, 112. CAN/CSA-ISO 10993-1 Fuller, J. (2005) Surgical technology- principles and practice (4th ed.). Philadelphia: Elsevier Saunders Gruendemann, B. & Mangum, S. (2001). Infection prevention in surgical settings. Toronto: W.B. Saunders, 258. Phillips N. (2007). Berry & Kohn’s Operating room technique. (11th ed) Toronto: Mosby. Rothrock, J. (2011) Alexander’s care of the patient in surgery. (14th ed). Toronto: Mosby.


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Thurston, A.J. (2007). Sources of infection in the operating theatre in the Evidence for Orthopaedic Surgery. Edited by David Limb and Stuart M Hay. Shewsbury, UK: tfm Publishing Limited.

QMENTUM Program 2010 Operating Room Standards

BIBLIOGRAPHY Barbara DeBraun, (2008). Evaluation of the Antimicrobial Properties of an Alcohol-free 2% Chlorhexidine

Gluconate. AORN Journal, 87(5), 925-931.

Draping

PRACTICE

RATIONALE

13.1.1 The scrub nurse shall adhere to established draping procedures, and select appropriate drapes for each draping procedure.

When draping, the following shall be considered: -the size of the sterile field; -the location and size of the incision; -the number of sterile persons at the operative field; and -the sterile instrumentation and equipment on the operative field.

13.1.2 Sterile drapes shall provide a moisture

barrier between the patient and the sterile field (Fuller, 2005, p.209).

Draping material should be maintained in a compact manner and held higher than the surgical site.

Use as little movement as possible when handling drapes (Rothrock, 2011, p. 107).

To prevent strike-through and contamination of the sterile field. Fanning , flipping or shaking drapes is unacceptable. Dust, lint and droplet nuclei may migrate on air currents from rapid drape movement. Controlled placement decreases the risk of contact with unsterile objects or surfaces.

13.1.3 Sterile gloved hands shall be protected by cuffing the drape over hands. While draping, gloved hands should not touch the skin of the patient (Phillips, 2007, p.523).

Avoids the risk of contaminating the gloves (Rothrock 2011 p.107).

13.1.4 Drape the incision area first and then the periphery. Always drape from a sterile to an unsterile area. Do not reach across a non-sterile surface (Rothrock, 2011, p.107).

The site of the incision will be defined and the surgical wound will be isolated. Controlled drape placement decreases the risk of the scrubbed personnel contaminating their gowns.

13.1.5 An impervious drape shall be placed around the operative site and wherever strike-through is likely to occur.

Strike-through produces a pathway for microorganisms.

13.1.6 Huck towels shall not be used as drapes. Although huck towels may be used to absorb fluids, they have no barrier properties. Their use would


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PRACTICE

RATIONALE

compromise the sterile field (CSA Z314.10, 2003).

13.1.7 A drape shall not be adjusted once it has been placed (Rothrock, 2011, p. 107).

Shifting or moving the drape may transport bacteria from an unprepared area of the patient’s skin into the surgical field (Rothrock, 2011, p. 107).

13.1.8 Non-perforating towel clamps or devices shall be used to hold drapes or to secure tubing and other items on the sterile field (Rothrock, 2011, p.107).

Perforations in a barrier provide portals of entry and exit for microorganisms, blood, and other potentially infectious body fluids (AORN, 2010 p. 95).

13.1.9 At the completion of the surgery, the scrub nurse shall ensure that all instruments, sponges, and equipment are removed from the drapes.

Assists with completion of surgical count. Loss of instruments and mechanical damage in the launderingprocess can occur and may be very costly. Risk of injury to personnel and the patient is minimized.

13.1.10 Only gowned and gloved personnel shall remove the drapes. Removal shall be carefully controlled by rolling the drapes into a bundle that confines the contamination.

Controlling the removal is necessary in order to confine and contain the contaminants. PPE worn by scrubbed personnel supplies protection from microbial contaminants.

13.1.11 The drapes shall be placed in the linen hamper or garbage container (if disposable) by gloved personnel following Routine Practices.

REFERENCES

Association of PeriOperative Registered Nurses. (2010). Perioperative standards and recommended practices. Denver: Author. Canadian Standards Association (2003). CSA Z314.10-03 Selection, Use, Maintenance & Laundering of Reusable Textile Wrappers, Surgical Gowns and Drapes for Health Care Facilities. Toronto: Author. Fuller, J. (2005) Surgical technology- principles and practice (4th ed.). Philadelphia: Elsevier Saunders. Phillips N. (2007). Berry & Kohn’s Operating room technique. (11th ed.). Toronto: Mosby. Rothrock, J. (2011) Alexander’s care of the patient in surgery. (14th ed.). Toronto: Mosby.

Dressing (s), Drain(s), Irrigation

Practice

Rationale


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Practice

Rationale

14.1 Dressing(s) 14.1.1 Appropriate dressings shall be applied to the

patient according to: -wound requirements; -surgeon’s preference; and -patient sensitivity.

Dressings protect the wound from trauma and contamination. Dressings will absorb drainage and enhance the patient’s physical comfort and aesthetic appearance. Dressings protect the incision free of microorganisms, both exogenous and endogenous. Dressings also support, splint, and immobilize a body part and incision area (Phillips, 2007).

14.1.2 Wound dressings shall not be opened for use until

the wound is closed and the final count is complete(Fuller, 2005; Phillips, 2007). Dressing that are included in custom packs shall remain sealed/isolated until the final count is complete.

Wound dressings do not have a radiopaque detectable strip and if opened prior to closure present a risk for being retained in the wound as a foreign object.

14.1.3 Before applying a dressing to a closed wound the skin around the incision shall be cleansed of blood with a sterile dampened sponge or towel (Phillips, 2007).

14.1.4 The scrub nurse shall hold a sterile sponge or towel over the incision while the drapes are removed. The dressing will be applied. If the dressing to be used is multilayered, the scrub nurse should place the initial dressing over the incision. The circulating nurse will apply the remaining dressing materials. Before taping, the patient’s skin condition shall be assessed. Non allergic tape shall be readily available.

To protect the wound/incision area from contamination and introduction of microorganisms. Gloves contaminated with blood or body fluids will contaminate the outside of the dressing.

14.1.5 A sponge with a radiopaque attached strip shall notbe used for a dressing.

R Radiopaque sponges could distort a postoperative x-ray or cause an incorrect count if the patient’s incision must be reopened.

14.2 Drain(s) 14.2.1 Safety precautions and Routine Practices

shall be followed when establishing a drainage system:

The type of drain used depends on, surgeon preference and the area to be drained. Proper handling minimizes or prevents cross contamination.

14.2.2 The circulating Registered Nurse shall record the exact location of the drain(s), the

Complete and accurate documentation helps provide consistency in patient care by communication of


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Practice

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type of drain(s), and the method of securing the drain(s) (Rothrock 2011, p. 265).

important information.

14.3 Irrigation 14.3.1 The circulating Registered Nurse shall

provide the appropriate irrigating fluid as ordered by the surgeon.)

Hazards may be encountered with different solutions such as the use of sterile water versus saline in urology procedures.

14.3.2 The scrub perioperative Registered Nurse shall keep track of the amount of irrigation fluid used when blood loss is being calculated (Phillips 2007).

14.3.3 Solutions and medications shall be checked for accuracy as to type and amount by the scrub and circulating Registered Nurse before being placed onto the sterile field (Rothrock, 2011, p. 39).

14.3.4 Solutions and medications on the sterile field shall be clearly labeled using a sterile marking pen or sterile labels (Rothrock, 2011, p. 39).

Solutions and medications that are clearly labeled reduce the risk of patient injury.

14.3.5 Use of all irrigating solutions and medications shall be documented on the operative record (Rothrock, 2011).

14.3.6 Some special procedures may require detailed fluid management as per the health care facility’s policy.

REFERENCES

Fuller, J. (2005) Surgical technology- principles and practice (4th ed.). Philadelphia: Elsevier Saunders Gruendemann, B. & Mangum, S. (2001). Infection prevention in surgical settings. Toronto: W.B. Saunders. Phillips N. (2007). Berry & Kohn’s Operating room technique. (11th ed) Toronto: Mosby. Rothrock, J. (2011) Alexander’s care of the patient in surgery. (14th ed). Toronto: Mosby.


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Section 3

Safety/Risk Prevention and Management


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Safety/Risk Prevention and Management Section 3


Section 3 Safety/Risk Prevention and Management

Introduction to Risk Management .................................................................................................................. 155 Risk Avoidance/Minimization ........................................................................................................................ 156

Patient Safety .................................................................................................................................................. 160

Ambulatory Patient Care Recommendations ................................................................................... 160 Patient Admission and Identification ............................................................................................... 163 Consent for Surgical Intervention .................................................................................................... 164 Surgical Site Verification ................................................................................................................. 165 Surgical Pause/”Time Out” ............................................................................................................. 166 Surgical Counts ................................................................................................................................ 167 Surgical Positions ............................................................................................................................. 178 Visitors to the Surgical Suite ............................................................................................................ 184 Gathering Medicolegal Evidence in the Surgical Suite .................................................................... 185

Guidelines for Collection of Evidence: (Appendix E) .................................................................... 189 Specimen Management .................................................................................................................... 190 Medication Management .................................................................................................................. 193 Nursing Documentation ................................................................................................................... 196 Electronic Health Records ................................................................................................................ 201 Organ and Tissue Procurement Protocol .......................................................................................... 203

Team Safety .................................................................................................................................................... 206

Credentialing .................................................................................................................................... 206 Occupational Health & Safety .......................................................................................................... 207 Students/Preceptors .......................................................................................................................... 209

Orientation/In-service/Continuing Education .................................................................................. 211 Environmental/Equipment Safety ................................................................................................................... 212

Construction/Renovation .................................................................................................................. 212 Equipment Selection/Trialing........................................................................................................... 221 Preventative Maintenance Programs ................................................................................................ 225 Risk Alerts/Recalls ........................................................................................................................... 225 Intra-operative Equipment Malfunction ........................................................................................... 226

Specialized Surgical Equipment ...................................................................................................... 226 Electrosurgery (ESU) .......................................................................................................... 226 Laser Safety and Administration .......................................................................................... 234 Minimally Invasive Surgery ................................................................................................. 242


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Introduction to Risk Management The risk management process is designed to identify the scope of potential or real risk related to patients, the health care team members and the health care facility. An effective risk management program requires the following:

- Key Structural Elements - enables the risk manager/delegate to develop and enforce the risk management program and enact needed changes in policy.

- Scope of Risk - related to patient, medical staff and employees. - Risk Strategies - techniques to manage risk, prevent risk and/or reduce risk. - Policies & Procedures - to ensure consistency and uniformity of the program.

Health care risk management is concerned with a tremendous variety of issues and situations that hold the potential for liability or casualty losses for an institution. To be truly comprehensive, a risk management program must address the full scope of the following categories of risk:

- Patient care - related risks - Medical staff - related risks - Employee related risks - Property related risks - Financial risks - Other risks

(Hagg-Rickert,1997, p. 39) This section will identify the processes and polices required in the surgical suite to determine:

- Risk acceptance - Risk avoidance - Risk transfer

The content of this section is organized under the following broad headings:

- Risk Avoidance or Minimization - Patient Safety - Team Safety - Environmental/Equipment Safety - Incident Reporting

REFERENCES

Hagg-Rickert, S. (1997). Foundations for healthcare risk management: elements of a risk management program. Risk Management Handbook. (2nd ed.). Roberta Carroll ed, American Hospital Publishing, pp. 35-51.

BIBLIOGRAPHY

Health Canada – retrieved November 6, 2008 www.hc-sc.gc.ca Woodhead, K and Wicker, Paul. (2005). Textbook of Perioperative Care. Toronto: Elsevier

RESOURCES

Canadian Nurses Association (CNA) Patient Safety Resource Guide. http://www.cna-nurses.ca/CNA/practice/environment/safety/guide/intro-e.aspx


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Canadian Nurses Association (CNA) (2006). Staffing for Safety http://www.cna-nurses.ca CIHI- Canadian Institute of Health Information. www.cihi.ca Safe Surgery Saves Lives, campaign from WHO challenging the world to make global surgery safer. http://www.who.int/patientsafety/safesurgery/ WHO World Health Organization www.who.int

Risk Avoidance/Minimization

The following policies and procedures, information and/or processes should be developed for the perioperative setting: PRACTICE RATIONALE

1.1 Physical layout of the department.

Facilitates patient and staff security and safety.

1.2 Hours of operation of the department.

1.3 Use of the surgical suite after hours and an auditing process of this use.

Most departments have reduced resources. Access is for emergent/urgent case type. Monitoring of this utilization will determine overuse and/or violation of access.

1.4 Physician/dentist credentials and privileges shall be available to staff and processes defined related to when physician/dentist exceeds privileges.

1.5 Identification of minimum educational requirements for health care professionals.

1.6 Annual confirmation of license/registration of health care professionals.

1.7 Utilization of unlicensed assistive personnel (UAP) to include:

- scope of practice of UAP; - education of the UAP in assigned tasks;

and - mechanism to monitor performance of

UAP. (AORN, 2004, p. 167)

1.8 Education to include but not limited to: - staff orientation; - in-service; and - regulations/requirements for WHMIS,

CPR, Fire and other mandatory review/certification programs.


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PRACTICE RATIONALE

1.9 The use of agency staff, as it relates to: - basic orientation; - reporting relationship to a regular staff

member; and - reference package so agency staff have

information readily accessible in written/electronic format.

1.10 Visitors (e.g., sales reps, students, etc.) in the surgical suite as it relates to:

- privileges; - acceptable behaviour; and confidentiality.

There is a legal precedent where a sales representative assisted during a surgical procedure resulting in a lawsuit to the health care facility. Confidentiality and privacy is a great concern.

1.11 Staff communication regarding new and revised policies and procedures:

- circulation to all staff; and - retention of outdated policies.

Staff need to be aware of new policies and procedures. Old policies may be required for legal defence.

1.12 Reporting of sentinel events, incidents and near misses, including a clear definition of each type.

Reporting assists in identifying trends, where policy & process development/revision is required.

1.13 Dissemination of information related to equipment/medical surgical device risk alerts and re-calls.

The health care facility needs to have a common entry and exit point for these alerts and recalls to ensure no areas are missed.

1.14 Equipment as it relates to selection, preventative maintenance and transportation from site to site.

Patient safety, team safety and risk need to be considered in the selection process. Preventative maintenance and routine maintenance assist in minimizing potential functionality problems of complex medical devices.

1.15 Consent to treatment shall follow provincial legislation and health care facility guidelines for the following:

- telephone consent; - emergency life/limb saving surgery

consent; - age of consent; - medicated patients giving consent; - alternate/substitute decision-maker

giving consent; - blood and blood products; and - interpreters.

1.16 Verification of surgical site as it relates to: - verification of patient identity;

- verification of surgical intervention site(s) and side (when involving laterality);

Clear indication/understanding of what is being marked (surgical site or non-surgical site) is required for patient safety.


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PRACTICE RATIONALE

- marking the surgical site(s); and - collaboration of team members for

verification process is necessary.

REFERENCES

Association of PeriOperative Registered Nurses. (2004). Position Statement on Use of Unlicensed Assistive

Personnel. Standards, Recommended Practices, and Guidelines. Denver: Author.

BIBLIOGRAPHY

Accreditation Canada www.accreditation-canada.ca - formerly known as Canadian Council on Health Services Accreditation (CCHSA). Allan, Sheila S, (2007). Creating a Culture of Safety. Journal of Perioperative Practice, 17(6), 244-246. Allen, Sheila S, (2007). Conflict in the Perioperative Environment. Journal of Perioperative Practice, 17(3), 96-97. Amato-Vealey, Elaine J, & Barba, Marianne, P, (2008). Hand-off Communication: A Requisite for Perioperative Patient Safety, AORN Journal, 88(5), 763-772. AORN, (2009). Perioperative Standards and Recommended Practices. Denver: Author. Baker, R et al, (2004). The Canadian adverse events Study: the incidence of adverse events among hospital patients in Canada. CMAJ, 170(11), 1678-1686. Beaumont, Kate, (2008). Recognizing and Responding to the Deteriorating Patient, Institute for Innovation and Improvement, NHS, http://www.library.nhs.uk/theatres/page.aspx?pagencine=ED11 Bilyk, C. (2008, September). Do not break the chain: importance of supply chain management in the operating room setting. Canadian Operating Room Nursing Journal, 26, (3), 21, 22, 30-32, 34. Brown, Y. (2004). Learning in a preceptorship. Canadian Nurse. 100 (6), Ottawa:

CNA. Canadian Council on Health Services Accreditation (CCHSA). (2004). Human Resources. AIM, Achieving Improved Measurement, Accreditation Program. 3rd ed. Now known as Accreditation Canada.

www.accreditation-canada.ca Carney, Brenda L, (2006). The Evolution of Wrong Site Surgery, AORN Journal, 83(5), 1115-1122. Cutler I, (2008). The safety of Medical Devices: The tools of your working day. Journal of Perioperative Practice, 18(9), 396-403. Edwards P. (2008). Ensuring Correct Site Surgery. Journal of Perioperative Practice, 18(4), 168-171. Edwards P. (2006). Promoting Correct Site Surgery: A national approach. Journal of Perioperative Practice, 16(2), 80-86.


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Forster, Alan J, (2004). Ottawa Hospital Patient Safety: Incidence and timing of adverse events in patients admitted to a Canadian teaching hospital. Canadian Medical Association Journal, 170(4), 1235-1240. Haines, Ted & Stringer Bernadette, (2007). Could the Death of a BC OR Nurse have been Prevented by Using the Hands-Free Technique? Canadian Operating Room Nurses Journal, 25(4). Hamlin, Lois, Richardson-Tench, Marilyn & Davies, Menna, (2009).Perioperative nursing an introductory text. Elsevier/Mosby, Sydney AU Giles, Sally G et all (2006). Experience of Wrong Site Surgery and Surgical Marking practices among clinicians in the UK. Qual Saf Healthcare, 15, 363-368. http://www.bmj.com/cgi/reprintfromjournals Haynes, Alex B et al, (2009). A surgical checklist to Reduce morbidity and Mortality in a Global Population. NEJM, 360(5), 491-499. Higgins Jackee, (2004). Thinking Outside the Box: Perioperative Preceptorship. Canadian Operating Room Nurses Journal, 22(1). Huff, Brenda, (2004). Leadership and Mentoring. Canadian Operating Room Nurses Journal, 22(1). International Federation of Perioperative Nurses (IFPN) & European Operating Room nurses Association (EORNA), (2005). Joint Position Statement on Patient Safety 1011, IFPN & EORNA, accessed April 16, 2009 from http://www.ifpn.org.uk Keith, N., & O'Reilly, Y. (2003). The legal connection: soon to be law – corporate decision - makers are accountable for employee safety. Canadian Occupational Health & Safety. 41(5).

Kwaan Mary K et al, (2006). Incidence, Patterns and Prevention of Wrong Site surgery, Arch Surg, 141. Accessed April 15, 2009 www.archsurg.com Lingard, Lorelei, et al, (2008). Evaluation of a Perioperative checklist and Team Briefing Among Surgeons, nurses and Anesthesiologists to Reduce Failures in communication, Arch Surg, 143(1), 12-17. Lingard, Lorelei, et al, (2004). Communication failures in the Operating Room: an observational classification of recurrent types and effects. Qual Saf Healthcare, 13, 330-334. Makary, Martin A, et al (2006). Operating Room Teamwork Among Physicians and Nurses: Teamwork in the Eye of the Beholder. Journal of American College of Surgeons, 202, 746-752. McNair, W, & Smith B, (2007). A Vision of Mentorship. Journal of Perioperative Practice, 17(9), 421-430. Phillips, N.M. (2007). Berry & Kohn’s operating room technique. (11th ed.) St Louis: Mosby. Porteous, J. (2008). Oh By the Way the Patient is Pregnant. Canadian Operating Room Nurses Journal, 26(2). Robson, R., & Marshall, P. (2003). Using dispute resolution to resolve health care conflicts: an essential tool in

hospital risk management. Risk Management in Canadian Health Care, 4 (7). Ryan-Nicholls, N. (2004). Preceptor recruitment and retention. Canadian Nurse, 100(6), Ottawa: CNA. Stahel, P. F. (2008). Learning from aviation safety: a call for “readback” in surgery. Patient Safety in Surgery, 2(8), accessed April 12, 2009, from http://www.pssjournal.com/content/21/21


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Spry, Cynthia, (2008). Essentials of Perioperative Nursing (4th ed.). Philadelphia: Jones & Bartlett. Stringer B & Haynes T, (2006). Hands-free technique: preventing occasional exposure during surgery. Journal of Perioperative practice, 16 (10), 495-500. Vincent, C.(2006). Patient Safety. London, UK.: Churchill Livingstone. Watson, V., & Steiert, M.J. (2002). Verbal abuse and violence: the quest for harmony in the OR. Surgical Services

Management. 8(4), pp. 16-22. Westhead, Cameron, (2007). Perioperative nursing management of the elderly Patient, Canadian Operating Room Nurses Journal. 25 (3).

Patient Safety

2.1 Ambulatory Patient Care In recognition of the ambulatory patient’s short stay the following best practices include but are not limited to: PRACTICE RATIONALE

2.1.1 The patient/ shall be educated about:

- the importance of complying with health care facility guidelines, e.g. nothing by mouth (NPO)/anesthesia considerations;

- importance of not driving or operating machinery post-operatively as per facility protocol;

- importance of not making important decisions;

- requirement of discharge in the company of a responsible adult; and

- compliance with post-discharge instructions.

The patient is informed about risk of aspiration with non-compliance. Presents a hazard to the patient and others. Medications used for induction and/or maintenance of anesthesia require a specified period for metabolism. Insurance providers do not provide coverage for policy holder for a specified period post-operatively. The responsible adult must be available to call for help if it is required.

2.1.2 Ambulatory surgical patients shall be provided with:

- contact information for agencies providing information and assistance following discharge (i.e. help line); and

- appropriate post-operative teaching instructions as per facility protocol.

Patient/responsible adult will be made aware of who to contact if a concern arises post-discharge (nursing and physician). Patient/ responsible adult should be able to understand and verbalize post-discharge information.

2.1.3 The perioperative Registered Nurse is

responsible for: - documenting patient teaching as per


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PRACTICE RATIONALE

facility protocol; - discharging patient according to the

health care facility discharge criteria; and

- following health care facility process for patient(s) who do not meet the discharge criteria or are non-compliant with discharge criteria.

BIBLIOGRAPHY Accreditation Canada www.accreditation-canada.ca - formerly known as Canadian Council on Health Services

Accreditation (CCHSA). Allan, Sheila S, (2007). Creating a Culture of Safety. Journal of Perioperative Practice, 17(6), 244-246. Allen, Sheila S, (2007). Conflict in the Perioperative Environment. Journal of Perioperative Practice, 17(3), 96-97. Amato-Vealey, Elaine J, & Barba, Marianne, P, (2008). Hand-off Communication: A Requisite for Perioperative

Patient Safety, AORN Journal, 88(5), 763-772. AORN, (2010). Perioperative Standards and Recommended Practices. Denver: Author. Baker, R et al, (2004). The Canadian adverse events Study: the incidence of adverse events among hospital patients in Canada. Canadian Medical Association Journal, 170(11), 1678-1686. Beaumont, Kate, (2008). Recognizing and Responding to the Deteriorating Patient. Institute for Innovation and

Improvement, NHS, http://www.library.nhs.uk/theatres/page.aspx?pagencine=ED11 Bilyk, C. (2008, September). Don’t break the chain: importance of supply chain management in the operating room

setting. Canadian Operating Room Nursing Journal, 26, (3), 21, 22, 30-32, 34. Brown, Y. (2004). Learning in a preceptorship. Canadian Nurse, 100 (6), Ottawa: Author. Canadian Council on Health Services Accreditation (CCHSA). (2004). Human Resources. AIM, Achieving Improved Measurement, Accreditation Program. 3rd ed. Now known as Accreditation Canada.

www.accreditation-canada.ca Carney, Brenda L, (2006). The Evolution of Wrong Site Surgery, AORN Journal, 83(5), 1115-1122. Cutler I, (2008). The safety of Medical Devices: The tools of your working day. Journal of Perioperative Practice,

18(9), 396-403. Edwards P. (2008). Ensuring Correct Site Surgery. Journal of Perioperative Practice, 18(4), 168-171. Edwards P. (2006). Promoting Correct Site Surgery: A national approach. Journal of Perioperative Practice, 16(2),

80-86. Forster, Alan J, (2004). Ottawa Hospital Patient Safety: Incidence and timing of adverse events in patients admitted

to a Canadian teaching hospital. Canadian Medical Association Journal (CMAJ), 170(4), 1235-1240.


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Giles, Sally G et all (2006). Experience of Wrong Site Surgery and Surgical Marking practices among clinicians in the UK. Quality Safe Healthcare, 15, 363-368. http://www.bmj.com/cgi/reprintfromjournals

Haines, Ted & Stringer Bernadette, (2007). Could the Death of a BC OR Nurse have been Prevented by Using the

Hands-Free Technique? Canadian Operating Room Nurses Journal. 25(4). Hamlin, Lois, Richardson-Tench, Marilyn & Davies, Menna, (2009).Perioperative nursing an introductory text.

Sydney AU: Elsevier/Mosby. Haynes, Alex B et al, (2009). A surgical checklist to Reduce morbidity and Mortality in a Global Population. NEJM,

360(5), 491-499. Higgins Jackee, (2004). Thinking Outside the Box: Perioperative Preceptorship. Canadian Operating Room Nurses

Journal, 22(1). Huff, Brenda, (2004). Leadership and Mentoring. Canadian Operating Room Nurses Journal, 22(1). International Federation of Perioperative Nurses (IFPN) & European Operating Room nurses Association (EORNA),

(2005). Joint Position Statement on Patient Safety 1011, IFPN & EORNA, accessed April 16, 2009 from http://www.ifpn.org.uk

Keith, N.,& O'Reilly, Y. (2003). The legal connection: Soon to be, law – corporate decision - makers are

accountable for employee safety. Canadian Occupational Health & Safety. 41(5).

Kwaan Mary K et al, (2006). Incidence, Patterns and Prevention of Wrong Site surgery, Arch Surg, 141. Accessed April 15, 2009 www.archsurg.com

Lingard, Lorelei, et al, (2008). Evaluation of a Perioperative checklist and Team Briefing Among Surgeons, nurses

and Anesthesiologists to Reduce Failures in communication, Arch Surg, 143(1), 12-17. Lingard, Lorelei, et al, (2004). Communication failures in the Operating Room: an observational classification of

recurrent types and effects. Quality Safe Healthcare, 13, 330-334. Makary, Martin A, et al (2006). Operating Room Teamwork Among Physicians and Nurses: Teamwork in the Eye of

the Beholder. Journal of American College of Surgeons, 202, 746-752. McNair, W, & Smith B, (2007). A Vision of Mentorship. Journal of Perioperative Practice,17(9), 421-430. Phillips, N.M. (2007). Berry & Kohn’s operating room technique. (11th ed.) St Louis: Mosby. Porteous, J. (2008). Oh By the Way the Patient is Pregnant. Canadian Operating Room Nurses Journal, 26(2). Robson, R., & Marshall, P. (2003). Using dispute resolution to resolve health care conflicts: an essential tool in

hospital risk management. Risk Management in Canadian Health Care, 4 (7). Stahel, P. F. (2008). Learning from aviation safety: a call for “readback” in surgery Patient Safety in Surgery. 2 (8)

accessed April 12, 2009 from http://www.pssjournal.com/content/21/21 Spry, Cynthia, (2008). Essentials of Perioperative Nursing(4th ed.). Philadelphia: Jones & Bartlett. Stringer B & Haynes T, (2006). Hands-free technique: preventing occasional exposure during surgery. Journal of

Perioperative Practice, 16 (10) 495-500.


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Vincent, C.(2006). Patient Safety. London, UK.: Churchill Livingstone. Westhead, Cameron, (2007). Perioperative nursing management of the elderly Patient, Canadian Operating Room Nurses Journal. 25 (3).

2.2 Patient Admission and Identification The perioperative Registered Nurse provides safety and comfort to each patient on admission to the operating room. PRACTICE RATIONALE

2.2.1 The surgical suite policy and procedure manual shall address the procedure and delegation of responsibilities for admitting a patient to the surgical suite.

Provides quality assurance for a consistent practice to reduce risks from errors and omissions.

The perioperative Registered Nurse is responsible for: 2.2.2 Admitting the patient in a professional

manner.

This reduces anxiety.

2.2.3 Identifying themselves (including name and job title) and asking the patient's name.

Active communication reduces risk of error.

2.2.4 Verifying the patient's identification with two patient identifiers i.e. name , facility identification number on arm band, date of birth (orally) with the patient or responsible adult identifier shall not be room number or patient location (Catalano and Fickenscher, 2008).

2.2.5 Reviewing the patient’s health record to confirm at minimum the presence and completeness of:

- documentation of consent; - pre-op checklist; and - history and physical

The responsibility for the consent lies with the surgeon; however, it is the perioperative Registered Nurse's responsibility to confirm all relevant records are present and complete prior to admission to the operating room.

2.2.6 Verifying the operative site, surgical site marking if laterality is involved, the

procedure, documentation of consent for accuracy/completeness. Taking the appropriate action according to the health care facility’s policy when a surgical consent is inadequate/incomplete.

Protects patient from potential injury and the health care facility from litigation.

2.2.7 Assessing the patient's emotional and physical condition and intervening as appropriate.

2.2.8 Caring for the patient's personal belongings Some items may be required for the emotional and


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PRACTICE RATIONALE

according to written protocols. No personal belongings other than the following exceptions should accompany the patient:

- items for pediatric patients; - religious medals/symbols; - clothing (when appropriate);

- hearing aids; - eye glasses - dentures; and - prostheses.

physical well being of the patient. Items may be misplaced.

2.2.9 Verifying the preoperative checklist is complete The checklist will include but not be limited to:

- patient identification band; identification card if used in facility;

- consent/documentation of consent completed and signed;

- consent or withdrawal of consent for blood products, if applicable;

- surgical site identification; - history and physical assessment; - all diagnostic reports present; - preoperative vital signs ; - allergies;

- NPO status; - prostheses - hearing aids; - eye glasses - dentures; and - jewellery, - medication including herbal remedies; and - presence of an advanced directive as necessary.

This step prevents oversights and omissions. The preoperative checklist should be a permanent part of the clinical record.

2.3 Consent for Surgical Intervention The perioperative Registered Nurse is responsible for: PRACTICE

RATIONALE

2.3.1 Checking the clinical record for documentation of consent and using active communication to verify the surgical procedure, site, and the patient’s understanding of the procedure.

Patient has the right to decide what or what will not be done to them. (CPSO, 2004) Patient understanding is a component of informed consent. The ultimate responsibility for obtaining informed consent is with the health care practitioner proposing the intervention.

2.3.2 Exercising professional judgment and following the guidelines established by their


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regulatory body, health care facility policy and provincial legislation with respect to the patient's capability to give informed consent for the proposed intervention.

REFERENCES

College of Physicians and Surgeons of Ontario. (2004). A guide for Canadian Physicians. www.cpso.on.ca

BIBLIOGRAPHY

Bernat, James L & Peterson, Lynn M, (2006). Patient-centered Informed Consent in Surgical practice. Arch Surg, 141; 86-92. Corfield L & Pomeroy A, (2008). Perioperative Consent: how to make sure your practice is legal part 1. Journal of Perioperative Practice, 18 ( 8) 326-328. Corfield L & Pomeroy A, (2008). Perioperative Consent: how to make sure your practice is legal part 2. Journal of Perioperative Practice, 18 (9) 392-395. Elke-Henner, W Kluge, (2008). Remains of the Body, Human Tissue, Competence and Consent in an Age of Profit, Canadian Operating Room Nurses Journal, 26 (2). Kuz, K.M. (2006). Young teenagers providing their own surgical consents. Canadian Operating Room Journal, 24 (2). 6-15. Rozovsky, L.E. (2003). The Canadian Law of Consent to Treatment (3rd. ed.). LexisNexis Butterworths: Markham. Stevenson G, (2006). Informed Consent, Journal of Perioperative Practice, 16(8) 384-388. 2.4 Surgical Site Verification Surgical site verification reduces the risk of adverse patient outcomes/events during a surgical experience. Surgical facilities shall have a policy in place regarding surgical site verification. The perioperative Registered Nurse is responsible for: PRACTICE

RATIONALE

2.4.1 Following the facility policy regarding surgical site verification.

2.4.2 Verifying the surgeon has marked the site (if applicable) prior to admission to the operating room.

2.4.3 Verifying the correct surgical procedure and site with patient/responsible adult.


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2.4.4 Confirming surgical site, site marking (if laterality, multiple sites, spine levels is/are involved), and procedure with the surgical team in the theatre.

The surgeon is responsible for marking the site.

BIBLIOGRAPHY

Beyea, S. (2002). Ensuring correct site surgery. AORN Journal, 76 (5) 880-882. Canadian Patient Safety Institute Surgical Safety Checklist & Scorecard: Canada, Version 1. Edmonton, AB:

Canadian Patient Safety Institute; 2009 Jan 9. www.safesurgerysaveslives.ca OR Manager: Patient Safety. (2003). Air Force's 11 patient safety tools build better team communication. OR

Manager, 19(2), pp. 12-18. Santa Fe: OR Manager Inc. OR Manager: Patient Safety. (2003). Frequent questions on marking the surgical site. OR Manager, 19(2)18-19. Patient Safety First Alert – Implementing a Correct site Surgery Policy and Procedure. (2003). AORN Journal. 76

(5), 785-788. 2.5 Surgical Pause/”Time Out” The World Health Organization (WHO) endorsed this procedure to reinforce safety practices and to foster better communication and teamwork between clinical disciplines. Surgical facilities shall have a policy regarding the requirement for the “surgical pause”. The perioperative Registered Nurse is responsible for: 2.5.1 Complying with the pause/time out policy. "Pausing" (following prepping and draping and before the incision is made) to verbally re-confirm: - correct patient; - surgical procedure(s); - correct surgeon; - correct operating room; - correct site(s); and - the administration of antibiotics if applicable.

Reduces risk of wrong site surgery.

2.5.2 Confirming (prior to incision being made) that all documentation agrees including:

- documentation of consent; - history and physical, service consults; - nursing assessment; - surgical schedule; and

- any discrepancies should be reported and resolved prior to surgical intervention. 2.5.3 Documenting the “pause” process.

Evidence the process was completed.


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BIBLIOGRAPHY

Canadian Patient Safety Institute. Surgical Safety Checklist & Scorecard: Canada, Version 1. Edmonton, AB: 2009 Jan 9. www.safesurgerysaveslives.ca 2.6 Surgical Counts The purpose is to protect the patient from the unintentional retention of a foreign body by accounting for any and every thing that could be left behind. PRACTICE

RATIONALE

Procedures, General Considerations 2.6.1 The health care facility surgical count

policy and procedure shall define: - the materials to be counted; - the times when the surgical count shall be performed; - actions to be followed for an incorrect surgical count; and - the documentation required.

The surgical count policy and procedure ensures standardization within the health care facility and is a legal document.

2.6.2 Instrument sets should be standardized within each facility.

Standardization assists in accuracy, efficiency, and continuity.

2.6.3 The count shall be the responsibility of the scrub personnel and the circulating perioperative Registered Nurse(s).

Perioperative nurses are accountable for the count.

2.6.4 The scrub personnel shall be aware of all counted items throughout the operative procedure and be involved in all parts of the count.

Consistent organization and tidiness of the sterile field reduces risk of error.

2.6.5 Counts shall be performed by two people, one of whom shall be a perioperative Registered Nurse. All items shall be visually observed and audibly counted concurrently by the scrub and circulating perioperative Registered Nurses.

Counts are a shared responsibility and both the scrub and circulating perioperative Registered Nurse are accountable.

2.6.6 All counts shall be conducted according to healthcare facility policy.

Healthcare facility policy will determine who initiates the count, i.e. scrub or circulating nurse.

2.6.7 All perioperative personnel involved in the count shall sign the count record.

2.6.8 If there is no scrub nurse, two perioperative personnel, (one of which must be a perioperative Registered Nurse) shall count


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PRACTICE

RATIONALE

together. If only one perioperative personnel are available, it must be a perioperative registered nurse who shall count with the surgeon. The perioperative Registered Nurse should print the surgeon’s name and/or follow facility policy.

2.6.9 A count of sponges, needles, suture reels,

blades and designated miscellaneous items shall be performed for all procedures, except for those cases clearly defined as superficial as per health care facility policy.

Examples of sharps includes scalpel blades, hypodermic needles, suture needles. Examples of designated miscellaneous items include, but not limited to: delicate instrument tip protectors; clip cartridges; ligaclip bars; vessel loops, clamps, inserts; umbilical and hernia tapes; ESU (cautery) pencils, blades, and scraper/scratch pads; wing nuts; screws; small endoscopic parts (i.e. trocar sealing caps, washers, O-rings, springs, caps); and any other small items in a surgical count that have the potential for being retained in a surgical wound.

2.6.10 Radiopaque materials should be used in surgery.

Radiopaque materials are more easily detected on x-ray if they are missing during the count.

2.6.11 Counts shall be done: - prior to commencement of surgery; - at the first layer of closure, depending

on the cavity entered ; - at the skin closure (instruments do not

require recounting at skin closure); - an additional count of sponges, sharps

and suture reels and designated miscellaneous items shall be done prior to closure of a cavity within a cavity, e.g., closure of the uterus during a Caesarean Section, and vaginal vault following hysterectomy;

- a full instrument count shall be completed if likelihood exists that an instrument could be retained in a surgical site or as per facility policy;

- a full count should be done at the time of permanent relief of the scrub and/or circulating perioperative Registered Nurse by the relief personnel; and

- during a changeover, when the situation does not allow visualization appropriate to the level of the count required, those items not visualized should be documented on the count sheet.

Additional areas requiring a full surgical count may be indicated by the surgeon and/or health care facility policy.


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PRACTICE

RATIONALE

2.6.12 The recommended sequence of surgical counts is: sponges, sharps, miscellaneous items and instruments.

Counts can be performed during the surgery at any time deemed necessary with minimal disruption of the surgical team.

2.6.13 Items should remain together until the initial count is done (e.g. sets/trays stay together & no setup can occur until count is complete).

A standard method of counting provides accuracy and consistency and reduces risk of errors.

2.6.14 Interruptions during a count should not occur. Once a count has been started, it should be completed. If an interruption occurs, the count shall be resumed at the end of the last recorded item.

This prevents items being missed from the count and assists in preventing commencement of case prior to the completion of the initial count.

2.6.15 All items shall be recorded as they are counted, before proceeding to the next item.

Assists in reducing errors.

2.6.16 Articles given to the scrub personnel during the procedure shall be immediately counted, recorded, and initialed on the count sheet.

Keeps an accurate account of items on the surgical field.

2.6.17 Once a count is initiated, items shall not be removed from the theatre, including garbage and laundry, until the final count is complete.

Confinement allows for complete checking should a counting error occur.

2.6.18 Needles that have fallen to the floor or have been removed from the sterile field shall be clearly displayed for both the scrub and circulating perioperative Registered Nurses to count.

2.6.19 At closure, items shall be counted according to the protocol established by the health care facility. The recommended sequence of surgical counts is: sponges, sharps, miscellaneous items and instruments starting from the sterile field to the mayo stand, to back table and then any item removed from the sterile field.

2.6.20 If the care of the patient requires more than one surgical instrument set-up, a separate count sheet shall be used for each set-up (e.g. Vaginal Repair and Abdominal Hysterectomy). The extent of the count for each set-up will default to the most extensive count performed.

A standard method of counting provides accuracy and consistency. Consistent counting sequence may assist in decreasing confusion and error.


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Items shall not be exchanged from one set-

up to another. The final count shall not be confirmed with

the surgeon until the last operative procedure is completed (e.g. multiple procedures with multiple tables for one surgical case). When performing bilateral procedures counts shall be completed at each incision closure. (e.g. Bilateral Knee Arthroplasty)

2.6.21 Results of all counts shall be announced audibly to the surgeon. The circulating perioperative Registered Nurse shall receive verbal acknowledgement from the surgeon.

Aids in obtaining an accurate count for both set-ups.Individual table/procedure counts may be relayed but the final surgical count is not confirmed until all procedure counts have been completed.

2.6.22 If an incision is re-opened after the final count, the closure count shall be repeated and documented as re-closure.

The surgeon shall be notified of the count outcome. An interruption of the closure may be required if the count is incorrect.

2.6.23 In a procedure where the necessity of a complete count is questionable, the count shall be done in its entirety prior to commencement of surgery. The count required at closure will be determined by the cavities entered.

2.6.24 In an emergency when an initial count is not performed, the scrub nurse shall attempt to account for items. The circulating perioperative Registered Nurse shall: - document on the perioperative record

the reason an initial count was not performed and the action taken at completion of the procedure;

- notify the appropriate management; - arrange for an x-ray at completion of

the procedure and prior to the patient leaving the operating theatre, if patient status permits;

- if the surgeon refuses the x-ray, document on the clinical record according to the health care facility policy; and

- complete an incident report.

If a cavity is not entered, a full count may not be required. The health record must reflect what occurred including the count results and action taken.


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Incorrect Counts 2.6.25 If a miscount occurs:

- notify the surgeon; - recount; - search the floor, garbage, laundry,

drapes; - notify the appropriate management; - in consultation with the surgeon

arrange for an x-ray at completion of the procedure and prior to the patient leaving the operating theatre, if patient status permits;

- document the appropriate x-ray results if known. If the surgeon refuses the x-ray, document on the clinical record according to the health care facility policy;

- complete an incident report according to the health care facility policy; and

- record the incorrect count on the count sheet, and document actions taken on the clinical record according to the health care facility policy.

2.6.26 If an item is inadvertently left in the patient, the surgeon assumes the responsibility of retrieval/non-retrieval and the circulating perioperative Registered Nurse will document this occurrence.

Documentation of Surgical Counts 2.6.27 The perioperative count record shall be included on the patient’s permanent record.

2.6.28 All personnel involved in the count shall sign the perioperative count record. Signatures identifying initials shall be recorded.

The perioperative circulating Registered Nurse is responsible to confirm that all personnel involved in the surgical count have signed the perioperative count record or appropriate document according to the health care facility policy.

The perioperative count record is a legal document and part of the patient’s health record.

2.6.29 When sterile items are added to the surgical field, during a procedure, the circulating

Documentation of nursing activities related to the patient’s perioperative care provides an accurate


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nurse shall document the items. A recommended practice for documenting includes writing the symbol “+”, the number, and the initials above and to the right of the number,

i.e. +5 JD

When large quantities sterile items (i.e. sponges/needles) are removed from (counted off of) the surgical field, during a procedure, the circulating nurse shall document the items. A recommended practice for documenting includes circling the number, and initialing the bottom right corner of the entry,

i.e.

+ 5 JD

picture of the nursing care administered and the outcomes of the care delivered.

2.6.30 Items being counted in a final count should be checked off, ticked off, or totaled in a column designated for the final count. Each and every item that has been presented to the sterile field shall be included in the final count. Documenting in a manner that will not obliterate the clarity of each number. The number of times items are counted shall be clearly identifiable on the record.

2.6.31 Health care facility policy shall be followed for incorrect entries on the client record.

2.6.32 Routine audits to determine compliance with count policy and procedure should occur.

White-out, eraser, or cross-outs are not legally acceptable. A single line through an entry with documenter’s initials identifies an error. All errors must remain visible or retrievable and do not obliterate or change another professional’s documentation. (Canadian Nurses Protective Society, 2007; College & Association of Registered Nurses of Alberta, 2006; Hamlin, et al, 2009; Perry & Potter, 2006) Audits are a component of quality assurance and may identify deficiencies in policy and/or procedure.

Sponges 2.6.33 Sponges used for surgery shall be

radiopaque and not cut during the procedure. Both the scrub and circulating perioperative Registered Nurse shall see the

Periodically in manufacturing, the radiopaque thread/tag is missed. Cutting of sponges will alter the counts and increase the potential for loss of a sponge portion.


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radiopaque marker on each sponge during counts.

2.6.34 Sponges shall be separated and counted

audibly twice (x2) at initial count and as dispensed. Count each dispensed package of sponges twice before counting the next package. Laparotomy sponges with tapes/tags shall be pull-tested to verify security.

2.6.35 Packages containing incorrect numbers of sponges shall be contained/bagged, labeled, isolated from the rest of the sponges and/or removed from the operating room as per facility policy.

2.6.36 When large quantities sterile items (i.e.

sponges/needles) are removed from (counted off of) the surgical field, during a procedure, the circulating perioperative Registered Nurse must document the items removed. A recommended practice is circling the number, and initialing the bottom right corner of the entry,

i.e. 5 MS

Errors in manufacturers packaging can occur. Confirming the correct number of sponges in the package reduces the risk of error in subsequent sponge counts. Removal of the entire package from the sterile field and/or operating room helps avoid errors in subsequent counts.

2.6.37 Sponges documented on the count sheet shall remain in the theatre until the final count is complete.

2.6.38 Radiopaque sponges shall not be used for gauze dressings. Gauze dressings shall not be added to the sterile field until the final count is complete.

2.6.39 Sponges without radiopaque marker used

for prep sets shall be discarded from the sterile field prior to the incision being made.

Tapes/tags may not be radiopaque. Radiopaque sponges, if used for gauze dressings/prep may cause confusion with the count.

2.6.40 If towels are used to protect the viscera or as packing, they shall be single-use, radiopaque, counted and shall be documented. The scrub personnel shall audibly notify the circulating perioperative Registered Nurse that a towel has been inserted. This shall be documented to serve as a safeguard that the towel has been

Surgical towels have been the subject of retained surgical item law suits.


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removed prior to closing. 2.6.41 Small sponges such as peanuts, pushers,

dissectors, kitners, gauze, etc., shall be attached to an instrument when used in a body cavity.

2.6.42 All counted sponges intentionally left in the patient as packing at the end of surgery shall be radiopaque. The type and number of sponges shall be documented.

This shall be documented as an incomplete count with number of sponges remaining in surgical site.

2.6.43 Patients returning to the operating room

with radiopaque packing insitu: - packing sponges will be removed by the

surgeon, removed from the sterile field, bagged and identified as packing material;

- document the type and number of sponges removed from the wound on the intraoperative record; and

- ff the surgical site is being permanently closed i.e. all packing material removed and no new packing material added an x-ray should be completed when patient is prepared to leave the operating room

Reduces risk of loss in the surgical site. This reduces confusion on the number of sponges used in the surgical procedure Increased incidents of incorrect counts occur where sponges were used as packing and/or for retraction. (OR Manager, 2003, p. 11) Identifies risk of inadvertent packing being retained.

Sharps

2.6.44 Suture needles should be counted according to the number marked on the outer package and verified by the scrub and circulating perioperative Registered Nurses when the package is opened.

Initial counts establish a baseline for subsequent counts.

2.6.45 Needles shall be counted initially, at time of dispensing, and required closure counts.

Opening all packages during initial needle count is not recommended and will result in needles being exposed during the entire surgical procedure. This will create additional opportunity for lost or retained needles during the procedure.

2.6.46 Multi-packaged needles shall be verified by the scrub and circulating perioperative Registered Nurses as each package is opened for use.

There may be a discrepancy between the number of needles stated on the package and the actual number in the package.

2.6.47 All needles on the set-up shall be mounted Reduces risk of lost needles and needle stick


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on a needle driver, sealed in packages, or confined on a needle counter.

injuries.

2.6.48 All segments of broken needles shall be accounted for.

Reduces risk of unintentional retention of a foreign body.

2.6.49 Needles should be handed to the surgeon on an exchange basis using a hands free technique. If the surgical procedure does not allow for needle exchange, the scrub person should keep account of all needles on the field and retrieve them as soon as possible.

Assists the scrub nurse in accounting for needles and is a safety measure.

2.6.50 If a glove is punctured with a needle, the glove, needle, and needle driver shall be removed from the sterile field. Blood should be removed from the hand before regloving. If injury has occurred, follow the health care facility's Occupational Health and Safety protocols.

Needle stick injury may subject the patient and the health care team member to blood borne infection.

2.6.51 Surgical team members should use a hands free technique/Neutral Zone whenever possible instead of passing needles and other sharp items.

Studies show that most sharps injuries occur when suture needles or sharps are passed between perioperative team members.

Instruments

2.6.52 Instrument sets shall be counted, if appropriate for the procedure, by the scrub person and circulating perioperative Registered Nurse immediately before the procedure.

Pre-counting of instrument sets (before sterilization) is not to be considered the initial count before the surgical procedure.

The scrub and the circulating nurses are accountable for their supplies. A count performed outside the operating room that is considered an initial count increases the number of variables that can contribute to an inaccurate count and unnecessarily extends the responsibility to personnel both involved and not involved in direct patient care.

2.6.53 Instruments should be inspected to ensure that all parts are present and functional. Instruments that are broken or disassembled during the procedure shall be accounted for in their entirety.

Facilitates efficiency and may prevent patient injury from retained foreign body.

2.6.54 Each health care facility policy shall state which instruments may be counted in a category (e.g., scissors are counted together).

Facilitates consistency and reduction in counting errors.

2.6.55 All instruments having component parts


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shall be counted in a consistent manner according to the health care facility policy.

2.6.56 Instruments shall not be removed from the

theatre prior to the final count.

Minimally Invasive Surgery

2.6.57 The sponges, needles, suture reels, blades, designated miscellaneous items, and instruments (includes endoscopic and non-endoscopic instruments), shall be counted initially. Hospital policy should direct the counting of individual instrument pieces or assembled instruments.

Reduces risk of inadvertent retained foreign body.

2.6.58 If the procedure remains endoscopic (i.e. does not convert to an open procedure) only a final count of sponges, needles, suture reels, blades, and designated miscellaneous items is required.

2.6.59 If the care of the patient requires more than

one surgical instrument set-up, a separate count sheet shall be used for each set-up (i.e. Laparoscopic assisted vaginal hysterectomy). The extent of the

count for each set-up will default to the most extensive count performed.

Items shall not be exchanged from one set- up to another.

2.6.60 The final count shall not be confirmed with the surgeon until the last operative procedure is completed (e.g. multiple procedures with multiple tables for one surgical case).

REFERENCES

Canadian Nurses Protective Society. (2007). InfoLAW Quality Documentation: Your Best Defence. Ottawa; Author. College & Association of Registered Nurses of Alberta. (2006). Documentation Guidelines for Registered Nurses. Edmonton; Author. Hamlin, Lois, Richardson-Tench, & Davies Menna, (2009). Perioperative nursing an introductory text. Sydney: Elsevier/Mosby.


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OR Manager. (2003). Patient safety: projects for improving safety of counts in the OR. OR Manager, 19(3), 11-12. Perry, A & Potter, P. (2006). Clinical Nursing Skills and Techniques. (6th ed.). St. Louis: Elsevier Mosby.

BIBLIOGRAPHY

Accreditation Canada. Formerly known as CCHSA. www.accreditation-canada.ca Association of PeriOperative Registered Nurses. (2010). Recommended practices for sponge, sharp, and instrument

counts. Perioperative Standard and Recommended Practices. Denver: Author. Downey, C. (2007). Counting as caring. Canadian Operating Room Nursing Journal, 25 (3), 6,8,10,11,13. Gawande, A., Studdert, D., Orav, E., et. al. (2003). Risk factors for retained instruments and sponges after surgery.

New England Journal of Medicine, 348, 229-235. Gibbs, Vera et al, (2005). The Prevention of Retained Foreign bodies After Surgery. Bulletin of American College of Surgeons. 90 (10). HealthStream, (2007). Ensuring Patient Safety During Laparascopic Procedures Study Guide. Denver: Author. HealthStream, (2006). Hand-Assisted Laparascopic colectomy: a minimally invasive Approach, clinical Study Guide. Denver: Author. Holm R & Bakewell, S (2008). Performing Surgical Counts. AORN Journal, 87 (2), 329-332. International Federation of Preoperative nurses (IFPN), (2006). Guideline 1002 for Surgical Counts-sponges, Sharps

and Instruments, IFPN accessed April 12, 2009 from http://www.ifpn.org.uk Lincourt, E et al, (2007). Retained foreign bodies after surgery. Journal of surgical research, 138 (2),170-174. McLeod, R.S. & Bohnen (2004). Canadian association of general surgeons’ evidence based reviews in surgery 9

risk factors for retained foreign bodies after surgery. Canadian Journal of Surgery , 47(February), 57-59 OR Manager. (2003). Patient safety: auditing and improving the sponge count process. 19(3), 13-14. OR Manager. (2003). Patient safety: study offers evidence on items left behind during surgical cases. OR Manager.

19(3), 1-10. Pare, Judy, (2006). Laparoscopic Radical prostatectomy: a Less Invasive Approach, Canadian Operating Room Nurses Journal, 24(3). Phillips, N.M. (2007). Berry & Kohn’s operating room technique. (11th ed.). St. Louis: Mosby. Porteous, J. (2004). Surgical counts can be risky business! Canadian Operating Room Nursing Journal, 22 (4), 6-12. Rothrock, J. (2007). Alexander’s care of the patient in surgery. (13th ed.). Toronto: Mosby. Shack, Carol, (2007). Laparoscopic Bowel Surgery. Canadian Operating Room Nurses Journal, 25 (2). Spry, Cynthia, (2008). Essentials of Perioperative Nursing (4th ed.). Toronto: Bartlett & Jones.


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2.7. Surgical Positions The perioperative Registered Nurse is responsible for: PRACTICE

RATIONALE

2.7.1 Applying knowledge of the various surgical positions and the impact of the positions on the circulatory, respiratory, musculoskeletal and neurological body systems; and being a patient advocate throughout the positioning process.

The position should be consistent with proper anatomical alignment and physiological functioning in order to promote the safety and comfort of the patient during surgery. Under general anesthesia, patients are unable to indicate when there is a problem.

2.7.2 Assessing the patient's positioning needs prior to transferring the patient to the OR bed. The assessment shall include patient and intra-operative factors.

Patient factors include, but are not limited

to: - age, height and weight; - skin condition; - nutritional status; - pre-existing conditions (vascular,

respiratory, circulatory, neurological, and immunocompromised); and

- physical/mobility limits (i.e., range of motion, implants, prostheses, etc).

Intra-operative factors include, but are not

limited to: - type of anesthesia; - length of surgery; and - position required.

To promote patient safety and comfort.

2.7.3 Confirming adequate staff are available and trained for transferring patients to and from the OR bed. The OR bed and stretcher/bed/ wheelchair shall be locked in place. Transfer devices are recommended for patients with a mobility deficit including but not limited to patients post general anesthesia;

The circulating perioperative Registered Nurse monitors safety of the patient at all times. Transfer devices assist in protecting staff and patients from injury.

2.7.4 Confirming that the patient is not left unattended on the OR bed;

2.7.5 Confirming that a safety strap is applied

prior to induction;

Protection from potential injury is essential. Safety measures help prevent injury.

2.7.6 Confirming that arm boards are secure on


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the OR bed prior to induction. Each arm board should have a security device for hand/wrist to prevent the arm from falling off the arm board during the procedure. Ulnar nerve padding shall be used under the arm before the security device is employed; - the arm board shall not be extended

greater than a 90º angle. - The height of the arm board mattress

should align with the OR bed mattress;

Padding the elbow reduces the risk of ulnar nerve damage. Additional padding may not be required; follow bed manufactures’ recommendations. Brachial plexus damage may result from hyperextension of the arm over 90º.

2.7.7 Being aware of the function and use of the OR bed and accessories. Following equipment manufacturer’s instructions. Selection criteria for positioning equipment and devices include but are not limited to: - availability in a variety of appropriate

shapes and sizes; - ability to allow normal capillary

interface pressure; - resistance to moisture and

microorganisms; - fire resistance; - non-allergenic to the patient; - ease of use; - durable material and design; - radiolucency; - easily cleaned and disinfected (if not

disposable); - easily stored, handled, and retrieved;

and - cost effectiveness.

Properly functioning equipment and devices contribute to patient safety and assist in providing adequate exposure of the surgical site.

2.7.8 Having available the appropriate OR table and positioning equipment and devices which are in proper working order prior to positioning the patient for surgery;

Firm and stable devices help distribute pressure evenly and decrease the potential for injury. Patient safety may be compromised if appropriate equipment not used.

2.7.9 Collaborating with the anesthesiologist and the surgeon when positioning the patient for surgery; 2.7.10 Confirming safety precautions related to

positioning in the supine position have been implemented. Measures include but not limited to: - elbows are padded and placed either

comfortably at the side with the palm facing the thigh and secured using a sheet or an arm support; or on an arm

Surgical positioning of the patient is a shared responsibility. Maintaining the patient's correct body alignment and supporting extremities and joints decreases the potential for injury during transfer and positioning. (AORN, 2010)


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board and secured; and - feet/legs are not crossed

2.7.11 Confirming safety precautions related to positioning the patient in lithotomy position are implemented. Measures include but not limited to: - Stirrups shall be securely attached to the

bed at a uniform height; - legs shall be raised/lowered

simultaneously in a slow controlled manner (with 2 people); padding shall be applied to any part of the leg or foot which comes in contact with the stirrups. Legs should not come in contact with the post of stirrups;

- verify position of hands/fingers as foot of OR bed is manipulated both at the beginning and end of the procedure;

- scrubbed personnel shall not lean on the patients legs/thighs; and

- hips shall not extend beyond the end of the OR bed.

2.7.12 Confirming safety precautions related to

positioning the patient in prone position are implemented. Measures include but not limited to:

- sufficient staff shall be available to safely turn a patient into the prone position allowing cervical and general body alignment to be maintained;

- padded head rest shall be used; - arms shall be tucked at the side or

placed on arm boards(less than 90 degrees);

- prone positioning devices(i.e. bolsters) shall allow for chest movement and not apply pressure to the abdomen; and

- feet shall be supported so the toes can hang freely.


positioning the patient in lateral position are implemented. Measures include but not limited to:

- sufficient staff shall be available to safely turn a patient into the lateral position allowing general body alignment to be maintained;

- anesthesia controls the patient’s head

This prevents circulatory impairment that could result in pressure sores or nerve damage Prevents muscle strain. Maintains hemodynamic status. Injury to the peroneal nerve can occur. Fingers can become pinched by the hinged section of the OR bed during movement of the bottom section of the bed. Avoids muscle strain. Reduces risk of injury for both patient and staff. Reduces direct pressure on the eyes. Allows access for airway management. Respiratory function may be affected. Maintains alignment of cervical and thoracic spine.


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and neck as the patient is turned maintaining the airway;

- the head is placed on a pillow or donut positioning device;

- for kidney procedures, the iliac crest is positioned just below the break in the

- OR bed; - the lower leg is flexed with knee

padded; - the upper leg is straight and placed on

pillow(s); - the upper arm should be placed on an

arm board or pillows, and secured; depending on the procedure being done,

- the lower shoulder should be slightly forward, with a roll just posterior to axilla; and

- positioning devices such as vac mattresses, peg boards, etc. should be padded wherever they come in contact with the patient.

2.7.14 Confirming safety precautions related to positioning the patient in Trendelenburg position are implemented. Measures include but not limited to: - knees should be positioned over the

break in the OR bed; - shoulder braces should only be used if

absolutely necessary, and must be well padded if used;

- after positioning, ensure there is no pressure on the feet by the mayo or over bed table; and

- movement into and out of trendelenburg should be done slowly to allow respiratory and circulatory systems to adjust to changes.


positioning the patient in reverse Trendelenburg position are implemented. Measures include but not limited to: - padded foot board may be used; and - sequential compression

stockings/devices may be used

2.7.16 Confirming safety precautions related to positioning the patient in sitting or semi-sitting position are implemented. Measures include but not limited to:

Protects peroneal nerve from damage. Maintains alignment Reduces pressure on the brachial plexus and can facilitate chest expansion. The foot of the bed may be adjusted to maintain position. High risk of injury to brachial plexus. Trendelenburg position increases intrathoracic and intracranial pressure. Reduces venous stasis.


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- arms should always be supported; - all pressure points shall be padded with

special attention to the ischial tuberosities and sacrum;

- the patient shall be secured to the table which is providing support to the upper torso with a strap or tape;

- the head shall be supported with a head rest such as a cranial headrest; and

- sequential compression devices should be used.

2.7.17 Implementing measures, which reduce the

risk of injury to the patient or the healthcare team when positioning morbidly obese patients. Measures include but not limited to: - confirming that positioning equipment

as well as the OR table is designed to be safely used with morbidly obese patients. Table extensions may be required depending on the patient’s size. Thicker mattress may be needed to provide adequate support, extra wide, extra long safety straps;

- all OR tables should be labeled with maximum weight restrictions; and

- an adequate number of staff to safely position patient,

These points are supporting the weight of upper body. Maintains alignment and eliminates movement during surgery. Reduces venous stasis.

2.7.18 Limiting exposure of patient's body during positioning.

Maintaining the dignity and privacy of the patient is important, and covering also assists in preventing loss of body temperature.

2.7.19 In collaboration with anesthesiologist and surgeon, evaluate the patient's body alignment and tissue integrity after positioning. The evaluation should include but not be limited to the following systems:

- Respiratory; - Circulatory; - Neurological; - Musculoskeletal; and - Integumentary.

After repositioning or any movement of the

patient, OR bed, or devices the patient should be re-assessed for body alignment and assessment of pressure points by the surgical team.

Respiratory function can be decreased by mechanical restriction of the rib cage. Circulatory function is influenced by anesthetic agents and surgical techniques that may result in vasodilatation, hypertension, decreased cardiac output, and inhibition of normal compensatory mechanisms. Nerve and muscle trauma result from stretching or compression when upper extremities are abducted at greater than 90 degrees to the body, hips are placed in excessive external rotation, and/or the head and neck is hyper-flexed or hyper-extended. Skin injury is a function of unrelieved pressure, duration of the pressure, and the location of the pressure on the body surface. Both high pressure for a short duration and low pressure for extended duration are risk factors. Other extrinsic factors for skin injury are shear forces and friction. (AORN, 2010, p. 343)


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2.7.20 Documentation including but not limited to:

- preoperative assessment; - type of position and any changes of

position; - type and location of

positioning/padding devices; - postoperative assessment; and - healthcare team members involved in

positioning the patient. 2.7.21 Actively participating in the healthcare

facility’s, Falls Prevention program.

Documentation provides an accurate picture of the patient's status and surgical position during surgery. Awareness reduces risk.

REFERENCES Association of PeriOperative Registered Nurses. (2010). Recommended practices for positioning the patient in the

perioperative practice setting. Perioperative Standards and Recommended Practices. Denver: Author

BIBLIOGRAPHY Goldman, Maxine A, (2008). Pocket Guide to the Operating Room (3rd ed.). Philadelphia: FA Davis. Goodman, Terri (2006). Positioning a Patient safety Initiative Study guide for Nurses. Aurora: Pfiedler Enterprises Hamlin, Lois, Richardson-Tench, & Davies Menna, (2009). Perioperative nursing an introductory text. Sydney: Elsevier/Mosby. Heizenroth, P. (2003). Positioning the patient for surgery. In Rothrock, J. (2003). Alexander’s care of the patient in

surgery. (12th ed.). Toronto: Mosby. Lord, Ellen V, (2005). Patient Positioning Competency Assessment Module, Denver: Competency & Credentialing Institute (CCI). Macapagal, M. (2004). Protect your patient-It’s never too late to reposition. AORN Journal, 79(5), 1017-1018. O’Connel, M. (2006). Positioning impact on the surgical patient. Nursing Clinics of North America, 41, 173-192. Phillips, N.M. (2007). Berry & Kohn’s operating room technique. (11th ed.). St. Louis: Mosby. Power, H. (2002). Patient positioning outcomes for women undergoing gynaecological surgeries. Canadian

Operating Room Nursing Journal, 20(3), 7-30. Rothrock, Jane C (2007). Alexander’s Care of the Patient in Surgery. (13th ed.). Toronto: Mosby. Spry, Cynthia, (2008). Essentials of Perioperative Nursing (4th ed.). Toronto: Bartlett & Jones.


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St-Arnaud, Danielle & Paquin, Marie-Josee, (2008). Safe Positioning for Neurosurgical Patients. AORN Journal, 87 (6), 1156- 1172. Walton-Geer, Patina S, (2009). Prevention of Pressure Ulcers in the Surgical Patient. AORN Journal, 89 (3). 2.8 Visitors to the Surgical Suite All visitors should be authorized in advance. PRACTICE RATIONALE

2.8.1 The surgical suite management shall

collaborate with risk management/delegate to develop an appropriate definition of a visitor and/or observer. Visitors/observers may include but are not limited to the following: - health care industry representatives; - health care students; - visiting health care providers; - media; - law enforcement; and - family members.

2.8.2 The perioperative Registered Nurse shall confirm that visitors/observers to the surgical suite agree not to interfere with the well-being, comfort, privacy, or confidentiality of patients and families.

2.8.3 Patients/designate should give consent to have a visitor/observer present.

2.8.4 Maximum recommended number of visitors/observers in an occupied theatre should be determined by surgical suite management in collaboration with infection control, taking into consideration the following: - type of surgical procedure; - size of theatre; - air handling capability; - type of visitor; and - purpose of visitor/observer.

2.8.5 All Visitors/External contractors must be provided with the necessary theatre attire and understand how it is worn. Visitors/External contractors should be clearly identified as such (i.e.: with a visitor nametag). (NATN, 2004, p. 80)

2.8.6 A visitor log should be kept to: Provides a mechanism to track those in contact with


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- monitor the name of the visitor and designation;

- theatre attended; - intent of the visit (i.e. education,

equipment instruction); - duration of the visit; and - authorization of visit.

the patient. Documentation is necessary for the duration of the visit in case of a health care facility emergency/disaster.

2.8.7 Health care industry representatives may act only as a resource regarding the representative product, and may not scrub or actively participate in patient care. (NATN, 2004, p. 81)

Health care industry representatives can provide technical assistance that expedites the procedure and facilitates the intended outcome for the patient.

REFERENCES National Association of Theatre Nurses (NATN). (2004). Visitors/External Contractors. Standards and

Recommendations for Safe Perioperative Practice Harrogate: UK.

BIBLIOGRAPHY

Association of PeriOperative Registered Nurses (2010). Guidance Statement Role of the Health care Industry Representative in the Perioperative Setting. Perioperative Standards and Recommended Practices. Denver: Author, 657-659

Phillips, N.M. (2007). Berry & Kohn’s operating room technique (11th ed.). St. Louis: Mosby. CMAJ. (2007). Traffic Controls, News, Health Authority Bans Physician Shadowing. CMAJ, 77 (1), 1339-1340. 2.9 Gathering Medicolegal Evidence In The Surgical Suite Patient safety and expedition of the case is the first priority. The following information is to assist the perioperative Registered Nurse with preserving forensic evidence. PRACTICE

RATIONALE

The perioperative Registered Nurse is responsible for: 2.9.1 Observing and documenting the patient’s

appearance and behavior on arrival to the theatre.

2.9.2 Recording any comments made by the patient’s family or persons accompanying the patient.

2.9.3 Recording patient comments as quotes. 2.9.4 Documenting all body marks accurately to

help preserve evidence.


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2.9.5 Describing blood stain patterns and bloody

fingerprints that are visible on the patient’s body or clothing.

2.9.6 Collecting evidence (see Appendix E) in all suspicious or unclear cases.

2.9.7 Confirming that the police have the patient’s or substitute decision-maker’s consent for disclosure of information or that the officer has a warrant for the release of information.

There must be evidence of consent or a warrant before information/evidence is given to the police.

2.9.8 Maintaining patient confidentiality by not releasing patient information over the phone.

2.9.9 Obtaining a warrant for seizure (verbal or written) from the coroner. Documenting the verbal warrant for seizure or attaching the written warrant for seizure to the chart.

This warrant allows the police to take evidence including the patient’s chart.

2.9.10 Establishing a chain of custody and documenting each person involved with custody of evidence.

For results of sample testing to be relied on by the court, the chain of events between taking the sample from the patient and presenting the test results in court must be proven and unbroken. Throughout the process, proper handling and labeling of samples is essential.

2.9.11 Establishing possession and proof of the integrity (clearly labeled identification of specimens) of evidence obtained; and

2.9.12 Obtaining a business card, badge number or name from the investigating officer and placing it on the chart.

Legal authorities decide whether to retain or discard evidence.

Collection of Evidence: (see Appendix E)

The perioperative Registered Nurse is responsible for: 2.9.13 Wearing gloves at all times. Changing

gloves, if possible, for handling each piece of evidence.

2.9.14 Preserving the integrity of the metal

evidence by not using metal instruments.

Wearing gloves avoids the presence of extra fingerprints on the evidence. Changing gloves between each piece of evidence avoids forensic cross contamination.

Metal can mark or damage metal evidence.

2.9.15 Identifying the evidence from each wound separately if two or more wounds.


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2.9.16 If not taken immediately, maintaining

evidence in a locked cupboard until picked up by the police or the coroner; and

2.9.17 Contacting the police/coroner for directions and documenting if evidence is not picked up within one week.

Death of a Victim or Suspected Perpetrator The perioperative Registered Nurse is responsible for: 2.9.18 Confirming the body is not moved unless

directed to by the coroner.

2.9.19 Telephoning the coroner for directions if the body must be moved. Keeping the body in a secure area until transported to the morgue.

2.9.20 Obtaining directions from the coroner regarding visitation.

2.9.21 Observing, monitoring and documenting any visitation. Visitation is limited to viewing only, but touching as per direction of the coroner may be allowed. Do not leave the family/visitors alone with the patient.

The family/person accompanying the patient may be the perpetrator.

Preparation of the Body: The perioperative Registered Nurse is responsible for: 2.9.22 Placing a brown paper bag over each hand.

Plastic bags cause condensation and trace evidence

may be lost. 2.9.23 Positioning the hands at the side, do not tie.

2.9.24 Marking with a small “X” attempted IV access sites and documenting same.

It is easier for the pathologist to distinguish between medical intervention and criminal evidence.

2.9.25 Retaining all evidence for the police. Do not clean blood stained areas. If cleaned prior to death, do not dispose of items used, i.e., sponges.

Documentation The perioperative Registered Nurse is responsible for: 2.9.26 Documenting any information pertaining to

the injuries:


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- wound; - location; - size; and

- evidence given to the chain of custody; - the chain of custody; - how evidence was preserved (see

Appendix E); and - all interactions with police,

including what has been released and the authority by which it was released.

This information will be invaluable in defense of a subsequent complaint for breach of confidentiality.

REFERENCE

Easter, C.R., & Muro, G.A. (1994) Clinical forensics for perioperative nurses. AORN Journal, 60(4), 585-591. Porteous, J. (2005) Don’t tip the scales! Care for patients involved in a police investigation. Canadian Operating

Room Nursing Journal, 23(3), 12-14, 16.

BIBLIOGRAPHY Association of PeriOperative Registered Nurses. (2010). Recommended practices for the care and handling of

specimens in the perioperative environment. Perioperative Standards and Recommended Practices. Denver: AORN.

Fatality Investigations Act. Nova Scotia Government (2004) Nova Scotia Legislature Coroner’s Act. Ontario Government reconfirmed. (2002, April). Ministry of Public Safety and Security. Ottawa. Wick, J. (2000). Don’t destroy the evidence! AORN Journal, 72 (5). 807-827.


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APPENDIX E Guidelines for Collection of Evidence: Label all specimens with patient identification and the following information:

Specimen Examples Preservation Methods Rationale Body fluid Blood, urine, gastric

contents, seminal fluid

� collect large amounts of fluid in dry tubes or dry specimen containers.

� collect fluids around the wounds or wet body fluid stains with a swab;

� absorb stain onto clean cotton swab;

� allow swab to air dry; � place swab in dry container.

Patient may have swallowed containers (e.g. balloons) of drugs. Leakage of a lethal substance could be the cause of death. Body fluids may be used to associate the crime victim and suspected perpetrator or eliminate suspected perpetrator from consideration.

Hair, fibres Loose hair, strands, shaved hair from around wound sites, carpet remnants, strings

� collect and place in separate dry container.

Hair and fibres may be transferred between the victim and the crime scene.

Debris Glass, paint chips, wood splinters, animal teeth

� collect and place in separate dry containers.

May connect the victim or suspected perpetrator with the crime scene.

Foreign Objects Bullets, fragments, pellets, knives

� handle as little as possible. � remove with rubber-tipped

forceps or latex gloves; � rinse with water; � when rinsing a bullet, be

aware of and collect any foreign material attached, such as fabric, etc.

� place in a cushioned box or zippered plastic bag.

Excess handling may alter the specimen. Rinsing off blood/tissue prevents microscopic markings from being destroyed. Soft packaging protects the specimen integrity.

Fabric, clothing All garments, pieces of garments, footwear, bed linen - home and hospital.

� remove carefully as intact as possible;

� avoid cutting through holes, tears or rips.

� hang to air dry, if possible and place paper under it.

� place on a flat piece of paper; � insert paper between the

layers of clothing; � roll or leave in a flat position; � place each article in a separate

bag; � include all linen from

transporting device and OR bed.

Minimizing the number of pieces facilitates reconstruction. Shoes may bear imprints of gas/brake pedals, which may assist in accident reconstruction. Close examination by experts of clothing tears and gunshot wound residue patterns provides information about firearm distance and direction of a bullet or other assault instrument. Blood/body fluid on clothing deteriorates if not dried. Bacterial/fungal growth increase when evidence is stored in a closed, plastic bag.

Tissue, bone Bone flap � collect and place in a separate dry container.

Facilitates reconstruction, i.e., blunt trauma to the head. Bone flap could assist in the identification of the weapon.

(Easter & Muro, 1994)


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2.10. Specimen Management PRACTICE

RATIONALE

2.10.1 Surgical specimens shall be saved unless designated for discard by provincial legislation, and/or health care facility policy. Surgeons/Registered Nurses may not override this legislation and policy.

The accurate and efficient care of specimens is essential in assisting the surgeon, pathologist, and laboratories to establish an accurate diagnosis and for future treatment of the patient.

2.10.2 The circulating perioperative Registered Nurse shall be prepared to respond to a request for specimen analysis throughout the procedure.

2.10.3 The scrub perioperative Registered Nurse shall preserve all specimens in the state received and assure that sterility of the specimen is preserved, when required.

2.10.4 The perioperative Registered Nurse shall verbally confirm with the surgeon the identity of the specimen and the testing required.

2.10.5 The perioperative Registered nurse shall

accurately document information on the specimen label, including: - two unique patient identifiers(i.e.

patient name and hospital number), - specimen type; - specimen site; and - current date and time. (AORN, 2010)

2.10.6 The circulating perioperative Registered Nurse shall add appropriate fixative/preservatives in consultation with the surgeon and/or pathologist. Specimens requiring formalin should be placed in containers as soon as possible.

Compliance with lab protocol is essential for proper care and handling of specimens. Staff should be aware that formaldehyde is a potent allergen, mutagen, and carcinogen. (Gruendemann & Mangum, 2001, p. 294)

2.10.7 Action should be taken to prevent drying-out of specimens. Specimens and cultures should be handed off the sterile field as soon as they are taken, and the surgeon has given consent.

This prevents inadvertent discard of specimen during or at the end of the procedure. (Gruendemann & Mangum, 2001, p. 293)

2.10.8 During special testing or research projects, the appropriate health care facility protocol should be followed (i.e., special consent).

2.10.9 Tissue and calculi should not be given to patients.

Specimens may require analysis and present a contamination risk.


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2.10.10 When laboratory personnel are in the theatre, the circulating perioperative Registered Nurse should: - assure the dress code is followed; - prevent unnecessary materials from

entering the theatre; - provide supplies and forms; and - prevent counted instruments or sponges

from leaving the theatre.

Removed items may interfere with the count.

2.10.11 The circulating perioperative Registered Nurse in preparing specimen(s) for the laboratory shall: - verify specimen identity with the scrub

nurse; - provide a separate container for each

specimen, if required; - prevent contamination of the outside of

the container; - use a hospital grade disinfectant to

remove contaminants from the outside of the container; (Gruendemann & Mangum, 2001, p. 294)

- sequentially number the specimens; - confirm that the label contains the

required information, including: -patient name; -identification (ID) number; -identity of specimen; -side if appropriate; -date; -any times as required; and -initials of person completing label. - after putting specimen in container confirm that the patient's name and identification (ID) number on the specimen label(s) match those on the requisition and operative nursing record; - protect the requisition form from

contamination; - wear gloves when handling specimens;

and - arrange transport of the specimen(s) to

the appropriate location.

Care in handling of specimens will: - prevent specimen contamination; - avoid cross-contamination; - protection of individual (self); and - avoid mislabeling or loss of specimen(s). Incorrectly, labeled specimens could result in an incorrect diagnosis, with possible critical implications for two patients. The loss of a specimen could prevent a definitive diagnosis and subsequent initiation of therapy.

2.10.12 The circulating perioperative Registered Nurse shall document: - required information on the appropriate

requisition; and

Recording specimen(s) sent to the lab assists in control and may prevent loss. This process may assist in error analysis when a specimen is lost. (Slavin, Best, & Aron, 2002, p. 55)


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- type and number of specimens sent to the lab on the operative record

according to the health care facility's policy.

2.10.13 A log should be kept to track the specimen from the theatre/surgical suite to the laboratory or pathology department. The log may include: - patient identification; - source of culture or type of tissue; - date & time of specimen log in; - name & signature of person sending

specimen; - name of person in lab to receive

specimen; and - time of transfer of specimen to

laboratory.

Proper documentation allows tracking of a specimen from its source to its disposition. (Gruendemann & Mangum, 2001, p. 297)

2.10.14 Reference material with samples of incomplete and completed requisitions should be available in the theatre.

2.10.15 Incident reports shall be completed for all errors related to specimen management.

2.10.16 There shall be a written policy and procedure regarding: - the handling of legal specimens (bullets,

knives, other foreign bodies); - presence of police officers in the

theatre; and - cooperation with police officers in the

course of an investigation.

(See ORNAC Standards for Gathering Medicolegal evidence). The perioperative Registered Nurse is accountable for forwarding the specimens(s) to the pathology department and may be called upon to attest to that continuity of care (or chain of custody) in a court of law.

REFERENCES

Association of PeriOperative Registered Nurses. (2010). Recommended practices for the care and handling of

specimens in the perioperative environment. Perioperative Standards and Recommended Practices. Denver: Author.

Phillips, N.M. (2007). Berry & Kohn’s operating room technique. (11th ed.). St. Louis: Mosby. Slavin, L., Best, M., & Aron, D. (2002). Gone but not forgotten: The search for the lost surgical specimens:

Applications of quality improvement techniques in reducing medical error. Journal of Nursing Care Quality, 16 (3), 50-59.


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BIBLIOGRAPHY Gruendemann, B., & Mangum, S. (2001). Infection prevention in surgical settings. Toronto: W.B. Saunders. Rothrock, J. (2007). Alexander's care of the patient in surgery. (13th ed.). Toronto: Mosby. Watson, D. & Crum, B. (2005). Improving specimen practices to reduce errors. AORN Journal, 82(6), 1051-1054. 2.11 Medication Management Safe delivery of medications should be a collaborative effort between all members of the surgical team. Medication Handling and Administration in the Surgical Suite PRACTICE RATIONALE

The perioperative Registered Nurse is responsible for: 2.11.1 Verifying medication orders according to

the health care facility policy and procedure.

2.11 .2 Sharing with the surgical team information learned from the preoperative checklist that may have an impact on the administration of medications i.e., allergies, herbal medications, etc.

Medication errors can occur as a result of having numerous providers involved in the patient's care as the patient moves from pre-op through ambulatory care to the surgical suite.

2.11.3 Verifying all medications and solutions listed on the surgeon's preference list with the surgeon before administering or delivering to the sterile field. (AORN, 2010) The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) “Do Not Use” list for abbreviations shall be applied to all medication orders. (Rothrock, 2007)

Improperly maintained preference cards result in inconsistencies in preference cards giving a false sense of security and may increases risk of error. ( Dawson, 2005) Some abbreviations, acronyms and symbols are confusing thus increasing risk to patient.

2.11.4 Confirming medication orders are documented according to the health care facility policy. Confirm verbal orders by repeating them back to the physician.

Only physicians or Registered Nurses’ should receive verbal orders. Complies with Goal #2 of the 2008 National Patient Safety Goals (USA)

2.11.5 Facilitating the administration of preoperative IV antibiotics in a timely, safe manner.

Timely and appropriate administration of IV antibiotics plays a significant role in reducing surgical site infection risks. (Safer Healthcare Now)

2.11.6 Verbally and visually verifying all medications and solutions (i.e. Sodium Chloride 0.9% and Sterile Water). (Accreditation Canada,2008)

2.11.7 Delivering medications to the sterile field

using aseptic technique. (Gruendemann &

Distractions are one of the main causes of medication errors in the perioperative setting. (Wanzer, 2005)


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Mangum, 2001, p. 254) 2.11.8 Using commercially available sterile transfer

devices whenever possible e.g. sterile vial spike, plastic catheter, etc.

2.11.9 Confirming every medication or solution on

the sterile field is labeled. Confirming that all medications & medication containers (i.e. med cups, syringes, basins) on and off the sterile field are labeled even if there is only one

2.11.10 Any medication or solution on or off the sterile field which is not labeled shall be discarded 2.11.11.Labels can be developed by the facility or available commercially. All labels should be verified verbally and visually by the professional perioperative scrub and circulating Nurses concurrently. 2.11.12 Labeling should include:

- name; - strength; and

dose of the medication. (AORN, 2010)

Reaching over the sterile table compromises the sterile field. Medications on the sterile field that are not labeled increase the r isk of error. (AORN, 2010) Medications on the sterile field that are not labeled increase the risk of error. (AORN, 2010)

2.11.13 When using medication intended for topical use, such as concentrated epinephrine, place medication in a solution bowl not parenteral syringe.

2.11.14 When using medication intended for

injection by the surgeon, the medication is drawn up into a syringe directly from the vial not from an open solution bowl

To prevent the risk of injection of the topical medication into the vascular system (ISMP Canada, 2010)

2.11.15 Verifying any medication discrepancies as it relates to patient allergies, drug dosage and drug compatibilities.

To reduce the risk of substitution error between medications intended for topical application and those intended for injection (ISMP Canada, 2010)

2.11.16 Communicating all medication(s) on the sterile field at shift change or break relief; and verifying the amount of medication administered. All medication calculations should be verified and independently double checked by an RN or another qualified

Medication errors can occur because of lack of communication/documentation at shift change or break relief.


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individual, (AORN 2008).

2.11.17 Retaining containers, in the theatre, of all medications used on sterile field until the end of the surgical procedure.

Narcotics and Controlled Drugs The perioperative Registered Nurse is responsible for: 2.11.18 Following the healthcare facility policy and

procedure related to narcotics and controlled drugs

The protocol for control of narcotics/controlled drugs is under federal jurisdiction.

REFERENCES

Association of PeriOperative Registered Nurses. (2010) AORN Guidance Statement: Safe medication practices in

perioperative settings across the life span. Perioperative Standards and Recommended Practices. Denver: Author.

Catalano, K., Fickenscher, K. (2008). Complying with the 2008 National Patient Safety Goals. AORN Journal, 87(3),

547-556 Dawson, A., Orsini, M., Cooper, M., Wollenburg, K. (2005). Medication safety: Reliability of preference cards.

AORN Journal, 82(3), 399-414. ISMP Canada www.ismp-canada.org Safer Healthcare Now. www.saferhealthcarenow.ca BIBLIOGRAPHY Case update: epinephrine death in Florida. ISMP Medication Safety Alert Newsletter, Acute Care. 1996 Dec 4 [retrieved 2010 Jun 18];1(21):1. Available from: http://www.ismp.org/Newsletters/acutecare/articles/19961204.asp Gruendemann, B., & Mangum, S. (2001). Infection prevention in surgical settings. Philadelphia: W.B. Sanders.

HealthStream, (2005). Medication errors in the OR Study Guide. Denver:. HealthStream,

Hendrickson, T. (2007). Verbal medication orders in the OR. AORN Journal, 86(4), 626-629. Phillips N.M. (2007).Berry & Kohn’s operating room technique. (11th ed.). Toronto: Mosby. Shumaker, R., Hickey, P. (2006) Medication diversion in the perioperative setting. AORN Journal, 83(3), 745-749. Wanzer, L. (2004) Perioperative initiatives for medication safety. AORN Journal, 82(4), 663-666. Venkatraman R & Durai R (2008). Errors in Medicine Administration: how can they be minimized? Journal of perioperative Practice, 18 (6), 249-53.


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2.12 Nursing Documentation Nursing documentation shall occur for every procedure as per facility policy. PRACTICE RATIONALE

2.12.1 Documentation of the diagnostic and/or

operative procedure plus nursing interventions is required by Accreditation Canada (previously known as the Canadian Council on Health Services Accreditation). All documentation is part of the patient’s legal chart.

The perioperative record provides an accurate contemporaneous account of nursing and/or medical activities throughout the perioperative phase. It provides a method to retrieve information for research, statistics (staffing, financial planning, patient acuity, and utilization), quality assurance, andlegal/ risk management purposes. (Phillips, 2007)

2.12.2 Documentation shall be done in ink or electronically (if implemented by the facility).

All entries are to be made in black pen. (Phillips, 2007; NATN, 2004) They shall be written clearly and in such a manner that the text cannot be erased. (NATN, 2004, p. l28)

2.12.3 Duplicate documentation by perioperative Registered Nurses and Anesthesiologists should be avoided.

Duplicate documentation may lead to questions regarding the accuracy of the documentation.

2.12.4 Documentation should be logically organized, easily communicated, and retrievable: - use check boxes whenever possible; - avoid blank spaces, skipped lines or

crowded entries; - write or print legibly using clear,

objective language; - use only health care facility approved

abbreviations; and - names and signatures shall be followed

by the professional designation, e.g. RN.

Documentation indicating the care given and patient response provides continuity of care and ensures communication among team members.

2.12.5 A single line shall be drawn through an incorrect entry, initialed, and marked according to the health care facility policy.

Whiteout, eraser, or excessive cross-outs are not legally acceptable.

2.12.6 Late entries shall be accurately dated, timed and signed according to the health care facility policy. (NATN, 2004, p. 28)

Documentation that occurs at/or near the time of the event is considered to be more accurate and reliable.

2.12.7 Preoperative admission to the surgical suite should be documented and signed. The following information should be present and reviewed: - patient identification band; - identification card (if used in facility);

- consent/documentation of consent completed and signed;

- consent or withdrawal of consent for

Information is required to provide safe care; and to meet legal and health care facility requirements.


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blood products, if applicable; - surgical site identification;

- history and physical assessment; - all diagnostic reports present; - preoperative vital signs ; - allergies;

- NPO status; - prosthesis (i.e. denture, glasses/contact lens, hearing aids, ); - jewellery, - medication including herbal remedies; and - presence of an advanced directive as necessary.

2.12.8 A preoperative assessment of the patient should be present and should include but is not limited to: - level of consciousness; - baseline physical data; - psychosocial status; - relevant nursing diagnoses; - a nursing care plan; - cultural concerns; and - spiritual concerns.

Assists with the perioperative nursing care plan for positioning, to prevent injury, and to document any pre-existing conditions.

2.12.9 Perioperative event times should be defined and include but not be limited to:

- start of room setup; - patient entry to theatre; - time of anesthesia start (induction); - surgeon enters room; - position/prep start; - procedure start (incision start); - procedure stop (dressing stop); and - patient exits theatre.

2.12.10 All personnel should use the same clock in

theatre to document time.

An accurate recording of time is required for legal purposes. Provides data (average times) for booking surgical cases. Allows that all documentation done in that theatre is accurate to the same clock’s time.

2.12.11 Document name and professional designation of all personnel involved in patient care and any visitors.

This is required for statistical,legal and quality assurance purposes.

2.12.12 Document the patient's positioning including: - restraints and positioning devices; - padding/supports; and - skin condition.

Accurate documentation is a medico-legal requirement. Information is necessary for monitoring patient outcomes and provides information in the event of an injury.


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2.12.13 Document any warming or cooling units used, including the serial number of the unit, temperature setting, and placement.


2.12.14 Documentation of a pneumatic tourniquet should include: - time of inflation/deflation; - pressure setting; - location and size of the cuff; - unit serial number, model, or designated

number; - equipment check with a pressure gauge

(for manual units); - surgeon notification of elapsed time;

and - condition of the skin following removal

of the cuff.


2.12.15 Documentation of laser use should include but not be limited to: - type of laser; - laser use time; - wattage; - laser safety precautions taken; and - name of Laser Safety Officer (LSO),

etc. as per health care facility policy.

Accurate documentation is a medical legal requirement. Information is necessary for monitoring patient outcomes and provides information in the event of an injury.

2.12.16 Documentation of the Electrosurgical Unit (ESU) should include: - type of unit and serial number; - hair removal; - location of dispersive electrode; - cutting and coagulation settings; - condition of skin after removal of the

dispersive electrode; and - teaching done if patient refuses/cannot

remove jewellery.

Accurate documentation is a medical legal requirement. Information is necessary for monitoring patient outcomes and provides information in the event of an injury.

2.12.17 Documentation of insufflators used in minimally invasive surgery should include: - model and serial number; - preset pressure, upper limit maximum; - flow rate; and

2.12.18 Documentation of mechanical irrigation

devices regulating the infusion of irrigation fluid should include:

- model and serial number; - fluid type infused; - preset pressure; and

Information is necessary for monitoring patient outcomes.


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- volume used. 2.12.18 Documentation of surgical equipment used during a procedure.

- model and serial number;

This could include devices such as harmonic scalpel consoles.

2.12.19 Document the application of monitoring devices not documented by the Anesthesiologist, or when doing local or monitored anesthesia care cases.

2.12.20 Document the skin preparation: - skin integrity; - hair removal; - type of solution used; and - condition of prepped skin at end of

surgery.

2.12.21 Document the surgical wound classification as per health care facility policy.

2.12.22 Document the following information for prostheses/implants: - quantity, size and type; - manufacturer; - lot number; and - serial number.

Records allow for recall of potentially defective prostheses and as a reference for removal.

2.12.23 Document packing including: - removal - insertion - number, size, and type; - location; and - method of securing. (NATN, 2004, p. 235)

2.12.24 Document drains and/or catheters remaining in the patient. Include: - number, size, and type; - location; - method of securing; and - presence of a collection device. (NATN, 2004, p. 235)

2.12.25 Document specimens and/or cultures taken, as per health care facility policy. Document if sent to an area other than labs to which specimens are routinely sent.


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2.12.26 Document use of intraoperative X-rays, fluoroscopy and type of patient protection including area(s) protected. (AORN, 2008, p. 312)

2.12.27 Document surgical counts and results and have them signed by those performing the counts as per health care facility policy.

2.12.28 Document medication, hemostatic agents, dyes, and irrigation administered by the surgeon and/or the nursing staff. Include:

- dosage; - volume; and - method of administration

2.12.29 Document urinary output, blood loss and IV infusions, if not already documented by the Anesthesiologist, according to procedure/health care facility policy.

2.12.30 Document the exact surgical procedure(s) performed (confirm with surgeon) using only health care facility approved abbreviations.

2.12.31 Blood and blood products should be checked, administered, and documented according to the health care facility's policy.

2.12.32 Document the initiation of special precautions used with patients having a latex allergy, and/or malignant hyperthermia.

2.12.33 Document any unusual occurrences, according to the health care facility policy, that are directly related to patient care and are pertinent to patient outcomes.

Incident reports are for the health care facility use only and do not become a permanent part of the patient record. Documentation and incident analysis are part of a facility's risk management and can be used to increase safety and effectiveness in patient care.

2.12.34 The documentation method should reflect patient care needs and be congruent with the health care facility policy.

Some facilities combine elements of different documentation methods to document care including but not limited to the following systems: - critical path/variance analysis (care mapping); - focus/charting; and - narrative. (CNO, 2002, p. 13)


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REFERENCES Association of PeriOperative Registered Nurses. (2008) Recommended practices for documentation of perioperative

nursing care. Perioperative Standards and Recommended Practices. Denver: Author. College of Nurses of Ontario (2002). Nursing Documentation Standards. Toronto: CNO. National Association of Theatre Nurses (NATN). (2004). Recommendation for local policy. Standards and

Recommendations for Safe Perioperative Practice. Harrogate: U.K: Author. Phillips, N.M. (2007). Berry & Kohn’s operating room technique. (11th ed.). Toronto: Mosby. 2.13 Electronic Health Records Electronic documentation systems must capture the same information as manual systems. PRACTICE RATIONALE

2.13.1 Electronic Health Records will comply with

national/provincial legislation related to patient information and any privacy acts enacted.

2.13.2 Selection of an electronic system shall be a collaborative decision involving but not limited to: - RNs; - RPNs/LPNs/ORTs; - managers; - medical records manager; - information technology; and - risk managers.

Collaboration assists in selecting a system that meets everyone's needs.

2.13.3 Access to the system shall be controlled and granted as per facility policy.

This assists in ensuring system security and patient confidentiality. (CNO, 2002).

2.13.4 The system should have back-ups so deletion/loss of information is prevented. Contingency for the system shall be in place for documenting during system failure including but not limited to paper documentation.

A complete picture of the patient encounter is necessary to provide proof of appropriate care. Effective patient care relies on documentation. May result in temporary return to paper documents used prior to electronic inputting.

2.13.5 Any changes to documentation should be clearly noted. Systems shall include tracking and audit tools.

Legal defense may require proof of changes made to documentation.

2.13.6 Retrieval of information shall be available. (CNO, 2002, p. 14)

Legal defense may rely on the ability to retrieve information.

2.13.7 Systems may allow corrections and clearly identify them as corrections, and ensure the

Legal defense may rely on credible proof that this has occurred.


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PRACTICE RATIONALE

original entry is maintained. This may be done using a tracking and audit system. 2.13.8 Electronic signatures shall be verifiable.

(CNO, 2002, p. 14)

2.13.9 Access to the electronic medical record shall be provided for temporary users according to healthcare facility policy depending on facility policy. (CNO, 2002, p. 14)

Agency staff and student nurses require access to deliver appropriate care and document care provided.

2.13.10 Electronic systems shall have integration with other departments, as appropriate, (pharmacy, laboratory, diagnostic imaging) dependant on the scope of the system.

Communication of care across the facility assists in providing patient focused care.

2.13.11 Policies and procedures shall be in place to ensure accuracy/verification of documentation when default fields are utilized in electronic systems.

Many electronic systems use defaults to assist in electronic documentation. These fields require verification by the documentor that the default does apply to a specific patient.

2.13.12 Electronic systems shall have security measures in place such as but not limited to the following: - passwords; - virus protection; - encryption; - firewalls; - unauthorized access to confidential client information; and - system failure.

Provisions for patient care and integrity of the data in the electronic health record rely on the security systems in place. Passwords must remain confidential and shall be changed based on facility policy. Logging off when not using or leaving the terminal is essential to maintain patient privacy and to ensure accurate documentation by the intended care provider.

2.13.13 A process that allows healthcare providers to audit or track entries to the electronic health record shall exist.

Breaches in security need to be tracked and dealt with.

2.13.14 Data entry shall occur at point of care. This supports the requirement for contemporaneous entries.

2.13.15 Data entry should occur in a space within the theatre that allows the perioperative Registered Nurse to observe the patient and surgical team while documenting.

The circulating perioperative Registered Nurse needs to have the ability to observe the patient and team on a continuous basis to meet patient care needs.

2.13.16 Information technology system support should be available to perioperative Registered Nursing staff.

Operating rooms provide patient care on a 24hr/365 day a year basis and need the back up support to assist in the delivery of care.


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REFERENCE

College of Nurses of Ontario (2005). Nursing Documentation Standards. Toronto: CNO. www.cno.org/docs/prac/41001_documentation.pdf 2.14 Organ and Tissue Procurement Protocol

The field of donation and transplantation of cells, tissues and organs (CTO’s) continues to change as the science evolves. All establishments that procure, import, process, distribute, and cells, tissues or organs must be registered with Health Canada, or do so under the direction and guidance of an establishment registered with Health Canada. Policies and procedures developed for ORs participating in any aspect of donation and transplantations should be developed in collaboration with the registered Health Canada establishment. The establishment registered with Health Canada is responsible for all donor suitability assessments, prior to CTO procurement.

PRACTICE RATIONALE

2.14.1 Facilities that procure, process, screen, import, or distribute CTOs must be either registered with Health Canada for those activities or under the guidance/direction of a registered establishment.

2.14.2 Organ donors fall within one of the following categories:

Living Donors - Living-related

- Paired-Exchange

Deceased Donors

- NDD

Organ and tissues procurement requires vigilant monitoring and regulation to assist in preserving the safety of CTOs for transplant Living-related donors are generally relatives of the recipient and often are preferred as donor-recipient HLT tissue typing are typically more compatible. Paired-Exchange or Paired Donation involves two pair of living kidney donors and transplant candidates who have incompatible blood types. The two candidates “trade” donors so that each candidate receives a kidney from a donor with a compatible blood type. In some cases, this type of exchange may involve multiple living kidney donors/transplant candidate pairs. NDD (Neurological Determination of Death) refers to the clinical determination of brain death following which the donor is maintained on mechanical ventilation to prevent ischemic damage to vital organs suitable for procurement until procurement occurs.


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PRACTICE RATIONALE

- DCD 2.14.3 Tissue donors can be living or deceased

Living Donors

Deceased Donors 2.14.4 Policies and procedures specific to

retrieval/transplant of CTO’s, should be established by the health care facility in collaboration with the registered Health Canada establishment and may include the following:

- confirmation of documented NDD (when applicable) in addition to consent, as part of usual confirmation check;

- provision of psychological/spiritual support to family members pre, intra, and post procurement;

- protocol for supplies and equipment related to organ/tissue procurement;

- documentation, procedures for handling the procured organ(s)/tissue(s); and

- protocol for identification of recipient(s).

DCD (Donation after Cardiac Death), refers to when the donor has sustained non-recoverable neurological injury and the family has decided to withdraw life support, but still wish to donate. Organs are surgically removed after cardiac death occurs. Organs must be retrieved within a specified time frame following cardiac cessation, to be viable for transplant. Living tissue donors generally refers to situations such as Surgical Bone and Amniotic Membrane Donation, where tissue is removed during a surgical procedure. Any death can result in a potential tissue donation. Tissue donation from deceased donors may include skin, musculoskeletal tissue, heart valves, blood vessels, amniotic membrane and ocular tissue.

2.14.5 Perioperative considerations by the procurement team should include but not be limited to:

- accurate and complete documentation as per Federal regulations and health care facility policy;

- removal of organ(s) and/or tissue(s) under sterile conditions;

All potential donors and families must be treated with respect and dignity. For traceability, documentation must be kept for 10 years. In some cases, multiple transplant procedures can occur simultaneously.


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PRACTICE RATIONALE

- preservation, labeling, packaging and transport of tissue or organs to the recipient(s)following Federal regulations;

- provision of respect and care as given to any other patient;

- surgical counts; and - appropriate after death care as per

health care facility policy. 2.14.6 Perioperative considerations for the transplant of organs and/or tissues include but are not limited to:

- accurate documentation per facility and Federal regulations; and

- accurate identification of both the recipient and the donor tissue/organ.

Sharp, sponge, and instrument counts should be considered for the safety of personnel and for inventory control.

2.14.7 Debriefing sessions, if required, should be available to applicable heath care team members as soon as possible.

The importance of the role of the health care professional in donor care cannot be over-emphasized. Issues related to ethical dilemmas arising from beliefs, values and attitudes can be addressed through these sessions and may help to reduce stress levels.

BIBLIOGRAPHY

American Association of Tissue Banks, (AATB) (2006). Standards for Tissue Banking, 11th edition, AATB Association of PeriOperative Registered Nurses. (2010). Recommended practices for surgical tissue banking.

Perioperative Standards and Recommended Practices. Denver: Author. Bernat, James L (2008). The boundaries of Organ donation After circulatory Death. New England Journal of Medicine, 359 (7), 669-671. Canadian Council for Donation and Transplantation. (2003). Severe Brain Injury to Neurological Determination of

Death: A Canadian Forum held in Vancouver, B.C. Edmonton: CCDT. Canadian Medical Association. (2000). CMA Policy Statement: Organ and Tissue Donation and Transplantation

(Update 2000). Ottawa: Author. Canadian Neurocritical Care Group. (1999). Guidelines for the diagnosis of brain death. Canadian Journal of

Neurological Science, 26, 64 – 66. Canadian Nurses Association. (2000). CNA Fact sheet: Organ donation and tissue transplantation. Ottawa: CNA. Canadian Standards Association. (2003). CSA Z900.1-03 Cells, Tissue and Organs for Transplantation and Assisted

Reproduction: General Requirements... Toronto: Author. Canadian Standards Association. (2003). CSA Z900.2.4-03 Ocular Tissues for Transplantation. Toronto: Author.


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Canadian Standards Association. (2003). CSA Z900.2.2-03 Tissues for Transplantation. Toronto: Author. Canadian Standards Association. (2003). CSA Z900.2.3-03 Perfusable Organs for Transplantation. Toronto: Author. Health Canada: Health Products and Food Branch. (2003). Guidance document: basic safety requirements for human

cells, tissues and organs for transplantation. Ottawa: Author. Hill, Sonia June (2008). Placental amniotic Membrane: the Pathway to Ocular transplantation, AORN Journal, 88 (5) 731-744. Howard, R., Cornell, D., Koval, C. (2008). When the donor says yes and the family says no. Progress in

transplantation, 18(1), 13-16. Humphries, L., Mansavage, V., (2006) Quality control in tissue banking: Ensuring the safety of allograft tissues.

AORN Journal, 385-398. Edwards, J., Mulvania, P., Robertson, V., George, G., Hasz, R., D’Alessandro, A. (2006) Maximizing organ

donation opportunities through donation after cardiac death. Critical Care Nurse, 26(2), 101-115. National Association of Theatre Nurses (NATN). (2004). Procedures related to organ donation. Standards and

Recommendations for Safe Perioperative Practice. Harrogate: U.K: Author.. O’Hara, J., Bramstedt, K., Flechner, S., Goldfarb, D. (2007) Ethical issues surrounding high-risk kidney recipients:

Implications for the living donor. Progress in Transplantation, 17(3), 180-182. Phillips, N.M. (2007). Berry & Kohn’s operating room technique. (11th ed.). Toronto: Mosby. Poser, K. (2008) Ensuring there are more opportunities to give. Canadian Nurse, April, p. 10-11 Rothrock, J. (2007). Alexander's care of the patient in surgery. (13th ed.). Toronto: Mosby. Shemie, S., Doig, C., Belitsky, P. (2003). Advancing toward a modern death: the path from severe brain injury to

neurological determination of death. CMAJ, April, 168(8).

Team Safety The following items need to be addressed to ensure team safety: 3.1 Credentialing PRACTICE RATIONALE

3.1.1 A process is required to verify if regulated

professionals have the necessary credentials to practice. The areas which need to be verified are:

- education / training licensure; and - ability to perform the procedures for which they are being hired.

Regulation of Health Professionals is a provincial mandate and varies from province to province. Regulation of Health Professions provides the public with a mechanism to file complaints related to the practice of the professional. These complaints may be filed outside the employing institution and investigations are deemed to be unbiased and have a


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PRACTICE RATIONALE

3.1.2 The process should be initiated but not limited

to: - upon hiring; - annually at a specified time of year; - upon transfer from one department to another; and - after suspension of credentials when the professional has satisfied the requirements for re-instatement.

greater degree of credibility for the complainant. (Phillips, 2007)

3.1.3 Job descriptions should be reviewed to ensure understanding and adherence to provincial scope of practice legislation.

Scope of practice of health professionals varies from profession to profession and province to province.

REFERENCE Phillips, N.M. (2007). Berry & Kohn’s operating room technique. (11th ed.) P. 58-59. St Louis: Mosby 3.2 Occupational Health and Safety PRACTICE RATIONALE

3.2.1 Policies and procedures to ensure adherence to

Occupational Health and Safety regulations are required and should include but not be limited to the following: - Workplace Hazardous Materials

Information System (WHMIS) legislation; - fire safety specific to the surgical suites; - laser safety; - radiation safety; - exposure to hazardous materials/chemicals; - Personal Protective Equipment (PPE) use

and adherence; - sharps safety; - electrical safety; - biological ( blood, and /or potentially

infectious body substances); - ergonomics; - physical safety, e.g. lifting heavy weights; - personal safety, e.g. workplace violence and

or harassment; - environmental safety; - workplace stress, - pandemic planning (SARS, Avian Flu,

pH1N1) and

Surgical suites have many pieces of equipment, chemicals and routines that hold significant potential for injury to staff. In June 2003 new legislation, Bill C-45 was introduced to hold corporate decision makers accountable for workplace accidents and fatalities. (Keith & O'Reilly, 2003) The health care facility is committed to the occupational health and safety of staff, independent practitioners, volunteers and students. (CCHSA, 2004, p. 24) Musculo Skeletal Injury Prevention Programs Workplace Violence Prevention Programs (Accreditation Canada, 2010) More information on Environmental and Workplace Health- Fitness to Work may be found at http://hc-sc.gc.ca/ewh-semt/occup-travail/index-eng.php (Government of Canada Occupational Health and Safety, 2010)


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PRACTICE RATIONALE

- employee assistance. 3.2.2 Orientation programs for new staff should

include but not be limited to the following: - WHMIS review; - fire review; - electrical safety; - radiation safety; - laser safety, if applicable; - sharps safety; and - use of Personal Protective Equipment

Employees need to understand expectations related to these issues within individual practice settings. The health care facility needs to create a safe, healthy, and positive work environment. (CCHSA, 2004, p. 22)

3.2.3 A process of due diligence that demonstrates regular auditing of adherence to policies and procedures related to safety.

This data may be required for legal defense of the health care facility.

3.2.4 A policy and procedure related to Workplace Violence that includes but is not limited to the following:

- definition of workplace violence i.e. Workplace violence includes: - threatening behaviour - such as shaking fists, destroying property or throwing objects; -verbal or written threats - any expression of an intent to inflict harm;

- harassment - any behaviour that demeans, embarrasses, humiliates, annoys, alarms or verbally abuses a person and that is known or would be expected to be unwelcome. This includes words, gestures, intimidation, bullying, or other inappropriate activities; -verbal abuse - swearing, insults or condescending language; - physical attacks - hitting, shoving, pushing or kicking; and - Rumours, swearing, verbal abuse, pranks, arguments, property damage, vandalism, sabotage, theft, psychological trauma, anger-related incidents, rape, arson and murder.

- process for reporting incidents; process to seek assistance during the

violent episode; and - clear expectations regarding reporting

investigation, and timelines for completion of the process.

“Most people think of violence as a physical assault. However, workplace violence is a much broader problem. It is any act in which a person is abused, threatened, intimidated or assaulted in his or her employment.” Canadian Centre for Occupational Health and Safety at, http://www.ccohs.ca/oshanswers/psychosocial/violence.html (2010)


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REFERENCE

Accreditation Canada (2010) http://www.accreditation.ca/educational-resources/education-materials

Canadian Centre for Occupational Health and Safety (2010) http://www.ccohs.ca/oshanswers/psychosocial/violence.html

Canadian Council on Health Services Accreditation. (2004). AIM, Achieving Improved Measurement, Accreditation Program. 3rd ed. Human Resources.

Government of Canada Occupational Health and Safety –Fitness to Work ( 2010) http://hc-sc.gc.ca/ewh-semt/occup-travail/index-eng.php Keith, N., & O'Reilly, Y. (2003). The legal connection: soon to be law - corporate decision - makers are accountable

for employee safety. Canadian Occupational Health & Safety, 41(5). Robson, R., & Marshall, P. (2003). Using dispute resolution to resolve health care conflicts: an essential tool in

hospital risk management. Risk Management in Canadian Health Care, 4(7). Watson, V., & Steiert, M.J. (2002). Verbal abuse and violence: the quest for harmony in the OR. Surgical Services

Management, 8(4). 3.3 Students/Preceptors PRACTICE RATIONALE

3.3.1 Guidelines related to preceptorship of

students should include but not be limited to: - clear communication processes

between student, educator and preceptor;

- role definition for each educator and preceptor;

- requirements of a preceptor, which should include:

interest, education and experience with adult learners; (Phillips, 2007)

- understanding of various learning styles; (Phillips, 2007)

- ability to assess learning needs through interview, observation, and -a skills checklist; (Phillips, 2007) - competent and confident; - consistent in their relationship with the learner; - supportive and respectful; - open and honest;

This may be required for legal defense of the student, the educator/educational institution, the preceptor and the health care facility should an untoward event occur. Working closely with the educator, the preceptor will assist in assessing the student’s abilities, assigning activities accordingly, assisting in carrying out duties safely (Phillips, 2007) and will aid in solving problems that arise during the clinical experience. (Ryan-Nichols, 2004, p. 21-22)

“The purpose of preceptorship is to enhance the quality of learning in the clinical environment, which in return helps novice nurses achieve excellence and confidence in their professional practice.” (Willemsen-McBride, 2010)


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PRACTICE RATIONALE

- able to set clear expectations; - able to mutually negotiate - learning objectives with the learner; - able to build on positive experiences, and the strengths and success of the preceptee; - willing to customize the learning experience to meet individual learning needs; - patience; - able to guide the learner and the learning experience; - knowledgeable about a wide range of learning resources; - knows the norms and culture of the setting; - an advocate for the learner (RNAO, 2004); and - designated supervision for the entire preceptorship period. 3.3.2 Requirements of the student should

include: - an expectation that the student should inform the responsible person (preceptor) if he/she is not qualified to perform an assigned task (Phillips, 2002, p. 25) ; and - adherence to the policies and procedures of the health care facility.

REFERENCES

Brown, Y. (2004). Learning in a preceptorship. Canadian Nurse. 100(6).

Phillips, C. (2002). Managing legal risks in preceptorships. Canadian Nurse, 98(9). Phillips, N.M. (2007). Berry & Kohn’s operating room technique. (11th ed.) St Louis: Mosby. Registered Nurses Association of Ontario. (2004) Preceptorship Resource Kit RNAO publisher Ryan-Nicholls, J. (2004). Preceptor recruitment and retention. Canadian Nurse. 100(6). Willemsen-McBride, T. (2010) Preceptorship planning is essential to perioperative nursing retention: Matching teaching and learning styles. Canadian Operating Room Nursing Journal, Volume 28, Issue 1(pg. 8-21).


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BIBLIOGRAPHY

Allen, S. A. (2006, December). Mentoring: the magic partnership. Canadian Operating Room Nursing Journal, 24 (4), 30-32, 37, 38. Huff, B. (2004). Leadership and mentoring. Canadian Operating Room Nurses Journal, 22(1), 20-21. Higgins, J. (2004). Thinking outside the box: perioperative preceptorship. Canadian Operating Room Nurses Journal, 22(1), 33-40. 3.4 Orientation/In-service/Continuing Education PRACTICE RATIONALE

3.4.1 A comprehensive orientation program for

new and/or returning employees should include but not be limited to the following: - philosophy, goals and role

expectations of the health care facility (Phillips, 2007) ;

- physical facilities specific to the health care facility(Phillips, 2007) ; - policies and procedures for the practice

area; - process for informing staff of new

policies; - process for introduction to new surgical

procedures; - emergency code policy reviews (fire,

disaster, bomb threat, etc.); - process for reporting near misses,

errors, incidents, and sentinel events; - policies and procedures specific to

occupational health and safety; - policies and procedures related to

patient confidentiality; - process to evaluate performance

expectations; (Phillips, 2007); and - assignment/buddied with a preceptor for

the entire period of the scheduled orientation.

Given that maternity paternity leave may last up to one calendar year, refreshing the returning nurse may require a full reorientation.

3.4.2 In-service programs should include but not be limited to: - review of new policies and procedures; - instruction related to new equipment,

procedures; - notification of any patient safety issues;- review of professional responsibilities

and accountability; and - procedures mandated annually


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PRACTICE RATIONALE

according to provincial/national legislation such as BCLS and WHMIS.

3.4.3 Policies, procedures and philosophy of the health care facility as it relates to continuing education should include but not be limited to: - expectations of the health care facility

as it relates to continuing education (delegated acts, advanced competencies, certifications);

- expectations of the health care facility related to personal accountability for continuing education/learning;

- expectations around performance review and personal educational goals setting;

- documentation of the above information; and

- identification of funding assistance available to employees.

3.4.4 Policies and procedures related to the use of

purchased/contract staff (agency) and casual staff should include but not be limited to: - basic orientation to the surgical suite; - identification of a reporting relationship

for staff; and - introduction to a "reference package" that is readily available to staff in case of confusion/question

REFERENCES Phillips, N.M. (2007). Berry & Kohn’s operating room technique. (11th ed.) St Louis: Mosby.

BIBLIOGRAPHY Phillips, C. (2002). Managing legal risks in preceptorships. Canadian Nurse, 98(9). Robson, R. & Marshall, P. (2003). Using dispute resolution to resolve health care conflicts: an essential tool in

hospital risk management. Risk Management in Canadian Health Care, 4(7).

Environmental/Equipment Safety

4.1 Construction/Renovation


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Overview Preplanning prior to beginning a construction project is critical to the success of the project. Planning & Design Phase PRACTICE RATIONALE

Consideration 4.1.1 The following steps should be taken to

design or redesign surgical suites: - assess current and future needs; - define goals and develop a master plan;- procure technical design and planning

expertise; - develop a project budget; - select staff members to provide front

line input; - select the right products; and - select vendors/suppliers with expertise

in equipment, installation and services. All specifications and contracts should

include comprehensive infection control, risk management and OHS clauses that clearly identify legislative requirements, site-specific requirements and impose sanctions for non-compliance. (CSA Z317.13-07)

Assess areas adjacent to the site including areas on the floor, above and below for potential risks. Assess potential risks to patients, staff and services.

Attention to detail in the planning stages will ensure correct processes are in place for the construction phase. Planners require expertise and knowledge about individual provincial guidelines and CSA Standards (Z317.13-07) for Construction and Renovation of Health Care Facilities. Risk assessment plays a crucial step in identifying potential hazards and the necessary containment required to carry out services.

4.1.2 Commit to vendor (contract or partnership agreement) early in the process to maximize the benefits of their knowledge/expertise.

Often room design and fixture placement is dependent on equipment/vendor chosen because of equipment specifications and dimensions.

4.1.3 All construction/renovation projects should have a project manager.

To co-ordinate all the meetings, functions and actions required to plan, design, build, commission and move into new/renovated space.

4.1.4 Establish a multidisciplinary team to include members outside the surgical suite. Responsibilities of the team include but is not limited to:

- considering business and service continuity;

- coordinating demolition, construction and renovation;

- occupational health and safety

A construction project affects many disciplines including people and other departments outside the surgical suite. Input is necessary from all involved stakeholders.


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PRACTICE RATIONALE

regulations - reviewing and implementing infection control practices for patients, staff and contractors; - ensuring compliance with technical

standards, contract revisions and regulations;

- a project schedule; and - maintaining summary statements of

activities 4.1.5 Clear lines of communication shall be

established with all the team members.

The roles/responsibilities of each team member should be outlined and documented.The team should include but not be limited to the following members: - Director and Manager of the Surgical

Suite; - Surgical Suite staff; - Nursing; - Ancillary Staff; and Business Director - Surgeon(s); - Anaesthesiologist(s); - PACU staff - Architects; - Construction Project Manager; - Engineering, Facilities Director; - Materials Management; - Equipment planner; - Infection Prevention and Control

Practitioners; - Reprocessing Department personnel; - Environmental Services personnel; - Information services/technology; - Medical Radiation Technologists; - Epidemiologists; and - Vendor representatives (as required

through the project build). 4.1.6 Construction and renovation projects involve

different phases which may overlap each other including but may not be limited to:

- needs assessment; - preplanning; - site selection and acquisition; - programming; - budgeting;

To facilitate efficiency and comprehensiveness throughout the project. . To enable the team to work effectively together, with a clear understanding of their respective roles. Each team member provides a distinct area of expertise. Breaks the project down into manageable, organized steps providing a building block to the end product.


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PRACTICE RATIONALE

- schematic design; - equipment selection; - design review; - design development; - preparation of construction documents; - bid/negotiation; and

construction 4.1.7 Infection Control Practitioners should educate all perioperative staff involved regarding activities that can reduce the spread of microbial contamination.

Construction and renovation projects in the operating room increase the risk of infections such as aspergillus. Infection control personnel play a major role in educating hospital staff, architects, engineers, and all people involved in any stage of the construction and/or renovation process.

4.1.8 Infection prevention measures shall be clearly outlined in relevant construction documents (e.g., drawings, specifications, tender or bid documents) before any construction project is started, and they shall be maintained for the duration of the project. (CSA Standard Z317.13-07, 2007, p. 9)

“The Health Canada publication Construction-related Nosocomial Infections for Hospitalized Patients: Decreasing the Risk of Aspergillus Legionella and Other Infections cites 25 outbreaks of nosocomial Aspergillus sp infections over a twenty year period resulting in 106 deaths. These deaths were either suspected or confirmed as being caused by construction activity.” (Loddon Mallee Region Infection Control Resource Centre, August 2005). “Health Canada has carried out an extensive review of literature of nosocomial infections over a 20-year period (1978-1998) and found numerous nosocomial outbreaks related to construction or renovation projects.” (American Industrial Hygiene Association, Controlling Hospital Acquired Infections, 2008 p.1) “Numerous published reports have linked construction activities in hospitals to outbreaks of Aspergillosis which have had fatal outcomes to multiple patients. It is essential that preventative measures be undertaken to decrease patient’s or resident’s exposure to dust particles contaminated with aspergillus spores.” (Camille Atrache, spring 2008 p.14)

4.1.9 Newly constructed/renovated facilities should give consideration to the ability to provide enhanced respiratory precautions.

Air sampling should be carried out before,

To establish site-specific infection control protocols which will aid in preventing unnecessary exposures of patients, visitors, staff and workers to infectious agents. Recent fears such as SARS among health care


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PRACTICE RATIONALE

during and at the end of the project. Samples should be taken by a technique that allows the analyst to provide results to the species level.

workers and patients have highlighted the importance of facility design for enhancing the control of infectious disease. To evaluate barrier integrity. To provide data in case there is an outbreak during or after the project.

4.1.10 Planning should include consideration for future upgrades of the surgical suite including but not limited to the following: - flow of patients, staff and materials;

placing a high priority on patient needs when planning for orientation of the OR bed, location of all doors, set-up area, and privacy;

- review departmental adjacencies such as the sharing of procedural and exam spaces, as well as patient, staff and public support spaces.

- advanced technology; consider pipe and power (conduit, electrical power and ceiling structure) to support future technology;

- plan for digital information images and remote conferencing;

- consider flat-screen versus cathode-ray tube monitors;

- give control to the OR team; and - integration of wireless technology.

The integration of multiple discreet systems under one centralized control system will be essential for both Minimally Invasive Surgery (MIS) and Open Suites. To focus on the processes and methods that will improve efficiency, productivity and outcome. PACS. Flat screens and other display are less cumbersome and easily accommodated overhead.

4.1.11 Continual observation and routine visits must be carried out through all phases of construction. 4.1.12 Plan the environmental infection-control and ventilation measures for operating rooms:

- maintain air pressure in the OR greater than corridors and adjacent areas

- maintain a minimum of ≥ 15 air exchanges per hour with at least 3 of these being fresh air; filter all re-circulated and fresh air through the appropriate filters, providing 90% efficiency (during spot testing) at a minimum;

- in rooms not engineered for horizontal laminar airflow, introduce air at the ceiling and exhaust near the floor;

do not use ultraviolet (UV) lights to

Things can go wrong during any part of the construction phase. Routine visits are crucial to ensure processes are set in place, and the project is monitored Use the architect, staff and physicians to identify sites to visit. Site visits can assist in identifying design features that may be applicable/not applicable to the health care facility’s needs. Maintains unidirectional airflow in the room and minimizes the amount of corridor air (less clean air) entering the OR. Ultraviolet light must be out of the direct line of vision and positioned so that air will pass over it as it is exhausted from the room; usually at ceiling level. Non-sealed areas are difficult to clean and keep cleaned. Appropriate environmental controls are crucial to infection prevention.


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prevent surgical-site infections; - walls, ceilings and floors must be

sealed; and - keep operating room doors closed

except for passage of equipment, personnel, and patients and limit entry to essential personnel

Requirements for environmental controls such as HVAC systems air flow/exchange, lighting etc. shall meet the specified recommendations as outlined by Canadian Standards and other recognized groups such as the Canadian Healthcare Engineering Society. 4.1.13 Ergonomics.

4.1.14 Patient flow: - access;

- signage; - reception area; - restricted, semi restricted and

unrestricted access; - washroom location - staff efficiency related to layout; - work areas for nursing documentation

and physician dictation; - traffic patterns/flow between theatres,

and other nursing units i.e. PACU, ICU; and

- transportation of patients (wheelchairs, stretchers, walking).

4.1.15 Seek feedback from patients and staff in regards to privacy, traffic patterns, work areas etc.

Design should consider patient feedback around access, privacy and efficiency.

Workflow should consider feedback from staff on work areas, traffic patterns and efficiency.

Patient comfort, privacy and staff efficiency play a major role in a smooth patient transfer/discharge from the surgical suite. Front line staff who are directly involved with the day to day running of the surgical suite and patients provide valuable information during the designing stage.

4.1.16 Supply & Instrument Movement Logistics: - which type of cart system will be

utilized; - sterilizer location in relation to the

theatre; - location of basic and back-up supplies; - supply replenishment system; - implant storage, dispense of and

accountability; - equipment storage area; and - space for sales representatives and

teaching functions.

To determine space needs for supplies and transport systems Rapid technological change requires that planning be for five years. (Mauck & Tolhurst, 2001, p. 29)

4.1.17 Room Set-up


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A focus group of anaesthesiologists, surgeons and staff for each surgical specialtyshould be established to determine room set-up, according to but not limited to the following criteria: - size of theatres, attempting to maintain

flexibility of the theatre; - door locations and size, patient

orientation, x-ray view boxes, cabinets, telephones, and computer access locations; and

- fixed room equipment such as surgical lights, gas columns, and room systems.

4.1.18 A foot printing exercise should occur. (This exercise allows the group to move blocks of space (e.g., the surgical suites) around to determine the best location in relationship to other departments/services.)

Some dedicated rooms may be required for some specialties. Dedicated rooms should be kept to a minimum as multifunction rooms provide more flexibility. Architects will develop plans based on square footage. This exercise allows the team to move equipment within the space to determine the best equipment placement and traffic flow for efficiency

4.1.19 Equipment: - a designated person responsible for

equipment planning - what equipment to re-locate from the

old area or structure; - what vendors the health care facility has

agreements with; - acquisition and in-service education of

staff; and - a designated person to manage the

tracking of equipment.

To avoid conflicts between equipment and other aspects of the design. If the health care facility has contracts and/or preferred vendor agreements, selection of equipment may be limited to these vendors. Vendors are also a valuable resource regarding construction infrastructure required for the product (i.e., ceiling structure required to support a microscope or lights). The timing of these functions is critical to meet deadlines.

Other areas that should be considered in the design phase: 4.1.20 Patient focus groups will assist in

identifying what patients expect/desire during their surgical experience. This may include but not be limited to the following: - family waiting areas during surgery; - private interview rooms for consultation

and discussion with surgeon/anesthetists;

- space for complementary therapies such as massage;

- clerical space; - music before, during and after surgery. - on call or sleep areas

Improve or increase patient satisfaction. Providing an environment which goes beyond clinical skills and technology assists in the healing process.

4.1.21 A lounge, which provides space for relaxation, eating, kitchen utilities i.e. microwave oven, refrigerator, sink and

With the shortage of qualified staff, this may be a recruitment incentive. Pleasant space contributes to staff health and well-being, which is cost effective.


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counter space. Construction Phase PRACTICE RATIONALE

4.1.22 The project manager shall be available at all times to oversee every step of the construction phase.

A system should be in place to manage major breaches.

The role of the project manager is to coordinate all functions and teams. Constant vigilance is required to ensure adherence to project plans. Things can go wrong during the construction phase.

4.1.23 Project team leaders should develop and review regularly check-lists of all items to be addressed.

To remain on the target timeline.

4.1.24 Project manager shall work closely with architects and construction foreman.

This ensures cost, timelines and any discrepancies are addressed.

4.1.25 Project manager should be involved in inspections for code requirements.

This allows the project manager to follow through any deficiencies identified.

4.1.26 The project team should do regular tours of the work site and include physician and staff in the tours.

This will assist to identify issues that may be corrected. (e.g., stretcher alcove not large enough for stretcher, doors located incorrectly).

4.1.27 The team, in conjunction with the Infection Prevention Officer, shall plan for the confinement and containment of dust, water, etc. during construction/renovation. (CSA, Z317.13.03-07)

Many construction/renovation projects are in close proximity to areas, which will continue to provide patient care. A formalized approach to risk management in conjunction with sound infection control procedures, greatly reduce the risk to patients from construction and maintenance activities.

4.1.28 The team shall discuss and plan how to deal with noise, vibration, and temperature fluctuations that may impact patient care in adjacent spaces.

Some equipment and surgical procedures require precision, which would be negatively impacted by vibrations.

4.1.29 Upon completion thoroughly clean and decontaminate all surfaces including but not limited to: - walls; - ceilings, - windows; - high-risk area ventilation systems; - service cavities; and - ceiling spaces.

Upon completion of the project, clean the work zone according to the facility

To provide an environment that is safe, and decrease the risk of infection due to dust and debris


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PRACTICE RATIONALE

procedures, and install barrier curtains to contain dust and debris before removing rigid barriers. (Chinn & Sehulster, 2003, p. 12) Operational Phase

PRACTICE RATIONALE

4.1.30 A plan shall be developed to coordinate all aspects of system changes.

Allows teams to identify and plan for required changes prior to moving into new space.

4.1.31 Changes which should be considered include but are not limited to the following: - policy & procedure changes (patient

flow, fire plan, evacuation routes, etc); - education of all staff and physicians

about new equipment, safety, traffic flow and infection control.;

- potential changes in staffing plans, skill mix and multi-tasking;

- signage of all spaces; - labeling of all supply shelves and

equipment locations; - security issues; and - the moving plan.

4.1.32 A systems check of all gas, electrical systems, humidity, air flow and exchanges should be done with maximum load. All systems should be stressed at the same time to mimic actual operations prior to the first day of operating.

To recognize and eliminate system failure and provide a smooth transition at surgical start-up.

4.1.33 A documented back-up plan for possible system failure shall be developed.

Provides a tool for transition during system failure.

Moving Phase 4.1.34 Consideration should be given but not limited

to: - when the move will occur; - whether the surgical schedule continue

in an adjacent space; - who needs to be present for the move; - developing a detailed plan/timeline for

moving day; - what the role for each staff type will be

on moving day; and - a plan for a trial surgical case.

To organize and prepare staff for a smooth transition.


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REFERENCES

American Industrial Hygiene Association. (2008). Controlling Hospital Acquired Infections. Canadian Standards Association. (2007). CSAZ317.13-07 Infection control during construction, renovation, and maintenance of health care facilities. Toronto: Author. Camille, A. (spring 2008) Building Strategies - Minimize Patient Exposure and Possible Litigation.

http://www.pcbdisposal.com/documents/bscorner3.pdf Chinn, R., & Sehulster, L. (2003). Guidelines for Environmental Infection Control Health-Care Facilities.

Recommendations of CDC and the Healthcare Infection Control Practices Advisor Committee (HICPAC). June 6, 2003/52 (rr10); 1-42 http:/www.cdc.gov/mmwr/preview/mmwrhtml/rr5210a1.htm

Loddon Malle Region Infection Control Resource Centre, (August 2005). Infection control principles for the management of construction, renovation, repairs and maintenance within health care facilities. A Manual for Reducing the Risk of Health Care Associated Infection by Dust and Water Borne Microganisms, (2nd Ed.) http://ihea.com.au/technical_resources/infection_control/InfectionControlManual.pdf Mauck, J., & Tolhurst, S. (2001). Constructing and designing a new OR. Surgical Services Management. 7(4).

BIBLIOGRAPHY

Cantrell, S. (April 2008). Renovating the surgical suite reaps sweet rewards. Healthcare Purchasing News. http://findarticles.com/p?articles/mi_m0BPC/is_/ai_n25151351

Malik, O., Arabzadeh, H., & Singh, J. (2008). Controlling Hospital-Acquired Infections. American Industry Hygiene Associate.

http://www.aiha.org/content/accessinfo/press/controlling+hospital-acquired+infections Health Care Standards – CSA – International Organization for Standardization ISO (issue 03 spring 06). Safety considerations in health care facility renovation – it’s all in the design http://www.csa.ca/standards/health_care/newsletter/archive/issue%203/default.asp?load=news1&langauge=english OR Manager. (2002). OR design & construction: Every project needs infection risk plan. OR Manager, 18(3).

OR Manager. (2002). OR design & construction: Healing environments in surgical suites. OR Manager, 18(3). OR Manager. (2001). OR design & construction: planning for upgradeable OR’s. OR Manager, 17(12). Stouffer, J. (2001). A high-touch approach to design. Surgical Services Management, 7 (4), pp. 33-38. Wetzel, J. (2001). Planning for effective OR design. Surgical Services Manager. Vol. 7 (4). 4.2 Equipment Selection/Trialing Surgical equipment and supply acquisitions need to be managed by having appropriate processes in place to ensure that the right product is available for the right application. Patient safety and staff safety should be considered.


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PRACTICE RATIONALE

4.2.1 Health care facilities should establish a multidisciplinary committee to review equipment/supply requests. This committee should include but not be limited to the following: - OR Manager/Leader; - OR Educator; - Perioperative nurses; - Infection Control personnel; - Finance representative; - Biomedical representative; - Maintenance representative; - Anaesthesiologist; - Surgeon; - Allied Health Professionals: - Materials management; and - Sterile Processing personnel

(CSA Z318.8-08)

Surgical suite equipment is expensive and technology is rapidly changing. Input from a variety of users is required to make the best purchase decision. The amount of dollars available for technology purchases is usually far less than the dollar value of requests made, so decisions must be sound.

4.2.2 A systemized process (Request For Proposal- RFP) for equipment requests should be in place and the process should include a feedback mechanism to inform the requester of the status of the request.

Most health care facilities have specific timelines for capital budget item requests. Non-capital items may be purchased within operating budgets.

4.2.3 Standardization, appropriate use and price reduction are the best way to reduce supply expenses.

4.2.4 The following criteria should be considered by the committee to narrow the choice of product/equipment to select/trial: - size, weight and specifications fit into

the physical environment; - the cost of the item falls into budgeted

dollars; - the item has the functionality to meet

the clinical end use; - the equipment is approved for use in

your jurisdiction (HPB/CSA approval);- the company or manufacturer shall

provide validated cleaning/reprocessing instructions for the equipment; and

- the necessary infrastructure is in place to support the use of the equipment. (CSA Z314.22-04)

Reviewing the equipment in this context will assist in creating a "short list" of products/equipment to evaluate. To decrease problems related to inappropriate equipment size, selection etc., avoid costly mistakes and waste of valuable time.

4.2.5 On site equipment evaluation should be completed prior to purchase.

To ensure equipment is functioning and suitable to patient, staff and departmental needs.

Contact and/or visit other sites to gather Input from other centres and staff provide valuable


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PRACTICE RATIONALE

information such as: - does the equipment meet the needs

specified; - what is the cost and is it acceptable; - are educational sessions offered through

the vendor; - how is the equipment reprocessed; - are staff satisfied with the product; - is the equipment reliable; - does the vendor provide

service/maintenance vendor; - what is the cost of upkeep; - was this the preferred choice; and - would they purchase the same item if

they had that choice

Document and save all information.

information related to equipment function, use and reliability. To be used for future reference and decision making.

4.2.6 The decision to trial new equipment/technology should consider but not be limited to the following: - do physicians and staff require training

prior to the use of the equipment;

- is the presence of the sales representative necessary to support the use of the technology; and

- should the patient be informed that new technology is being used

To plan the necessary arrangements for training.

The presence of a sales representative to lend technical assistance related to the device should not substitute for orientation and training of nursing staff members in the use of the equipment; neither should such presence substitute for formal instruction of the surgeon before using new equipment in the OR. (Murphy, 2001, p. 824)

The sales rep should be readily available to assist in appropriate equipment selection/use.

Sales representatives are not employees of the hospital and therefore should not be regarded as an extra set of hands for tying gowns or opening supplies. The representative’s legitimate role is to provide technical assistance related to the device for the safe care of the patient. (Murphy, 2001, p. 824)

To acknowledge the patient’s input and provide the necessary information required for consent. The patient’s decision to consent to (or refuse) treatment must be informed; that is, the patient must receive information about the nature of the proposed treatment, its expected benefits, the material risks, special risks or material side effects associated with it, alternative courses of action and the likely consequences of not having the treatment. (CPSO, 2001, p. 3)

4.2.7 Health care facilities should develop policies and procedures related to equipment trials involving but not limited to: - Risk manager;


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PRACTICE RATIONALE

- Bioethicist; - Physicians; - OR Manager; - Perioperative Registered Nurses; - Allied Health Professionals; and - Infection Control Practitioners.

4.2.8 Develop a user friendly evaluation tool to provide objective criteria for decision making when assessing different technologies.

A user friendly tool may increase completion and return rate.

The decision to purchase a piece of equipment should include but not be limited to the following considerations:

- does it meet the clinical need; - does it pose a safety concern for the

patient or team; for the patient - ergonomics - what are the ongoing costs of

consumable items; - is physician, staff and biomedical

education included (videos, CDs, manuals);

- are operating/reprocessing instructions resources included (videos, CDs, manuals);

- are maintenance instructions available for biomed/maintenance department;

- are preventative maintenance contracts available with the vendor (videos, CDs, manuals);

- what is the warranty on the item; and - are there opportunities to lease or lease-

to-own.

Sound business principles combined with knowledge of clinical practice should drive the acquisition decision. (Berhardy, 2001, p. 26)

REFERENCES

Beney, D. (March 2005). OR design: four steps for success, Resources for OR Design and Construction

http://www.ordesignandconstruction.com/dp/foursteps.htm Berhardy, J. (2001). Strategies for successful technology assessment. Surgical Services Management. 7 (6). Canadian Standards Association. (2004). CSA Z314.22-04. Management of Loaned, Shared and Leased Medical

Devices. Toronto: Author. Canadian Standards Association. (2008). Z314.08-08. CAN/CSA. Decontamination of reusable medical devices. Toronto: Author. Cantrell, S. (April 2008). Renovating the surgical suite reaps sweet rewards. Healthcare Purchasing News.


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http://findarticles.com?p?articles?mi_m0BPC/is_/ai_n25151351 College of Physicians and Surgeons of Ontario. (2001). Consent to Medical Treatment.

http://www.cpso.on.ca/Policies/consent.htm Murphy, E., (2001). The presence of sales representatives in the OR. AORN Journal. 73(4), 822-824.

BIBLIOGRAPHY Baker, D., & Hale, D. (2003). Potential cost-saving opportunities in the supply chain. Surgical Services

Management. 9 (2). OR Manager (2003). Technology in surgery: top ten safety issues with medical devices. OR Manager, 19 (4). OR Manager (2003). OR technology: are you planning for staff training and safety for new energy modes? OR

Manager, 19 (6). OR Manager (2003). Materials management: strategies for involving physicians in a product conversion project.

OR Manager, 19 (7). 4.3 Preventative Maintenance Programs PRACTICE

RATIONALE

4.3.1 All equipment should be on a preventative maintenance program. The frequency of the routine will vary according to the risk class of the equipment.

Equipment is classified according to the potential of the equipment to injure/malfunction and according to the severity of an injury should one occur.

4.3.2 Documentation of preventative maintenance checks should include but not be limited to: - date of inspection/intervention; - identity of equipment inspected (serial

number, asset number); - type of inspection that was carried out; - results of inspection; - name and title of person carrying out the

inspection/intervention; and - any repairs/replacement of parts.

Provides the information required for an investigation should an incident occur.

4.3.3 Documentation should be retained and immediately available to perioperative staff.

May be required for legal defence and/or quality control.

4.4 Risk Alerts/Recalls PRACTICE

RATIONALE

4.4.1 Health care facilities shall have a process that defines how "recalls" or risk alerts will be

Having a policy in place to define the recall process and outline to whom the recall notice will go to


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handled. The policy should include, but not be limited to: - defining common entry point/person for

recall notices; - defining distribution of the recall notice

to all departments/individuals; - defining action to be taken for specific

types of recall; - consistency in the approach to manage

recalls; - documentation of action taken should be

retained by a designated individual; and - discontinuation of the sterilizer until its

performance can be verified. Recall notices are generally sent to the risk manager, materials management or the biomedical technician for further dissemination to department heads and or departments.

increases efficiency and helps eliminate confusion. Documentation may assist in legal defence.

4.5 Intra-operative Equipment Malfunction PRACTICE RATIONALE 4.5.1 Health care facilities shall have clear

policies and procedures related to the reporting of equipment failures during surgery.

Documentation of events may assist in identifying equipment that needs replacement, processes that require revision, and/or equipment that may lead to patient injury in the future.

REFERENCES

Canadian Standards Association. (2004). CSA Z314.22-04. Management of Loaned, Shared and Leased medical

Devices. Toronto: Author.

BIBLIOGRAPHY Accreditation Canada. Formerly known as CCHSA. www.accreditation-canada.ca Canadian Patient Safety Institute (CPSI). www.patientsafetyinstitute.ca OR Manager (2002). What you should know about device recalls. OR Manager.18 (4), p. 21. Santa Fe: OR

Manager Inc. 4.6 Specialized Surgical Equipment 4.6.1 Electrosurgery Unit (ESU) Whenever an Electrosurgery Unit is used, it shall be operated in conjunction with a smoke evacuator.


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PRACTICE RATIONALE

4.6.1.1 Initial education and ongoing continuing education regarding the use of ESU’s shall be provided to all perioperative staff.

4.6.1.2 Perioperative nursing staff should understand the principles of electricity.

Education decreases errors and potential injuries to patients and staff. Understanding these priniciples enhances the nurse’s ability to operate the machine safely and troubleshoot appropriately. (Megadyne, 2010)

4.6.1.3 As part of an ongoing preventative maintenance program ach ESU shall have an identification number.

The identification number will assist in the follow-up record of repairs and checks and will assist in the investigation of a sentinel event.

4.6.1.4 All defective or suspect equipment shall be removed from service immediately, labeled for repair and checked by biomedical engineering or maintenance personnel (as authorized by the facility).

Defective equipment may result in patient or staff injury.

4.6.1.5 A brief set of clearly readable operating instructions should be readily accessible with each system. These instructions should be

placed on or attached to each ESU for reference (AORN, 2008, p. 316). A complete

manufacturer's operational manual should also be readily available.

Provides a quick reference for equipment review and use.

4.6.1.6 Metal jewellery should be removed.

Metallic jewellery, including that used in body piercing, presents a potential risk of burn from directed current (i.e. active electrode touching it), heat conducted before an electrode cools, and leakage current. Small metal objects touching the electrode can concentrate current and result in patient injury. Eliminating contact with metal minimizes the risk. (AORN, 2008)

4.6.1.7 Electrical cords, plugs and footswitch cords shall be checked for fraying and damage prior to each procedure.

Electrical cords in good repair will prevent potential injuries to patients and staff.

4.6.1.8 The ESU footswitch should be covered with a clear, impervious cover if there is a potential for fluid spills.

Liquids may pose an electrical hazard. This facilitates easier cleaning.

4.6.1.9 ESU units shall be completely visible when in operation. 4.6.1.10 Supplies, solutions and drapes shall not be placed on the unit.

Visual accessibility allows for continuous monitoring. Fluid spills may cause the unit to short circuit

4.6.1.11 The alarm system and audio signal shall be functional, loud enough to be heard over other

Ensures awareness of the ESU activation and alerts personnel to mechanical or electrical malfunction.


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PRACTICE RATIONALE

sounds and shall not be turned off.

4.6.1.12 Follow manufacturer’s instructions for compatibility and proper function when using two or more electrosurgical units simultaneously.

To ensure safe practice.

4.6.1.13 Confirm that the prepped area is dry prior to applying surgical drapes. Plastic adhesive drapes may also be used to cover the surgical area.

Flammable agents such as alcohol are potential fire hazards. “Alcohol based surgical prep solutions can ignite with the use of electrocautery and lead to fire in the operating room. Covering the skin with a clear plastic adhesive drape also reduces the collection of alcohol vapor at the site, thus reducing the chances of fire”. (Batra, S. & Gupta, R. Patient Safety in Surgery 2008)

4.6.1.14 The ESU should be operated at the lowest effective power setting for coagulation and cutting. Increased power settings beyond recommended levels should be questioned and documented.

4.6.1.15 If the operator requests a continual increase in

power, personnel should check the entire ESU and accessories circuit for correct/complete installation.

Excessive power may indicate an operational or mechanical problem. To confirm the system is functioning appropriately.

4.6.1.16 Assess the patient’s skin integrity pre and postoperatively for alternate site burns. Ensure the area under ECG leads, and any other potentially grounded sites are included in the assessment.

“Patients are exposed to alternate site burns because (1) current follows the easiest, most conductive path; (2) any grounded object, not just the generator, can complete the circuit; (3) the surgical environment offers many alternative routes to ground; (4) if the resistance of the alternative pathway is low enough and the current flowing to the ground in that path is sufficiently concentrated, an unintended burn may be produced at the alternate ground site”. (Valleylab, 2007 ) “Although sticky adhesive patient return pads rarely cause pressure ulcers, the adhesives can contribute to skin problems that break down further during a patient’s recovery period.” (Megadyne, 2010, pdf pg.10)

4.6.1.17 Any adapters used must be approved by the manufacture and shall not impede the safety features of the generator.

To ensure patient safety .

4.6.1.18 Documentation should include : - type of unit and serial number; - hair removal, if applicable; - location of dispersive electrode;

Documentation helps health risk management in the event of an injury to patients or staff. Documentation provides a baseline assessment and future reference. It may also be used as a legal


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PRACTICE RATIONALE

- cutting and coagulation settings; - name of the perioperative Registered

Nurse applying the dispersive electrode; and

- condition of skin after removal of the dispersive electrodes.

document.

Disposable Dispersive Electrode Pad

4.6.1.19 Manufacturer’s recommendations shall be followed related to the type of disposable dispersive electrode pad to be used with the ESU.

4.6.1.20 A dispersive electrode pad should not be

applied when using only bipolar electrosurgery accessories.

The current flows between the tines of the bipolar forcep and not through the patient. If a pad is applied, the electrosurgical effect may not be limited to the tissue between the bipolar electrodes.

4.6.1.21 Pre-gelled disposable dispersive electrode pads should remain in a sealed protective outer package until time of use.

Integrity of the gel/adhesive is protected while in a sealed package.

4.6.1.22 Pre-gelled disposable electrode pads shall be checked for expiry date and discarded if expired.

Integrity of the pad may be altered over time. Manufacturer cannot be held accountable if the product that was used has expired

4.6.1.23 Appropriate sized, disposable dispersive electrode pad shall be used for adult, paediatric, infant and neonate patients.

Using the appropriate size pad will minimize the potential for patient injuries. With extremely obese patients, a second parallel dispersive electrode may sometimes be used to increase the overall dispersive pad surface area, decrease the electrode-to-skin contact impedance, and reduce current density. Some ESU manufacturer’s provide adapters that permit users to attach two return electrodes to their units when used with obese patients. (ECRI, 2008)

4.6.1.24 The disposable dispersive electrode pad shall not be cut or adjusted in size and should be visually inspected for integrity, discoloration, and insufficient amounts of conductive adhesion.

The size of the pad is proportionate to the current it can disperse. To ensure a damaged or faulty pad is not used.

4.6.1.25 Excessive hair, oils, or lotions should be removed prior to application of the disposable dispersive electrode pad.

Excessive hair, oils, and chemicals interfere with current conduction and adherence of the disposable dispersive electrode pad. An unshaved area underneath the dispersive electrode will inhibit complete electrode-to-skin contact, result in high electrode-to-skin contact impedance, and lead to heating of or arcing to the tissue under the electrode. (ECRI 2008)


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PRACTICE RATIONALE

4.6.1.26 The disposable dispersive electrode pad shall be applied to a well-muscled, clean, dry area as close to the operative site as possible, ensuring that uniform body contact is maintained.

Vascular supply in muscle assists in the dispersal of heat generated thereby reducing the potential for skin burns. Uniform application prevents wrinkling and tenting and ensures adequate grounding of the patient.

4.6.1.27 Avoid placing the disposable dispersive electrode pad on areas of the body with bony prominences, skin folds, scar tissue, prostheses, areas of erythema or other skin lesions, or areas of impaired circulation.

Pad placement on healthy, intact skin will minimize risk of patient injury. Fatty tissue may impede electrosurgical return current flow “Surface area impedance can be compromised by: excessive hair, adipose tissue, bony prominences, fluid invasion, adhesive failure, scar tissue, and many other variables”. (Valleylab 2007)

4.6.1.28 The disposable dispersive electrode pad shall be positioned and protected from areas of potential fluid spills. A disposable dispersive electrode pad subjected to spills shall be replaced.

See rationale 4.6.1.22. Fluid may cause loosening of the disposable dispersive electrode pad and increase the susceptibility of the patient to thermal or chemical burns.

4.6.1.29 Disposable dispersive electrode pad shall be positioned away from implantable devices i.e. pacemakers, metal prostheses and areas distal to the tourniquet if used.

Electrical interference may occur with multiple medical devices. Burns may also occur when the electrical current seeks an alternate device or pathway. Adequate tissue perfusion is necessary for the promotion of electrical conductivity and heat dissipation.

4.6.1.30 The disposable dispersive electrode pad that is removed shall not be re-applied or re-adjusted. 4.6.1.31 Tape shall not be used to secure disposable

dispersive electrode pads in position.

The adhesive and gel portion of the electrode may be rendered ineffective after removal or repositioning. Non-adherence of the tape to the skin may result in a patient burn.

4.6.1.32 The disposable dispersive electrode pad shall be applied after all positioning is complete. If the patient is repositioned during surgery, the disposable dispersive electrode pad and cable shall be checked for contact and adherence to the skin and replaced if necessary.

The disposable dispersive electrode pad and cable may be dislocated or damaged by repositioning.

4.6.1.33 Personnel should place the dispersive electrodes as close as possible to their respective surgical sites and ensure that single-use dispersive electrodes do not overlap”. (AORN, 2008, p. 320)

4.6.1.34 The cable attached to a disposable dispersive electrode pad shall be in good repair and fit snugly into the correct receptacle of the ESU machine.

Damaged or poorly fitting cables are potentially hazardous and may cause patient injury.


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PRACTICE RATIONALE

4.6.1.35 The cable length should be adequate to prevent tension on the disposable dispersive electrode pad.

Cable tension may result in disconnection from electrosurgery unit, and/or tenting of the disposable dispersive electrode pad.

Reusable Capacitively - Coupled Return Electrode

4.6.1.36 A commercially prepared reusable capacitively-

coupled return electrode may be used. It provides a larger area for dispersal of current and

therefore, potential injury to delicate, fragile skin is lessened.

4.6.1.37 Inspect reusable return electrode for integrity and expiration date. Never cut or adjust the size of the return electrode.

Damaged and expired return electrodes may not provide the necessary protection required. If used the manufacturer may not accept any responsibility should the patient endure injury. Cutting or altering the return electrode may interfere with the electrodes ability to protect the patient and properly alert the system of failure.

4.6.1.38 The cable attached to a reusable capacitive return electrode shall be in good repair and fit snugly into the correct receptacle of the ESU machine.

Damaged or poorly fitting cables are potentially hazardous and may cause patient injury.

4.6.1.39 The surface of a reusable return electrode pad shall be free from cracks, tears, and holes. If a sheath covering is used it shall be clean and intact.

4.6.1.40 Manufacturer's recommendations shall be followed regarding the use of reusable return electrode pads including but not limited to: - patient’s age and size; - type of generator it may be used with; - positioning; and - settings

“This electrode pad is inappropriate for patients weighing less than 25 lb because adequate contact (weight-bearing area) could not be achieved”. (Rothrock, J. 2007, p. 222)

4.6.1.41 Manufacturer's recommendations shall be followed in the cleaning and storage of reusable electrode pads.

To decrease potential cross contamination to the patient and increase life expectancy of the pad.

Cord/Hand Piece - Active Electrode

4.6.1.42 Verify that the activation tone functions at the minimum control setting during all acceptance and routine ESU inspections. Check the ESUs in inventory to be sure the activation tone is functioning properly. (ECRI, 2008)

Testing ensures the activation tone is functioning and can be heard appropriately.


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PRACTICE RATIONALE

4.6.1.43 Single-use active electrodes shall not be reused.

Single-use medical devices are not sold with reprocessing instructions.

4.6.1.44 The integrity of the active electrode shall be checked prior to each use (metal has smooth surface, with no chips or grooves; Teflon coat has no chips or cracks).

To ensure the electrode is safe to use and has not been damaged in the shipping or with reprocessing

4.6.1.45 A non-piercing clip or a cloth/Velcro® fastener should be used to secure the active electrode cord to the drape.

Prevents the electrode from falling off the sterile field.Piercing towel clips may damage the cord of the active electrode.

4.6.1.46 Place electrodes in a clean, dry, well-insulated protective holder when not in use.

Reduces the risk of injury due to accidental activation of the ESU.

4.6.1.47 Activation of the electrode should occur when ready to deliver the electrosurgical current and the tip of the active electrode is in view. Deactivate the electrode before the tip leaves the surgical site.

Required as a patient safety measure.

4.6.1.48 When foot controlled active electrodes are used, the foot pedal shall be activated by the operator holding the active electrode being activated.

Reduces the potential for injury to the patient and/or members of the surgical team.

4.6.1.49 Prolonged activation of the active electrode should be avoided.

Short bursts rather than continuous activation reduces the chance of burns.

4.6.1.50 A disposable scratch pad should be used to decrease the build-up of eschar on the electrode tip (except if using Teflon coated electrode tips/blades). Sponges should not be used to clean active electrode tip.

4.6.1.51 Check your provincial legislation regarding the authority to deliver an electrical current to the patient. If not authorized directly, this will require a delegation from medicine to nursing.

The tip of the active electrode must be kept free from debris to function properly. A clean tip decreases activation time to produce the desired effect. Use of a sharp to clean the electrode may damage the electrode and is a potential for injury to staff. The potential for fire is increased if a sponge is used to clean tip (accidental firing of electrode). Wet sponges will conduct electricity. Legislation regarding the application of energy. Delegation is a legal process within the legislation of each province.

Use of Electrosurgery in Laparoscopic Procedures For electrosurgery unit issues related to laparoscopic procedures see Section 3 - Minimally Invasive Surgery 4.6.2. Argon-Enhanced Coagulation An argon enhanced electrosurgical device combines argon gas with electrosurgical energy to improve the effectiveness of the electrosurgical current” (Rothrock, J. 2007, p. 225).


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4.6.2.1 The following recommendations should be followed when using argon-enhanced coagulation (AEC):

- Limit the argon flow settings to the lowest levels that will provide the desired clinical effect (i.e., 4 L/min or less);

- Purge the electrode and argon gas tank line of air according to the manufacturer’s instructions;

- Always leave one instrument cannula vent open to the atmosphere during AEC, and remove the electrode from the body cavity when AEC is not being performed;

- Use only laparoscopic insufflators with nondefeatable audible and visual overpressurization alarms;

- Use patient monitoring (e.g., end-tidal carbon dioxide Doppler flow) that is considered effective for early detection of venous or pulmonary gas embolism; and

- Follow the manufacturer’s specific recommendations, and continue to follow established procedures to prevent gas embolism during laparoscopic surgery; ensure that staff is properly trained to detect and manage gas embolism in laparoscopic procedures (ERCI)

The flow of argon gas clears the surgical site of blood and fluids and blows away oxygen. Argon gas is heavier than air, inert, and non-combustible, providing an efficient pathway for the electrosurgical energy from the electrode to the target tissue. Provides better visibility of the bleeding site or target area and decreases the chance of combustion and surgical smoke. Minimizes risk of potential injury to patients and staff. The pressure of the Argon gas clearly exceeds the pressure in the venous system. To decreases the risk of gas embolism.

4.6.2.2 Manufacturer's safety and cleaning instructions shall be followed.

To prevent injury or cross contamination to the patient.

4.6.3 Ultrasound Technology 4.6.3.1 Manufacturer's recommendations shall be followed relating to the safe use and cleaning of equipment.

Minimizes risk of potential injury to patients and staff.

REFERENCES

Association of PeriOperative Registered Nurses. (2008). Recommended practices for electrosurgery. Perioperative Standards and Recommended Practices. Denver: Author. Batra, S. & Gupta, R. (2008). Alcohol based surgical prep solution and the risk of fire in the operating room: a case report. Patient Safety in Surgery, 2008-10-14 http://www.pssjournal.com/content/2/1/10 ECRI, (2008). Electrosurgical Unit Activation Tone Control, http://www.mdsr.ecri.org/summary/detail.aspx?doc_id=8189


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ECRI, (2008). ESU Burns from Poor Dispersive Electrode Site Preparation, http://www.mdsr.ecri.org/summary/detail.aspx?doc_id=8204 ECRI, ( 2008). Electrosurgery Checklist. http://www.mdsr.ecri.org/summary/detail.aspx?doc_id=8271 ECRI, ( 2008). Fatal Gas Embolism Caused by Overpressurization during Laparoscopic Use of Argon Enhanced Coagulation, http://www.mdsr.ecri.org/summary/detail.aspx?doc_id=8248 Megadyne, (2010) Principles of Electrosurgery, http://www.megadyne.com/pdf/Electrosurgery1.pdf Rothrock, J. (2007). Alexander’s care of the patient in surgery, (13thed.) Toronto: Mosby. Valleylab, (2007). Principles of Electrosurgery, http://www.valleylab.com/education/poes/poes_02.html

BIBLIOGRAPHY

Australian College of Operating Room Nurses Ltd. (2004) ESU equipment in the perioperative setting. Standards, Guidelines & Policy Statements. Reference A5

Canadian Standards Association (2008). CSAZ305.13-09 Plume scavenging in surgical, therapeutic, diagnostic and

esthetic settings. Toronto: Author. Cunnington, J (2006). Facilitating benefit, minimizing risk: responsibilities of the surgical practioner during electrosurgery, 16 (4), 195-202. HealthStream, (2005). Measuring Competency in electrosurgery A Study guide. Denver: Author. HealthStream, (2005). Understanding Electrosurgery from Active electrodes to Return Electrodes. Denver: Author. National Association of Theatre Nurses (NATN). (2004). Electrosurgical Equipment. Standards and

Recommendations for Safe Perioperative Practice. NATN: Harrogate: UK: Author. Phillips, N.M. (2007). Berry & Kohn's operating room technique (11th ed.). Toronto: Mosby. 4.6.4 Laser Safety/Administration

Light Amplification by Stimulated Emission of Radiation Medical Lasers are Class III and Class IV lasers. PRACTICE RATIONALE

Laser Committee

4.6.4.1 Health care facilities in which laser technology is used shall have a laser committee (LC).

Laser committee is responsible for: -setting the credentialing parameters for laser use in the facility; - providing oversight of the laser safety program - promoting safe laser use;


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4.6.4.2 Membership should include but not be limited to:

- facility administrator; - medical laser safety officer; - risk manager; - manager surgical suite; - perioperative laser nurse; - physicians from every specialty using

lasers; - clinical educator; - biomedical engineer; - occupational health and safety officer;

and - anaesthesiologist.

- reviewing and assessing incidents; and - planning educational needs. Each member will bring input from his/her own experience and specialty in order to create a safer environment. To provide a consistent and efficient laser service within the institution. Educators may be called on to assist with policy statements.

Credentialing 4.6.4.3 Perioperative Registered Nurses shall be

made aware of those physicians who have been credentialed and granted privileges by the facilities Laser Committee to use a laser. This information will include the type of laser they are credentialed for.

4.6.4.4 Perioperative Registered Nurses shall be credentialed/recredentialed annually to operate the laser The course consists of, but is not limited to:

- laser physics and laser tissue interaction;

- laser type classifications; - clinical applications - laser safety issues for the patient and

operator; - laser hazards; and - “hands-on” experience.

4.6.4.5 A record of physicians with laser privileges,

Laser Safety Officers, and perioperative Registered Nurses’, who are credentialled in lasers and their use, should be available and updated regularly according to the institution’s laser policy.

To ensure a safe laser program is implemented throughout the institution. To maintain an updated list of staff with laser privileges and education. To provide proof of certification and/or recertification

Medical Laser Safety Officer (LSO)

4.6.4.6 Responsibilities include but are not limited

Provides a nationally recognized standard of care


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to: - implementing CSA Z386-08 standards; - being responsible for knowing and

understanding both the Nominal Hazard Zone (NHZ) and the Maximum Permissible Exposure (MPE) for each type of laser used in the surgical suite;

- being responsible for all laser activity and reporting to the Laser Committee; (CSA Z386-08);

- reviewing the manufacturer’s instructions for installation and maintenance of the laser equipment and ensuring the equipment is properly installed;

- confirming the currency of the health care facility policy and procedure manual yearly based on CSA Standards;(CSA Z386-08);

- monitoring and enforcing compliance with required standards and regulations;

- assessing educational needs and planning in-services (yearly or as needed); (CSA Z386-08);

- organizing safety audits (at least yearly); (CSA Z386-08);

- appointing LSO deputies if required; (CSA Z386-08);

- confirming a current list of credentialed physicians and perioperative Registered Nurses, if health care facility determines it to be necessary. (Ball, 2004., p. 62);

- confirming that the laser operating manual and the laser policy and procedure manual are easily accessible; (CSA Z386-08);

- confirming that a maintenance file be kept for every laser and preventive maintenance be done by authorized personnel; (CSA Z386-08); and

- collaborating with the Laser Committee analyzing all accident reports and recommending changes as required. (CSA Z386-08).

Laser Perioperative Registered Nurse 4.6.4.7 Responsibilities include but not limited to:

- understanding the terms controlled area, NHZ and MPE and ensuring these areas

Is a resource person for all staff. Provides a safe environment. CSA Standards provide a basis for revision as required. Ensures a safe environment for patients and staff. Improves safety in the laser program. Maintains safety in laser program. Assistance may be required at times. For legal purposes and patient safety. For reference if required. To maintain laser in full operating function. Also may be used for legal purposes. Analysis determines the cause and prevents similar incidents from occurring by modification of the laser policy and procedure manual.


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have the appropriate signage and personal protective equipment.

- transporting appropriate laser-related equipment to the theatre/treatment room and assembling all needed equipment and disposable items;

- completing the listed responsibilities as outlined within the controlled area.

- turning off the laser machine and removing the key if the machine is left unattended in the theatre; (CSA Z386- 08) - allowing the laser to run through a self check program noting any errors;

- errors will be documented and the laser will be taken out of service until cleared by biomedical engineering;

- prior to bringing the patient into the room calibrating and/or test firing according to manufacturer’s instructions where applicable; If unable to test fire prior to patient entering the theatre, then test fire should be completed prior to applying the laser to the patient;

- positioning the foot pedal when the surgeon is ready to operate the laser and removing all other foot pedals away from the surgeon;

- the laser foot pedal shall be operated by the surgeon;

- constantly being in attendance while the laser machine is in use;

- the laser machine shall be in standby mode at all times unless verbally directed by the surgeon to the ready mode;

- when the laser is in the ready mode, the laser nurse’s responsibility will be entirely directed to the laser and the surgeon;

- covering exposed tissue around the surgical site with wet towels, sponges or non-flammable materials;

- making sure all personnel in or about to enter the laser treatment area are wearing appropriate protective equipment and apparel. This includes goggles designed for the wavelength of the laser being used, long sleeve warm up jackets or gowns to reduce the amount of exposed skin;

Affirms equipment is in proper working order. Prevents inadvertent activation of the laser. The moisture disperses the energy of the beam in the non-operative areas To decrease potential injury due to abherrant beams in the nominal hazard zone (NHZ).


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- remove any volatile solutions and have appropriate fire extinguisher immediately available;

- ensure skin prep solutions have dried before applying drapes; - entering data in a log book for each

laser procedure i.e., patient name, file number, treatment performed, name of physician activating the laser , name of the perioperative Registered Nurse attending the laser, laser, hand piece or fibre used and parameters used; (CSA Z386-08);

- completing a laser safety checklist for each procedure; (CSA Z386-08) and

- removing laser keys and storing away from the laser when not in use (CSA Z386-08).

4.6.4.8 Documentation should include but not be limited to :

- type of laser (fibre, handpiece) used; - eye protection used by the patient and

the health care team; - skin protection and if wet towels were

applied; - parameters set;

- length of treatment and power used; and

- use of smoke evacuation equipment. (CSA Z386-08).

Alcohol based prep solutions may ignite if the alcohol has not evaporated off For reference purposes. Log book is kept for legal purposes. Retain records as per health care facility policy For legal purposes and to confirm delivery of patient care. Removal of keys prevents unauthorized use of the laser by untrained personnel. (Some newer machines have a numeric code that is to be entered in order to activate the laser) .

Controlled Area

4.6.4.9 The Laser Perioperative Registered Nurse shall be aware of the controlled area for safe laser use. The treatment room or theatre becomes that controlled area and she/he shall: - restrict traffic to key personnel only; - place warning signs conspicuously at all

entrances to the theatre/treatment room to alert bystanders to the type of laser in use;

- signage will include: the word, “Danger”, the starburst symbol, the precautions to take-including the optical density of the glasses required, the laser type, class and wavelength;

- remove signs when the laser procedure

To protect the patient and the health care team. Avoids unnecessary risk to other health care team members. Warning signs and/or light systems alert personnel to implement laser safety requirements, which reduce exposure of eyes and skin to hazardous levels of laser radiation.


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is complete; - lighted signs are optional; - Keep doors to the room closed and

cover windows and openings (i.e. space between the door frame, observation deck etc.) with a barrier that blocks transmission of a beam as appropriate to the type of laser being used;

reduce reflective surfaces as much as possible;

- have an appropriate fire extinguisher immediately available; and

- if laser safety protocols are being breached , inform the MLSO, follow the healthcare facility’s laser policy and risk management process.

Safe and appropriate use of the laser during surgical intervention is a priority.

Eye Protection 4.6.4.10 Personnel:

Eye protection specific to the wavelength of the laser in use: - shall be worn by all health care team

members in the controlled area; - shall be approved by the MLSO; - shall be permanently labeled with the

wavelength and the ocular density; - shall be available at each entrance to the

controlled area; - shall be inspected prior to each use for

damage/scratches. If there is a concern, consult the manufacturer of the eye wear;

- should have side-shields; and - should be stored in individual cases or

sleeves when not in use.

To protect health care team members against eye injuries from an unwanted reflected beam, a break in a fibre or a sudden disconnection of a laser coupler. Prescription glasses do not provide adequate protection with CO2 laser. (Ball, 2004). Different laser wavelengths require different eyewear. Coating degradation or scratched surfaces of glasses/goggles may allow the laser beam to penetrate which may damage the wearer's eyes. Scratches can change the optical density and leave the wearer vulnerable to a laser injury To protect them from damage.

4.6.4.11 If the patient is awake for treatment: same eye protection worn by the health care team shall be worn by the patient. Ensure that in the supine position, there are no gaps between the goggles and the patient’s face.

4.6.4.12 For a patient requiring general anaesthesia, eye protection is provided by:

- using a water-based lubricant on the conjunctiva gently closing the patient’s eye lids and securing with tape;

- covering the eyes with moistened eye

Prevents injury to eyes. Avoids creating lid injuries. Water-based gel is not flammable whereas an oil- based ointment is. Wet eye pads will diffuse the beam and the


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pads (there should be aluminum foil-shiny side up or black felt between 2 wet eye pads for wavelengths between 0.4 and 1.4 micrometers) and securing with waterproof tape;

- covering the eyes with a wet towel; and- water-base gel and special corneal - shields should be used for treatment

close to the eyes or on the eyelids.

waterproof tape will help retain moisture in the pads. Provides the best protection available.

Fire Safety 4.6.4.13 Patients and health care team members

should be protected from fire hazards associated with laser use. Including but not limited to:

- Never use flammable solutions on the

surgical field if laser is planned; skin preparation should be non flammable; - ensure the area prepped is dry before

applying drapes; - “Drape the rectum with wet towels or

use a saline-soaked radiopaque sponge in the rectum to prevent unintentional expulsion of methane gas”. (Andersen, 2004);

- protect tissue adjacent to laser impact site, with wet or fire retardant drapes; (CSA Z386-08)

- water based gels only should be used on the patient (e.g. to slick down hair);

- a bowl of sterile water or normal saline solution and wet towels should be readily available on the sterile field; and

- a fire extinguisher shall be available in each room. (CSA Z386-08)

4.6.4.14 For upper airway laser procedures the Perioperative Registered Nurse should be aware that the anesthesiologist will require:

- a laser- safe endotracheal tube ( already contains the dye in the cuff) - a back-up tube tested and ready for use- inflating the endotracheal tube cuff with dyed saline if laser safe tubes are not available. (AORN, 2008, ) - a tracheostomy set available in the

Laser beams can cause fires if they strike directly or are reflected onto combustible material i.e. rubber, paper alcohol based-preparations etc. To decrease the potential for fire. “Methane gas (i.e. flatus) is a concern when the surgeon is working in the perineal area with a CO2 laser”. (Andersen, 2004) To avoid thermal burns. Water based gels are not flammable. To extinguish a small fire on the patient or drapes. To control a fire in the room and/or laser system. Class IV laser beams can ignite flammable materials. To recognize punctures and take immediate action.A solution in the cuff will absorb more energy before perforating. Surface of these tubes will give diffuse reflections if hit by the beam. If the airway cannot be re-established following an airway fire, a tracheostomy must be performed.


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room.; and - a flexible bronchoscope shall be

available.

4.6.4.15 The Perioperative Registered Nurse will collaborate with the anesthesiologist regarding facility protocol for dealing

with jet ventilation using hunsaker ventilation tubes when laser surgery is required.

Instruments 4.6.4.16 Anodized, dull non-reflective or matte finished instruments shall be used near the laser site. Instruments that have been coated (i.e. ebonised) should be inspected regularly to ensure the integrity of the coating.

To reduce the reflectivity of laser beams

Plume (Laser Smoke) 4.6.4.17 Laser plume shall be evacuated at the source by a smoke evacuator in compliance with CSAZ305.13-09. 4.6.4.18 Wear a surgical masks that provides adequate filtration(0.1micron filtration) fitted snugly around the face.

For further information on laser plume evacuation, refer to Smoke Evacuators, Section 3.

Carcinogenic substances along with chemicals and viruses are present in plume. Laser-specific masks are intended to minimize inhalation of particles and viruses in plume. A mask, if not worn properly, will not protect the user.

REFERENCES Andersen, K. (Jan. 2004). Safe use of lasers in the operating room: what a perioperative nurse should know. AORN http://www.findarticles.com/p/articles/mi_m0FSL/is_/ai_112686288 Ball, K. A. (2004). Lasers: The perioperative challenge. (3rd ed.). Denver: Author. Canadian Standards Association (2008). CSA Z386 01-08 Laser Safety in Health Care Facilities. Toronto: Author.

BIBLIOGRAPHY

Association for Perioperative Practice (United Kingdom). Prior to 2005 known as National Association of Theatre Nurses (NATN). www.afpp.org.uk Association of PeriOperative Registered Nurses. (2008). Recommended practice for perioperative nursing laser

safety in the practice setting. Perioperative Standards and Recommended Practices. Denver: Author.


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BC Centre for Disease Control, Radiation Protection Services (September 2005). Laser Hair Removal Devices – Safety Guidelines for Owners/Operators – http://www.bccdc.org/downloads/pdf/rps/reports/Guidelines%20of%20Hair%20Removal%20Laser%20Workers%20

Rev5RR9external%20revBPrevRBPrevvRR1final.pdf Ball, K.A. Surgical Modalities in Rothrock, J.C.(2003) Alexander’s Care of the Patient in Surgery. (12th ed.)

Toronto: Mosby. Canadian Centre for Occupational Health and Safety Lasers – Health Care Facilities, Documented last updated July

4, 2003 Copyright 1997-2008 http://www.ccohs.ca/oshanswers/phys_agents/lasers.html Canadian Standards Association. (2008). CSAZ305.13-09 Plume scavenging in surgical, therapeutic, diagnostic and

esthetic settings. Toronto: Author. Koivula, Brenda & Minielly, Brenda, (2006). Canadian Introduction to Green Light Laser. Canadian OperatingRoom Nurses Journal. 24 (1). National Association of Theatre Nurses (NATN). (2004), Lasers. Standards and Recommendations for Safe

Perioperative Practice. NATN: Harrogate: UK.: Author. York University (September 2008), Laser Safety Program. http://www.yorku.ca/dohs/documents/lasersafety.pdf The University of Western Ontario, Human Resources Occupational Health and Safety. Laser Safety Manual (April

1, 2006). http://www.uwo.ca/humanresources/docandform/docs/ohs1/manuals/laser_safety_manual.pdf 4.7 Minimally Invasive Surgery (MIS) PRACTICE

RATIONALE

The Perioperative Registered Nurse is responsible for:

4.7.1 Understanding the differences between endoscopic and non endoscopic reusable instruments.

4.7.2 Obtaining and maintaining skill in the care, handling and management of equipment including scopes, light sources, micro-endoscopic instrumentation, video cameras and insufflators.

To provide safe, efficient care. To provide safe, efficient care.

4.7.3 Monitoring the functioning of equipment and the integrity of endoscopic instruments in collaboration with other health care team members.

To ensure equipment is safe and functioning appropriately.

4.7.4 Confirming a brief set of operational directions are readily accessible with each system . These instructions should

Availability of proper written instructions assists in the safe use and handling of equipment and thereby reduces the potential


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be placed on or attached to the equipment in the theatre. A complete manufacturer’s operational manual should be available.

risk of patient injury.

4.7.5 Ensuring information regarding correct assembly and intended use is available .

4.7.6 Having a clear understanding of the instructions for reprocessing including disassembly; and reassembly.

Assists in the safe use of equipment.

Assists in the safe use of equipment.

4.7.7 Monitoring that disposable, reusable and multi-use instruments are used according to manufacturer's recommendations. This includes endoscopic trocars meeting the safety criteria established for the practice setting.

The most frequent catastrophic patient injury involves trocars. Organ and vessel trauma may occur from excessive use of pressure during trocar insertion (AORN, 2008, p. 336)

4.7.8 Confirming that sharps such as trocars and varres needles are handled, processed, and stored appropriately.

Reduces the risk of injury to patients and staff.

4.7.9 Confirming that: - each piece of endoscopic equipment

(i.e. video camera, monitor, insufflator) has an assigned identification number;

- video monitors are secured to carts or ceiling mounts and are positioned for good visibility by surgical team members;

- a new single use compatible hydrophobic filter is attached to the carbon dioxide insufflator for each case;

- the insufflation tubing is flushed with gas before connecting to the cannula;

- the insufflator is elevated above the level of the operative site;

- the tubing is disconnected before turning of the insufflators

- disconnect the tubing from the cannula - if CO2 is not piped in a second full gas

cylinder is readily available; - the ESU is set at the lowest setting to

achieve the desired tissue effect; - cannulae are all metal or all plastic and

not a hybrid system; - electrodes are visually inspected pre-

operatively and post-operatively for


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possible loss of insulation integrity and replaced as necessary;

- the power is decreased on light sources prior to turning the machine off;

- endoscopic light cords not connected to the telescope are turned off or placed in standby mode;

- appropriate precautions (e.g. eye protection) are taken during endoscopic surgery and at the time of release of CO2 from the abdomen;

- if an active electrode monitoring device is to be used with an ESU, it is turned on; and

- instruments and supplies for an open procedure are readily available.

4.8 Flexible Endoscopes 4.8.1 Manufacturer’s instructions must be

followed for the use, care and reprocessing of flexible endoscopes.

4.8.2 Flexible endoscopes shall be inspected for

functionality and cleanliness prior to and following use.

Inspection includes but is not limited to : - the control section and the endoscope

connector for loose parts, irregularities, and deformities;

- the angulation knobs for ease and control;

- the boot and entire insertion tube for dents, bulges, holes, cracks and other irregularities;

- the lens at the distal end of the insertion tube for scratches, cracks, stains or other deformities; and

- running your fingers down the entire length of the insertion tube to check for smoothness and to ensure no objects are protruding through the tube.

4.8.3 Manual cleaning shall commence

immediately following the clinical procedure. It is recommended that the

manufacturer’s recommendations for leak

Endoscopes are complex, delicate structures.. Manufacturer’s instructions are crucial to ensure the endoscope is safe for patient use and to prevent damage to the scope. Using an endoscope that is not functioning properly may cause injury to the operator or patient and result in more severe damage to the endoscope. Poorly cleaned endoscopes pose an infection-control risk to the patient and/or operator performing the procedure.


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testing and manual cleaning be followed. This includes but is not limited to:

- removing debris from instruments by wiping with a soft cloth; - Leak test as per manufacturer’s Instruction; - if scope fails leak test, remove from service and send to biomedical department or service contract holder; - if scope passes leak test continue; - disassemble the instruments; - remove sealing caps; and - pen all stopcocks. 4.8.4 Thoroughly rinse all instrument components with water. The water temperature should not exceed 20° C

(68°F). 4.8.5 Use a medical-grade, low-foaming, neutral pH detergent or enzymatic detergent and follow the manufacturer's dilution and temperature recommendations. 4.8.6 When instruments with lumens are cleaned, ensure that the cleaning solution

contacts all surfaces of the lumen. Always rinse residual cleaning solution and debris from lumens by connecting them to a water hose or a syringe.

4.8.7 Thoroughly rinse all of the instrument’s

components with deionized or sterile water to remove all disinfectant residues.

4.8.8 If non-sterile water is used for rinsing,

wipe the instrument components and flush the channels with 70% ethyl or isopropyl alcohol.

4.8.9 After the alcohol rinse, flush air through

the channels to remove all alcohol. Do not reuse rinsing water.

4.8.10 Do not immerse instrumentation in cleaning solution for more than 1 hour. 4.8.11 Use a soft cloth to wipe off any remaining

Leaks in the endoscope can lead to fluid invasion escalating damage to the endoscope and increasing the risk of cross-contamination. Perforation of the sheath may have occurred during the procedure Lumens are very difficult to check, debris left sitting will dry quickly making it difficult to effectively reprocess. Channels with debris can not be disinfected or sterilized. Clogged nozzles and channels jeopardize patient safety. Cleaning solutions may contain various aggressive compounds (e.g. chlorine) which can corrode the instrument. To remove all residues, rinse the instrument thoroughly with deionized or sterile water.


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water. 4.8.12 Automatic washer disinfectors may be

used. Use only washer-disinfectors which are intended specifically for cleaning and disinfection of endoscopic instruments and accessories by the washer disinfector manufacturer. Also refer to the washer-disinfector's instruction manual.

4.8.13 Reprocess according to manufacturer’s recommendations. This may include: - Steam sterilization; - Ethylene oxide sterilization;

- Peracetic Acid sterilization; or at a minimum,

- high level disinfection. 4.8.14 Documentation of decontamination

and/or reprocessing should include but is not limited to:

- the patient’s name; - record number;

- procedure performed; - date and time; - serial number;

- person manually decontaminating scope; and

- method of reprocessing.

Each scope is numbered for tracking purposes. To assist in outbreak investigation.

REFERENCES Association of PeriOperative Registered Nurses. (2010). Recommended practices for endoscopic minimally invasive

surgery. Standards, Recommended Practices and Guidelines. Denver: AORN. CSA Z 314.8-08 Decontamination of reusable medical devices Olympus “System Guide-Endoscopy”, Olympus publisher (2010)

Ontario Provincial Infectious Disease Advisory Committee. (2007) Best Practices for Infection Prevention and

Control Programs in Ontario in All Health Care Settings. Retrieved April 26, 2009 from http://www.health.gov.on.ca/english/providers/program/infectious/pidac/pidac_fs.html

4.9 Telerobotics

4.9.1 Perioperative Registered Nurses should understand the goals and the objectives of

Telerobotics has evolved from a diagnostic modality and minimally invasive surgical


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telerobotic surgery. technique to advanced information technology offering treatments and procedures over long distances.

4.9.2 Telerobotic surgery requires that the perioperative Registered Nurse has additional education and training.

Telerobotic surgery programs allow distant experts to assist physically in operations through the use of a robotic device. To assist surgeons in telerobotic surgery.

BIBLIOGRAPHY Chapman, T., Jansen, H., Tyler, L., Prowse, C., Little, C., McGrinder,D. (2001). iView Centre for minimal access

surgery nursing program. (Version 1.0) [CD ROM]: Hamilton, ON: Chapman Interactive. Ellis, K. (11/07/2006). Endoscope Cleaning and Repair Keeping valuable scopes fit for duty. EndoNurse. http://www.endonurse.com/articles/681feat2.html Gandsas, A. (n.d.). Internet site for laparoscopic surgery. Retrieved April 28, 2003, from

http://www.laparoscopy.com John, A., Clement, L., & Strul, T. (May 05, 2007). Sharpen your focus on endoscope reprocessing http://www.matmanmag.com/manmatmag_app/jsp/articledisplay.jsp?dcrpath=MATMANMAG/PubsNewsArticleGen/data/05MAY2007/0705MMH_FEA_Hotline

Rothrock, J. (2007). Alexander’s care of the patient in surgery. (13th ed.). Toronto:Mosby. Schraag, J. (05/01/2007). Ask the experts: endoscope reprocessing. http://www.surgicenteronline.com/articles/751feat.html


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Section 4

Environmental Hazards and Responsibilities


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Environmental Hazards/Responsibility Section 4 Revision Date: March 2011 of 334

Section 4 Environmental Hazards and Responsibilities

Physical Hazards ............................................................................................................................................ 250 Environmental Factors ..................................................................................................................... 250 Light ...................................................................................................................................... 250 Noise ...................................................................................................................................... 251 Ventilation/Temperature/Humidity ....................................................................................... 252 Electricity ......................................................................................................................................... 254 Radiation Safety ............................................................................................................................... 256 Fire/Explosion .................................................................................................................................. 260 Chemical Hazards ........................................................................................................................................... 263 Anesthetic Agents ............................................................................................................................ 263 Sterilizing Agents - Ethylene Oxide ................................................................................................. 264 Other Sterilizing Agents ................................................................................................................... 264 Formaldehyde ........................................................................................................................ 265 Glutaraldehyde ...................................................................................................................... 265 Methyl Methacrylate ........................................................................................................................ 265 Drugs: Cytotoxic, Dyes, Pharmaceuticals ........................................................................................ 266 Waste Management ........................................................................................................................................ 266 Infectious/Biohazardous Waste ........................................................................................................ 266 Latex Sensitivity/Allergy: Staff ...................................................................................................................... 268


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Physical Hazards

1.1 Environmental Factors 1.1.1 Light PRACTICE RATIONALE

1.1.1.1 Lighting levels shall be maintained to

provide safe patient care. 1.1.1.2 Consideration should be given to the

purchase of matte, satin or grey coloured finished instruments.

1.1.1.3 Appropriate colour selection for surgical

drapes, walls, and ceilings should be considered to facilitate the reduction of glare causing eyestrain and fatigue.

1.1.1.4 An emergency lighting system must provide

dependable illumination while the primary lighting system is off.

1.1.1.5 In the event that the emergency lighting

system does not automatically activate, an alternate means of illumination should be readily available.

Provides adequate illumination for assessment and treatment of patient. Allows acceptable visualization of surgical field. Inadequate lighting (i.e. intensity, glare, and colour) can distort tissue appearance. Excessive glare causes eye fatigue and strain. Matte, satin or grey-coloured finishes eliminate glare and reduce eyestrain. Soft, cool colours, especially blues, greys, and greens, are less reflective for drapes and walls than white is. Failure of a lighting system could create conditions dangerous to the health and safety of patients and members of the healthcare team. An emergency lighting system must be provided for the workplace and the exit routes. It is essential that in the event of a power outage, and no back up generation, those illumination devices such as flashlights be easily accessible. Flashlights should be available in every OR, they should be available in the same location in each OR (locating items in the dark is a challenge) and a regular maintenance schedule for the batteries should be set.

BIBLIOGRAPHY

Canadian Centre for Occupational Health and Safety. http://www.ccohs.ca/oshanswers/phys_agents/noise_basic.html Canadian Standards Association compendium of Occupational Health and Safety Standards. http://csa.ca/standards/occupational/Default.asp?language=english (CSA Standands Z1000-06 Occupation Health and Safety Management)


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Philips, N.M. (2007). Berry & Kohn’s operating room technique. (11th ed). Toronto: Mosby 1.1.2 Noise 1.1.2.1 The theatre should be as quiet as possible

except for the essential sounds of communication between team members directly concerned with the patient's care.

Talking can increase airborne microorganisms. Working in a quiet environment produces fewer psychological and physiologic patient adverse effects and is less fatiguing to healthcare team members. Talking should be limited to the essential. Annoyance, stress and interference with oral communication are of primary concern in a noisy OR. Effective communication is essential to minimize the potential for error. Even during deep stages of anaesthesia, an anaesthetized patient may perceive noises and conversations that occur during the surgical procedure and may have recall.

1.1.2.2 Noise levels should not exceed the provincial Occupational Health & Safety parameters or impede hearing in the room.

1.1.2.3 Consideration should be given to the use of

appropriate, low volume music to reduce anxiety and/or distract the patient during the procedure.

Extreme noise from drills, fan motors in equipment, and other sources can be annoying and potentially dangerous to patients and personnel. The noise can become intense enough to increase blood pressure and to provoke peripheral vasoconstriction, dilation of the pupils, and other subtle physiologic effects. It can also interfere with necessary communication and thereby provoke irritation. (Phillips, 2007, p. 215) Study results indicate that patients who listen to their choice of music during surgery experienced significantly lower anxiety levels, heart rates, and blood pressure than patients who did not listen to music.

1.1.2.4 Music should be selected in collaboration with the patient.

1.1.2.5 Music should be turned off at the request of

the patient or any member of the health care team.

Music may be relaxing for the patient and effect efficiency of the health care team.

To provide a respectful environment.

REFERENCES Phillips, N.M. (2007). Berry & Kohn’s operating room technique. (11th ed.). Toronto: Mosby. Nilsson, U. (2008).The anxiety and pain reducing effects of music interventions: a systematic review. AORN

Journal. 87(4), 780-807.


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BIBLIOGRAPHY Canadian Centre for Occupational Health and Safety. http://www.ccohs.ca/oshanswers/phys_agents/noise_basic.html Canadian Standards Association compendium of Occupational Health and Safety Standards. http://csa.ca/standards/occupational/Default.asp?language=english Hamlin, L., Richardson-Tench, M. & Davis, M. (2009). Perioperative nursing an introductory text. Sydney: Elsevier. Nilsson, Ulrica. (2008). The anxiety-and pain-reducing effects of music interventions: A systematic review. AORN

Journal, 87(4), 780-807. Rothrock, J. (2011). Alexander’s care of the patient in surgery. (14th ed.). Toronto: Mosby. Worley, D. J. & Hohler, S. E. (2008). OR Construction & Renovations. AORN, 88 (6) 917-941.

1.1.3 Ventilation/Temperature/Humidity PRACTICE

RATIONALE

1.1.3.1 The ventilating system in the perioperative environment shall provide air exchanges as recommended by provincial and/or CSA (Z317.2.10) standards. Ventilation should consider asepsis as well as physical comfort.

1.1.3.2 A scent free environment should be part of

the institution’s policies and procedures. 1.1.3.3 Ventilation systems should help remove

toxic fumes and anesthetic gas waste.

1.1.3.4 OR ventilation shall be maintained at positive pressure with respect to the corridors and adjacent areas.

1.1.3.5 All air should be introduced at the ceiling

level and evacuated near the floor level. 1.1.3.6 Efforts shall be made to minimize personnel

traffic and ensure that the OR doors remain closed.

Ventilation enables air dilution and the removal of airborne microorganisms. This minimizes the potential for infection via airborne/droplet transmission. Perfume and other odours can cause nausea or respiratory congestion in sensitive persons. Removal of air pollution protects surgical suite personnel. Positive air pressure prevents infiltration of microorganisms from the corridor and adjacent areas. Note: it may be necessary to reverse the air pressure to negative in the presence of an operative patient carrying an airborne disease such as TB or measles. OR air may contain microbial laden dust, lint, skin squamous or respiratory droplets and is directly proportional to the number of personnel moving about in the room. Closed doors maintain positive pressure.


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Environmental Factors- Temperature

PRACTICE

1.1.3.7 The temperature of an OR should be maintained between 20-24 degrees C (AORN, 2010). Exceptions may include pediatric, burn, geriatric, or hypothermic patients.

Environmental Factors- Humidity

PRACTICE

1.1.3.8 Surgical suites shall maintain a relative humidity of 30-60% (CSA Z317.2.10).

1.1.3.9 Humidity levels should be reviewed on a

regular basis to ensure compliance with CSA Z317.2.10 Standards.

RATIONALE

An OR temperature in this range may inhibit bacterial growth. This range is one that most patients can tolerate and is most comfortable for personnel. Increased room temperature may be necessary to attain and maintain normothermia.

RATIONALE

A relative humidity of 30% to 60% inhibits bacterial growth and decreases the potential for static electricity. A relative humidity that is too high can result in damp or moist supplies with added opportunities for mold growth. A relative humidity that is too low can result in excessive bacteria laden dust within the surgical environment. Relative humidity levels may be difficult to maintain in certain geographical locations and during certain times of the year

REFERENCES

Association of PeriOperative Registered Nurses. (2010). Recommended practices for a safe environment of care. Perioperative Standards and Recommended Practices. Denver: AORN.

Canadian Standards Association (2010). CSAZ317.2-2.10) Special requirements for heating, ventilation, and air

conditioning (HVAC) systems in health care facilities. Toronto: Author.

BIBLIOGRAPHY

Canadian Standards Association compendium of Standards for Health Care Facility Engineering. www.csa.ca Gruendemann,B., Mangum, S., (2001). Infection Prevention in the Surgical Setting. Philadelphia: Saunders

Mayhall, C. G. (2004). Design & Maintanence of hospital ventilation systems and the prevention of airborne


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infections, Hospital epidemiology & Infection Control (3rd ed.). Philadelphia: Lippincott Williams & Wilkens Phillips, N.(2007)Berry & Kohn’s operating room technique. (11th ed). Toronto: Mosby. Phippen, M. & Wells, M. (2002). Patient care during operative and invasive procedures. Toronto: W.B. Saunders. Rothrock, J. (2011). Alexander’s care of the patient in surgery. (14th ed.). Toronto: Mosby. Woodhead, K. & Wicker, P (2005). A textbook of Perioperative care. Philadelphia: Churchill Livingstone 1.2 Electricity PRACTICE

RATIONALE

1.2.1 Only CSA-approved electrical equipment shall be used.

1.2.2 A qualified biomedical electrical staff member

shall check the electrical safety and integrity of each piece of equipment prior to entering the workplace.

1.2.3 The circulating Perioperative Registered

Nurse shall have knowledge of the safe use and function of each piece of electrical equipment. Operator manuals shall be available for each electrical device.

1.2.4 The circulating Perioperative Registered

Nurse is responsible to provide the healthcare team with properly maintained equipment and to report deficiencies to management.

1.2.5 Staff members shall be competent using

electrical equipment. Electrical equipment should be inspected before use; including review of outlets and switch plates for damage, checking power cords and plugs for fraying or other damage.

1.2.6 All defective or suspect equipment shall be

removed from service immediately, labeled for repair and checked by authorized personnel.

1.2.7 Follow facility policy and procedures

regarding faulty/damaged/dropped electrical

Safe electrical equipment reduces injury potential to patients and members of the health care team. Equipment may be damaged during shipment/movement. Malfunctioning equipment and non-compliance with manufacturer’s instructions may put patients and healthcare team members at risk. The circulating perioperative Registered nurse is responsible for confirming equipment is available and working order. Defective equipment may result in patient or staff injury.


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PRACTICE

RATIONALE

equipment. 1.2.8 All electrical devices used for patient care

shall be included in a preventative maintenance program incorporating specific manufacturer’s recommendations.

A systematic program helps identify when each piece of equipment is due for a routine check or preventative maintenance.

1.2.9 Electrical "alerts" from external agencies shall be provided to surgical suite management, following health care facility policy.

Recall and removal of defective equipment is an important risk management function.

1.2.10 Line isolation monitoring systems or ground fault interrupting systems should be provided for continuous monitoring of current leakage. Surgical suite personnel shall follow the facility’s procedure when a warning signal is activated.

Systems that monitor current leakage and ground integrity identify the potential risks of shock, cardiac fibrillation, or burns produced by electrical current flowing through the patient’s body to ground hazards in the surgical environment.

1.2.11 Liquids shall never be placed on an electrical device.

1.2.12 The electrical device shall be turned off when

plugging into or unplugging from the power receptacle.

When disconnecting the plug from the electrical outlet, the plug rather than the cord, shall be handled.

A spill could cause an internal short circuit and injury to a patient or members of the healthcare team. Proper handling prevents fibre breakage within the electrical equipment.

1.2.13 Electrical extension cords should not be used in operating rooms. If necessary, use only power bars with built in breakers that have been approved by the Biomedical Department. Electrical cords of adequate length should be attached to equipment. Cords shall not be revised unless specific manufacturer's approval is obtained.

Extension cords are associated with current leakage.

1.2.14 Cords lying on the floor shall be secured (taped/covered) to prevent tripping.

1.2.15 If power bars are used, they must not be

placed on the floor.

Securing cords can prevent accidental unplugging of equipment and injury from tripping. Fluids may enter the bar causing a loss of power.


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PRACTICE

RATIONALE

1.2.16 Electrical cords shall be loosely coiled during storage.

1.2.17 Electrical/biomedical departments shall be

consulted in the decision to purchase, replace/repair electrical equipment.

1.2.18 In the event of a power failure, Perioperative

Registered Nurses should be aware of the effects to critical equipment during transfer from regular power to generated power i.e. automatic shut down of equipment, or data loss.

BIBLIOGRAPHY

Association of PeriOperative Registered Nurses. (2010). Recommended practices for a safe environment of care. Perioperative Standards and Recommended Practices. Denver: AORN.

Canadian Standards Association (2008). Z462-08 Workplace Electrical Safety Standard. Toronto: Author. Phillips, N.(2007). Berry & Kohn’s operating room technique. (11th ed.). Toronto: Mosby. Rothrock, J. (2011). Alexander’s care of the patient in surgery. (14th ed.). Toronto: Mosby. 1.3 Radiation Safety PRACTICE

RATIONALE

1.3.1 Radiation Protection Acts of each province and CSA Standards shall be followed.

Provincial and federal legislation regulates the recording and reporting process of radiation monitoring.

1.3.2 Health care facility policies and procedures shall be developed and implemented in accordance with provincial and federal government regulations.

Current radiation safety policies and procedures will contribute to quality patient and personnel care.

1.3.3 All persons exposed to ionizing radiation with significant frequency or during prolonged procedures may be required to wear a dosimeter, a device used to measure levels of ionizing radiation in the workplace.

A dosimeter will allow monitoring of exposure to radiation on a regular basis and will help occupational health specialists assess the risk in case of accidental exposure. A dosimeter can help ensure that best practices are followed to keep doses as low as can reasonably be achieved.


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PRACTICE

RATIONALE

1.3.4 Dosimeters are worn on the area of the body with the highest likelihood of radiation. A dosimeter is assigned to a specific individual. Do not loan or exchange your dosimeter with another person. Thermoluminescent dosimeter = TLD

1.3.5 Radiation safety policies and procedures should be included in the orientation and annual education of all members of the healthcare team.

Radiation safety practices will be reinforced and misconceptions or unrealistic practices related to radiation exposure and monitoring will be corrected.

1.3.6 Diagnostic Imaging (DI) equipment shall be operated by, or under the direct supervision of, qualified individuals (Health Canada, 2008).

Optimum safety for patients and personnel is achieved by safe work practices.

1.3.7 During a procedure, the constant monitoring of radiation safety precautions for patients and personnel shall be a shared responsibility between perioperative Registered Nurses, Diagnostic Imaging Technicians and Physicians.

The perioperative Registered Nurse is responsible for: 1.3.8 Confirming that safety precautions are in

place to protect patients and members of the healthcare team from the potential hazards of ionizing radiation.

“X-rays of all frequencies can damage tissues and may produce long-term effects. The effects of radiation are dose-dependent and cumulative: the larger the dose or the more frequent the exposure, the greater the risk of the effects of radiation” (Rothrock, 2007, p. 20). Ionizing radiation can accumulate in human tissue and alter cell composition. Exposure to ionizing radiation should be kept as low as possible.

1.3.9 Providing patient protection during DI procedures by: - maintaining the integrity of the sterile

field during radiographic examination; - using an appropriate lead shield

positioned between the patient and radiation sources if it will not interfere with the sterile field or visualization for the DI study. Shields should be placed:- over reproductive organs during

radiographic studies of the abdomen, hips, and upper legs,

Being cognizant of the key factors of radiation protection: time, distance, and shielding.


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PRACTICE

RATIONALE

where possible; and - over the thyroid/sternum during

radiographic studies of the head neck, and upper extremities;

- using a lead shield to protect the fetus of a pregnant patient;

- reconciling an incorrect surgical count before using a radiological examination;

- documenting on the perioperative record; type of radiographic equipment used, type of patient protection used and area(s) protected.

Low levels of ionizing radiation may be harmful to a fetus if x-ray is done in close proximity.

1.3.10 Confirming the following precautions for the health care team are used to limit the length of exposure to radiation: - pregnant staff should wear a lead apron

which wraps around and covers the back;

- provide relief/replacement staff, where possible, for pregnant staff to eliminate/reduce exposure during pregnancy;

- radiation equipment is turned off when not in use;

- Regulations related to specific radioactive materials shall be available to the health care team including handling of the material/containers, safe proximity to the radiated patient, handling of body tissues or fluids emitting radioactivity.

Although radiation is present only when the equipment is energized, turning off the unit when not in use will prevent inadvertent activation.

1.3.11 Confirming the following precautions are used to distance personnel as far as possible from the source of ionizing radiation: - unsterile team members who can safely

do so should leave the theatre during each single DI exposure;

- sterile team members and others who cannot leave the theatre should stand 2 meters (6 ft) or more from the patient, and behind a portable lead screen which is positioned behind a portable x-ray machine if possible, and out of the direct beam during exposure;

- lead shielding shall be provided to

Exposure is significantly reduced at this distance.


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PRACTICE

RATIONALE

personnel who cannot stand 2 meters (6 ft) away from the x-ray tube and patient, or follow equipment manufacturer’s instructions.

- that if the lead apron does not wrap around the body, team members should face the radiation source;

- holding devices, such as slings, traction devices, sandbags, and cassette holders, should be used to maintain the position of the patient and x-ray film; and

- wearing of radio protective gloves in addition to aprons and thyroid shields/collars if the patient must be held;

To provide protection, the lead apron must be between the source of radiation and the body. Lead screens and/or lead aprons and thyroid shields minimize exposure to scattered ionizing radiation. Holding devices allow personnel to reduce their exposure by distancing themselves from direct and scattered ionizing radiation.

1.3.12 Confirming that during fluoroscopy, in addition to leaded aprons, personnel should wear: - thyroid shields if they are in proximity

to the patient; - eye protection (lead-glass lenses or face

masks with lead-acrylic windows) if they are next to the patient during frequent or long periods of fluoroscopy; and

- radio protective gloves if their hands are exposed to the direct beam.

The potential for exposure to radiation is greater during fluoroscopy than during conventional radiographic studies due to increased radiation scatter and exposure time.

1.3.13 Confirming that lead aprons and thyroid collars are appropriately hung or laid flat when not in use;

Folding can crack the lead, making the shield ineffective.

1.3.14 Confirming that lead shields/aprons and thyroid collars be tested upon receipt and routinely by the diagnostic imaging department to fulfill provincial requirements;

Defects may not be visually detected.

1.3.15 Confirming that warning signs for DI equipment are affixed to the theatre door(s) when radiographic equipment is in use.

Personnel are alerted to the presence of ionizing radiation being used, and can take appropriate radiation protection precautions before entering the theatre.


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REFERENCES

Health Canada. (2008). Safety procedures for the installation, use and control of x-ray equipment in large medical

radiological facilities. Safety Code 35, Ministry of Health: Ottawa. Phillips, N.M. (2007). Berry & Kohn’s operating room technique. (11th ed.). Toronto: Mosby Rothrock, J. (2011). Alexander’s care of the patient in surgery. (14th ed.). Toronto: Mosby.

BIBLIOGRAPHY

Association of PeriOperative Registered Nurses. (2010). Recommended practices for reducing radiological exposure in the perioperative practice setting. Perioperative Standards and Recommended Practices. Denver: AORN.

Canadian Standards Association (2005). CSA C22.2 number 114-M90 Diagnostic Imaging & Radiation therapy Equipment . Toronto: Author. Chaffins, J. (2008) Radiation protection and procedures in the OR. Radiologic Technology, 79(5), 415-428. Phillips, N.M. (2007). Berry & Kohn’s operating room technique. (11th ed.). Toronto: Mosby. Ursprung, W., Howe, J., Yochum, T., Kettner, N. (2006) Plain film radiography, pregnancy, and therapeutic abortion

revisited. Journal of Manipulative and Physiological Therapeutics, 29(1), 83-87

1.4 Fire/Explosion PRACTICE

RATIONALE

1.4.1 The potential of fire should be a matter of prime concern in the surgical suite.

1.4.2 All personnel shall be educated about the fire

safety program during initial orientation and reviewed on a regular basis according to facility/regional policy. Specific instructions about the expectations for the perioperative setting and the response and role of each employee in the event of a fire should be described.

1.4.3 Practice drills should be conducted routinely according to facility/regional policy.

The fire triad/triangle in the perioperative setting consists of fuel (flammable and combustible liquids, vapours, and gases, prep solutions, drapes, sponges, etc) and an ignition source (ESU, Laser, electrical equipment) in an oxygen-rich environment. Expedient and proficient performance is required in a disaster This represents a key component of fire safety preparedness. Annual fire and patient safety training


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PRACTICE

RATIONALE

1.4.4 Surgical suite personnel should be

knowledgeable regarding: - the location of fire alarms; - the location of exits; - the evacuation routes and techniques; - the steps in reporting a fire; - automatic fire detection and suppression

systems; - the location of shutoff valves for oxygen

and other gases; and - the types, uses and location in the unit of

the fire extinguishers. 1.4.5 Precautions shall be taken when using heat-

generating equipment. Surgical suite personnel shall identify fire hazards and apply appropriate safeguards, such as: - the anaesthesia machines, cylinders of

compressed gas, and flammable liquid containers should be kept away from any source of heat and must not touch each other;

- oil or grease is not used on oxygen valves or parts of anesthetic machines. Oil or grease should not contact any cylinders, including those containing ethylene oxide, compressed air, or nitrogen;

- if flammable antiseptics and fat solvents are used for preoperative skin preparation before laser and electrosurgery, they shall be allowed to dry; following manufacturer’s recommendations;

- precautions shall be taken when using a possible ignition source, such as laser, the electrosurgical unit or fiber optic light cables;

- precautions shall be taken when using

heat generating equipment such as the operating microscope; and

- apply a small drip of sterile water on a moving drill/burr of power tools.

1.4.6 Volatile liquids shall be stored according to

manufacturer’s recommendations and provincial fire codes.

programs can help to maintain skills and knowledge. A mixture of gases under high pressure is hazardous. Spontaneous combustion can occur when flammable agents are exposed to an ignition source in the presence of oxygen. Pooled solutions and vapours can ignite. Laser and other heated objects can cause fire or explosion. Light cords can spontaneously ignite drapes. Connect all light cords to telescopes prior to turning the light source on. Always use a safety holster for electrosurgical tips. Heat may build up under coverings of heat generating equipment. Helps to reduce heat build-up as drill/burr moves through the bone. Chemical components may be altered by temperature and lighting variances.


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PRACTICE

RATIONALE

1.4.7 Fire extinguishers shall be regularly

maintained and dated according to provincial regulations.

1.4.8 Instructions for activating fire alarms shall be

posted at each alarm location. 1.4.9 If fire blankets are available for use, follow

manufacturer’s instructions. Fire blankets shall not be used for a fire burning on a patient.

Outdated extinguishers present an additional hazard. The fire can continue to burn unobserved under the blanket.

REFERENCES

Canadian Standards Association. (2009). Z 305.13-09 CAN/CSA Plume scavenging in surgical, diagnostic,

therapeutic, and aesthetic settings. Toronto: Author. Phillips, N.M. (2007). Berry & Kohn’s operating room technique. (11th ed.). Toronto: Mosby.

BIBLIOGRAPHY

AMT Electrosurgery. Nurses Advocating Smoke –free Theatres Immediately. http://www.becomenasti.com/resources.htm Association of PeriOperative Registered Nurses AORN (2010). Perioperative Standards and, Recommended Practices.Denver: Author. Association of PeriOperative Registered Nurses. (2005). Recommended practices for electrosurgery. Standards,

Recommended Practices, and Guidelines. Denver: AORN. Hamlin, L., Richardson-Tench, M. & Davis, M. (2009). Perioperative nursing an introductory text. Sydney: Elsevier. National Institute for Occupational Safety and Health (NIOSH 1998). Control of smoke from laser/electric surgical

procedures. NIOSH Publication No. 96. p. 128. http://www.cdc.gov/niosh/hc11.html Phippen, Mark L., Wells, Maryanne Papanier, Patient Care during Operative and Invasive Procedures, 2000, p. 155,

W.B. Saunders Company Toronto. Rothrock, J. (2010). Alexander’s care of the patient in surgery. (14th ed.). Toronto: Mosby. Taylor, S. (2009). The OR: Smoking in a Designated Non-Smoking Area. Canadian Operating Room Nurses

Journal, 27( 1).


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Chemical Hazards

Monitoring of exposure to Chemical Hazards shall comply with provincial legislation/guidelines. 2.1 Anesthetic Agents PRACTICE

RATIONALE

2.1.1 A waste gas control program using scavenging equipment and procedures shall be used.

Personnel exposure is reduced by 90-95% with proper use of scavenging equipment. (Rothrock, 2011)

2.1.2 The air quality should be checked according to the health care facility’s policy and provincial guidelines.

Safe air quality will improve the environment for the health and safety of the healthcare team.

2.1.3 The manufacturer’s liquid anesthetic dispensing devices shall be used when transferring anesthetic agents into vaporizers.

Control of anesthetic agent’s pollution into the environment protects the health care team.

2.1.4 Qualified personnel shall maintain anesthetic machines daily and provide routine preventative maintenance.

2.1.5 Engineering control procedures should maintain a high flow rate of fresh air into the air-conditioning system.

The rate of removal of gases by the disposal system depends on the rate at which fresh air enters the surgical suite and the pattern taken by the air currents as they circulate through the theatre.

2.1.6 A surgical suite atmospheric monitoring program shall be utilized to record trace anesthetic levels.

Monitoring devices (i.e. personal dosimeters) will determine the effectiveness of the waste anesthetic gas control measures.

REFERENCES

Rothrock, J. (2011). Alexander’s care of the patient in surgery. (14th ed.). Toronto: Mosby.

BIBLIOGRAPHY

Ontario Occupational Health and Safety Act. Control of exposure to biological or chemical agents. Regulation 833,am. O. Regs. 513/92: 592/94.

Worker’s Compensation Board of British Columbia, Occupational Health & Safety Regulation 296/297. Core Requirements (parts 5-19) pp. 5-10 to 5-14


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CAN/CSA Anesthetic Gas Scavenging Disposal Systems. CAN/CSA-Z7396.2-09 Phillips, N.M. (2007). Berry & Kohn’s operating room technique. (11th ed.). Toronto: Mosby. 2.2 Sterilizing Agents – Ethylene Oxide (EtO) PRACTICE RATIONALE

2.2.1 Items sterilized with EtO shall be thoroughly

aerated prior to handling or use according to the device manufacturer’s instructions. Personnel shall not interrupt the aeration cycle to remove items for use. (CSA Z314.2-09)

Residual by-products of EtO gas can be toxic in direct contact with the skin or by inhalation. Exposure can cause dizziness, nausea, and vomiting. EtO is known to be a mutagen and carcinogen.

2.2.2 EtO gas shall be vented from the sterilizer to the outside atmosphere according to CSA and provincial guidelines to avoid personnel exposure and environmental pollution. Audible and visual alarm systems shall be installed to indicate a failure in the ventilation system.

2.2.3 An evacuation plan shall be in place, posted

and initiated in event of an alarm/leak. 2.2.4 Air quality monitoring shall be in place and

comply with OH&S and CSA standards.

Toxic emissions and residues of EtO present health hazards to patients, members of the healthcare team and the environment. OH&S is responsible for monitoring this process.

2.3 Other Sterilizing Agents 2.3.1 Manufacturer’s instructions for use shall be

followed. Material Safety Data Sheets (MSDS) shall be available.

Examples of sterilizing agents include but are not limited to: - Para Acetic Acid; - Hydrogen Peroxide Plasma; - Ozone Gas; and - Chemical sterilant in solution i.e.

Glutaraldehydes or orthophthalaldehyde (OPA).

2.3.2 Provincial/municipal and occupational health regulations shall be adhered to as they relate to: - personal exposure limits;


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- monitoring of exposures; - installation of systems; - mixing of chemicals; - testing of solutions; - venting of systems; and - disposal of end products.

2.3.1 Formaldehyde 2.3.1.1 Care shall be taken to provide adequate

protection for workers to prevent exposure to skin and respiratory tract.

Use of Personal Protective Equipment (PPE) and adequate ventilation, along with routine periodic monitoring of the environment, protects employees. Formaldehyde is a potent allergen, mutagen, and carcinogen, and is NOT recommended for use. Vapors may be toxic (Phillips, 2007, p 321).

2.3.2 Glutaraldehyde 2.3.2.1 MSDS shall be available. 2.3.2.2 Protective apparel to be worn per

manufacturer’s instructions when using chemical disinfectants.

The Public health agency of Canada issues regulations to educate and communicate material hazards under legislated Workplace Hazardous Information System (WHMIS) in the form of Material Safety Data Sheets (MSDS). The fumes from the liquid form of Glutaraldehyde may be irritating to the eyes, nose and throat. Contact dermatitis has been reported.

2.3.2.3 Glutaraldehyde shall be used according to manufacturer’s instructions.

2.3.2.4 Glutaraldehyde air monitoring systems

should be used.

An exposure limit of 0.2 ppm in room air averaged over 8 hours has been established by OSHA. (Phillips, 2007, p 321).

2.4 Methyl Methacrylate 2.4.1 A closed mixing system should be used

according to manufacturer’s instructions.

The vapours released during mixing are irritating to the eyes and can damage soft contact lenses. The vapours are also irritating to the respiratory tract and they may cause drowsiness. Methyl Methacrylate may be a mutagen, a carcinogen, or toxic to the liver. Pregnant personnel are encouraged to leave the room during mixing and application.

2.4.2 Eye protection shall be worn when handling/mixing methyl methacrylate.

The liquid solvent can cause corneal burns if it splashes into the eyes. It can also diffuse through


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Gloves that are impermeable to this solvent are available.

latex gloves to cause an allergic dermatitis.

2.5 Drugs: Cytotoxic, Dyes, Pharmaceuticals 2.5.1 All chemical agents should be prepared and

administered to minimize unnecessary exposure for both patients and personnel.

Antineoplastic cytotoxic drugs used for chemotherapy can be hazardous, as can laser dyes and other pharmaceuticals.

REFERENCES Canadian Standards Association. (2009). CSA Z 314.2-09 Effective sterilization in health care facilities by the

ethylene oxide process. Toronto: Author. Phillips, N.M. (2007). Berry & Kohn’s operating room technique. (11th ed.). Toronto: Mosby.

BIBLIOGRAPHY Canadian Standards Association. (2009). CSA Z314.9-09 Installation, ventilation, and safe use of ethylene oxide

sterilizers in health care facilities. Toronto: Author. Canadian Standards Association. (2009). CSA Z314.1-09 Ethylene oxide sterilizers for health care facilities.

Toronto: Author.

Cloft, H. J,. Easton, D. N,. Jensen, M. E., Kallmes, D. F. & Dion, J. E (2006) . Exposure of Medical Personnel to Methylmethacrylate Vapor during Percutaneous Vertebroplasty. American Journal of Neuroradiology. Retrieved April 26, 2009 from http://www.ajnr.org/cgi/content/full/20/2/352

Murphy, L. (2006). Ozone-The Latest Advance in Sterilization of Medical Devices. Canadian Operating Room

Nurses Journal 24 (2). Rothrock, J. (2011). Alexander's care of the patient in surgery. (14th ed.). Toronto: Mosby. Worker’s Compensation Board of British Columbia, Occupational Health & Safety Regulation 296/297 Core

Requirements (parts 5-19) pp. 5-27.

Waste Management

3.1 Infectious/Biohazardous Waste PRACTICE RATIONALE

3.1.1 Local/provincial/federal requirements shall

be followed when handling potentially infectious/biohazardous waste.

Medical waste that poses public health and environmental risks is regulated.


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PRACTICE RATIONALE

3.1.2 Potentially infectious waste shall be segregated from general waste at point of use as outlined in CSA Z317.10-09.

3.1.3 Potentially infectious waste shall be placed

in leak proof containers or bags strong enough to maintain integrity during transport to biohazardous waste disposal.

Biohazardous Bags shall be colour-coded according to local/provincial/federal requirements to differentiate infectious waste.

All handlers of infectious waste must be protected from risk of infection/contamination with proper containment that remains intact to the point of final disposal.

3.1.4 Needles and sharps shall be put into tamper proof, puncture-resistant containers clearly labeled as biohazardous.

3.1.5 Fluid containers with blood and body fluids shall be handled with care. Containers shall be impermeable to moisture, resistant to puncture/rupture and sealed to prevent leakage.

3.1.6 Potentially infectious substances and contaminated equipment shall be handled carefully by the health care team and discarded or decontaminated as appropriate i.e. double bagging if outside of the container has been contaminated.

3.1.7 Liquid contaminated waste shall be

transported by: - solidifying at point of use - contained containers. Suctioned blood and body fluids shall be disposed of according to local/provincial/federal requirements. Fluids may be poured down a drain connected to a sanitary sewer. Team members shall take caution when pouring liquids, and wear Personal Protective Equipment such as mask and glasses when disposing of liquids.

Reduces the risk of healthcare team exposure. Treat all blood and body fluids as potential sources of infection. Caution must be taken when pouring liquids to minimize the aerosols.


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PRACTICE RATIONALE

3.1.8 Perioperative Registered Nurses should be aware of and participate in recycling according to the healthcare facility’s policies and procedures.

Reduces environmental impact of high volume long lasting waste materials. A successful program can promote health care team satisfaction.

REFERENCES Canadian Standards Association. (2009). CSA Z317.10-09 Handling of waste materials in health care facilities and

veterinary health care facilities. Toronto: Author.

BIBLIOGRAPHY Phillips, N.M. (2007). Berry & Kohn’s operating room technique. (11th ed.). Toronto: Mosby. CCME Canadian Council of Ministers of the Environment (CCME) http://www.ccme.ca WHO Health Care Waste Management http://www.healthcarewaste.org/en/en/115_overview.html

Latex Sensitivity/Allergy: Staff

True latex allergies are a serious risk to patient and personnel; latex sensitivities may lead to true allergy, therefore all reasonable attempts to reduce latex items from the operating room should be taken. PRACTICE

RATIONALE

4.1 All staff should receive an annual educational session on the following: - awareness of the potential risk of

sensitization to latex and other allergic sensitizers; and

- awareness of products, which contain latex and available alternatives.

4.2 Health care team members should limit their

exposure to latex by: - appropriate use of unsterile latex

gloves. Latex gloves are the glove of choice for high risk situations, involving potential exposure to blood borne pathogens. (Gruendemann & Mangum, 2001, p. 133);

- drying hands thoroughly before donning latex gloves;

Latex allergy is a reaction to certain proteins in natural rubber latex. Latex allergy rates among surgeons and direct care providers are reported between 6-12%. Warm, wet skin absorbs latex particles more readily than dry skin.


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PRACTICE

RATIONALE

- avoiding touching eyes, nose, and mouth while wearing latex gloves;

- removing gloves in a gentle manner; and

- washing hands immediately after

removing latex gloves.

Latex protein molecules can be transferred to sensitive mucous membranes. Glove powder has been shown to bind to free natural rubber latex protein in latex gloves, becoming airborne during glove donning and removal and leaving residue to be inhaled by people in the immediate environment or settle on furniture and equipment. (Cumming, 2002, p. 288) Latex proteins and other contaminants, which are present in powder, are removed by hand washing.

4.3 Avoid lotions that contain oils including mineral, lanolin, coconut, palm or jojoba, as well as Vaseline and other petroleum-based products. Use only water or silicone based moisturizing creams. Confirm with manufacturers of skin care agents to verify latex compatibility.

4.4 Surgical latex gloves should be of low-

protein construction and powder-free. (NIOSH, 1997, No. 97-135)

Petroleum/oil-based products can compromise the integrity of latex by breaking down chemical bonds in the material. Through chemical-mechanical means, the oils disrupt the protective molecular bonds within the glove, compromising protection. (Truscott & Stoessel, 2002, p. 26) Latex proteins bound to cornstarch are allergens, which may induce allergic reactions and increase the risk of upper airway allergies.

4.5 Health care facilities should promote purchasing and/or tender practices indicatingthat non-latex products are preferred.

4.6 Health care facilities should advocate that latex content be well labeled on all products.

Immediate knowledge of latex content of product may avoid potential reaction for latex sensitive staff and patients.

REFERENCES Cumming, R. G. (2002). Reducing the Hazards of Exposure to Cornstarch Glove Powder. AORN Journal. 76(2).

Denver: AORN. Gruendemann, B. & Mangum, S. (2001). Infection prevention in surgical settings. Toronto: W.B. Saunders. Truscott, W., Stoessel, K. (2002, May). Factors Impacting the Infection Control Capability of Gloves. Managing

Infection Control. 18-32.

BIBLIOGRAPHY Association of PeriOperative Registered Nurses. (2010). AORN latex guideline. Perioperative Standards and


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Recommended Practices. Denver: Author. Australian College of Operating Room Nurses. www.acorn.org.au Canadian Standards Association. www.csa.ca DeFreitas Saab, T. (2008). US Dept of Labor Office of Disability Employment, Accommodation and Compliance Series, Employees with Latex Allergy, Job Accommodation Network, Morgantown, WV. Fuller, J. (2005). Surgical technology- principles and practice (4th ed). Philadelphia: Saunders. Goldman, M. A. (2008). Pocket Guide to the Operating Room (3rd ed.). Philadelphia: FA Davies. Hamlin, L., Richardson-Tench, M. & Davis, M. (2009). Perioperative nursing an introductory text. Sydney: Elsevier. Health Canada. http://www.hc-sc.gc.ca International Federation of Perioperative Nurses. www.ifpn.org.uk International Association Healthcare Central Services Material Management (2007) Central Services Technical

Manual. Author. http://iahcsmm.org/ Phillips, N.M. (2007). Berry & Kohn’s operating room technique. (11th ed.). Toronto: Mosby. Public Health Agency of Canada www.publichealth.gc.ca . Rothrock, J. (2011). Alexander's care of the patient in surgery. (14th ed.). Toronto: Mosby. Spry, C. (2009). Essentials of Perioperative Nursing (4th ed.). Toronto: Jones & Bartlett. Woodhead, K and Wicker, Paul. (2005). Textbook of Perioperative Care. Toronto: Elsevier. Workplace BC (2005). Dealing with “Latex Allergies” at Work. Workers’ Compensation Board of BC, Vancouver BC.


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Section 5

Nursing Care of the Anesthetized Patient


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Nursing Care of the Anesthetized Patient Section 5 Revision Date: March 2011 of 334

Section 5 Nursing Care of the Anesthetised Patient

Preoperative Considerations ...........................................................................................................................273

Intraoperative Considerations .........................................................................................................................275 Postoperative Considerations ..........................................................................................................................279 Local Anesthesia.............................................................................................................................................281 Procedural Sedation/Analgesia .......................................................................................................................283 Intravenous Regional Anesthesia (Bier Block) ..............................................................................................288 Regional Anesthesia-Spinal, Epidural, Peripheral Nerve Blocks ...................................................................290 Herbal Remedies.............................................................................................................................................292 Blood and Blood Products ..............................................................................................................................294 Emergency Situations .....................................................................................................................................296 Malignant Hyperthermia ..................................................................................................................296 Latex Allergy....................................................................................................................................298 Cardiac Arrest ..................................................................................................................................300

Disseminated Intravascular Coagulation ..........................................................................................302 Death ................................................................................................................................................304


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Preoperative Considerations

PRACTICE RATIONALE

The perioperative Registered Nurse is responsible for: 1.1 Performing a perioperative nursing

assessment and review of the health care facility’s Preoperative Checklist prior to patient transfer to the OR theatre. This includes but is not limited to: - verification of patient - physiological systems risks i.e. injury, infection: - psychological response to surgical intervention i.e. NPO status; and - relevant allergies are identified and confirmed The perioperative nurse shall ensure the patient’s chart includes but is not limited to:

- history and physical examination; a surgical consent that is complete and matches the planned procedure ; and

- any other documents as required by the health care facility’s policy.

Sources of assessment data include but are not limited to:

- the patient; - patient’s record; and - patient’s family support

Perioperative knowledge to create an individualized patient care plan facilitates patient safety. Perioperative assessment is a key component in the assessment and management of risk. It enhances patient care and improves efficiency.

1.2 Establishing a supportive and caring relationship by: - introducing him/herself by name and

designation; - speaking directly to the patient using

eye contact (without a mask); - actively listening to the patient; and - using touch to convey support and

caring. 1.3 Establishing nursing diagnoses and

planning interventions that are individualized and culturally sensitive, based on assessments that may consider: - co-morbidities; - physical limitations;


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- infection; - fluid balance; - temperature regulation; - pain; - anxiety; - privacy and confidentiality. - glycemic indications - antibiotic prophylaxis; and - risk for venous thromoembolism

(VTE)

1.4 In collaboration with the anesthetic care provider, providing and updating a list of the routine supplies, equipment, and drugs required for the administration of anesthesia and confirming that the listed items are available in the theatre and functioning prior to the patient’s admittance to the operating room.

1.5 Communicating key information identified

in the preoperative assessment to the surgical team

1.6 Applying knowledge and skills in assisting

the anesthesia care provider to assemble, prepare for use, and disassemble anesthetic equipment and supplies required for administration of a specific anesthetic technique i.e. regional blocks, epidurals, spinals, neurolept analgesia, conscious sedation and general anesthesia.

1.7 Confirming that equipment has been

properly cleaned, decontaminated, disinfected, and/or sterilized between each patient as required by healthcare facility’s policies and procedures, provincial and/or federal regulations, and according to manufacturer’s recommendations.

1.8 Overseeing a safe transfer to the OR bed

by: - locking the wheels; - securing and protecting the IV,

drains, tubes and other necessary equipment; and

- providing support to the head, arms, and legs.

Resources are necessary for the anaesthetic care team to function efficiently.

Anaesthesia equipment that has come in contact with mucous membranes, blood or body fluids is decontaminated and reprocessed after use to render it safe for handling and for subsequent patient use. The anaesthesia equipment may harbour microorganisms that spread infections.

To prevent injury to the patient or equipment damage.


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BIBLIOGRAPHY Association of PeriOperative Registered Nurses. (2008). Perioperative Standards and Recommended Practices.

Denver: Author. Australian College of Operating Room Nurses. www.acorn.org.au Canadian Standards Association. www.csa.ca Canadian Standards Association PLUS 1112 (2nd ed.). (Mr. 2004) Infection prevention and control in office-based

health care and allied health. Canadian Standards Association. (2008). Decontamination of reusable medical devices. CSA Standard Z314.8-08.

CSA: Toronto. Crenshaw, J., Winslow, E. (2008). Preoperative fasting duration: Are we improving. AORN Journal, 88(6), 963-976. Fuller, J. (2005). Surgical technology- principles and practice (4th ed). Philadelphia: Saunders. Goldman, M. A. (2008). Pocket Guide to the Operating Room (3rd ed.). Philadelphia: FA Davies. Hamlin, L., Richardson-Tench, M. & Davis, M. (2009). Perioperative nursing an introductory text. Sydney: Elsevier. Neil, J. (2008). Caring for patients with tuberculosis. AORN Journal, 88(6), 942-958. Philips, N. (2007). Berry & Kohn’s operating room technique. (11th ed.). Toronto: Mosby. Provincial Infectious Diseases Advisory Committee (PIDAC). (April 30, 2006) Best Practices for cleaning, disinfection and sterilization (April 30, 2006). Ontario. Retrieved April 26, 2009 from http://www.health.gov.on.ca/english/providers/program/infectious/pidac/pidac_fs.html Rothrock, J. (2010). Alexander’s care of the patient in surgery. (14th ed). Toronto: Mosby. Ryan, K., Johnson, S. (2009). Preventing DVT: A perioperative perspective. AORN Journal, 19(2), 55-59. Spry, C. (2008) Essentials of perioperative nursing. (4th ed.). Mississauga: Jones and Bartlett. Wicker, P., Smith, B. (2006). Checking the anesthetic machine. Journal of Perioperative Practice, 16(12), 585-590. Woodhead, K., & Wicker, P. (2005). A textbook of perioperative care. Toronto: Elsevier.

Intraoperative Considerations

PRACTICE RATIONALE

The perioperative Registered Nurse is responsible for:: 2.1 Ensuring availability and functionality of

equipment prior to admission of the patient


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to the OR theatre. (i.e. fully lighted laryngoscope and suction).

2.2 Remaining at the patient’s side during induction. Being alert to potential induction/intubation complications and able to acquire appropriate and immediate assistance, i.e. suction, difficult intubation equipment.

2.3 Assisting the anesthesia care provider

during induction and as required during the intraoperative period.

2.4 Under direction of the anesthesia care provider, applying effective cricoid pressure, support head positioning, and oxygen administration.

To provide physical protection, and emotional support. Anesthesia involves the administration of potentially lethal drugs and gases. Interaction of these with human physiology can be profound. (Philips, 2007) Cricoid pressure will prevent aspiration of regurgitated stomach contents and is maintained until: - intubation is accomplished; - the cuff on the endotracheal tube is inflated; - bilateral breath sounds have been verified; and - instructed by the anesthesia care provider. Cricoid pressure is contraindicated when: -there is trauma to the anterior neck - unstable C spine -patient is actively vomiting prior to induction

2.5 Maintaining awareness of patient monitoring and communicating/collaborating with the anesthesia care provider during anesthesia.

2.6 Avoiding undue stimulation and providing

a quiet environment that supports anesthetic readiness, patient safety and comfort during induction.

Observation will immediately detect changes in the patient’s condition during the perioperative phases so that adjustments in treatment, as warranted, can be made. Tactile or auditory stimulation may produce excitement in the patient during induction.

2.7 Practicing patient advocacy and taking appropriate action regarding instances of incompetent, unethical, or illegal acts by any member of the health care team or system.

The perioperative Registered Nurse has the unique opportunity to speak on behalf of the patient and interpret individual needs and responses to others who participate in his/her care. Advocacy is a critical issue for surgical patients who are unconscious or sedated and unable to make decisions related to their care. (Boyle, 2005, p 250)

2.8 Keeping the patient appropriately covered.

To maintain patient dignity and privacy; and facilitate normothermia.

2.9 Providing appropriate care to pediatric patients by considering the following: - allowing parental/care giver to be

present if the health care facility

The presence of the parent/care giver may decrease anxiety.


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policy allows; - allowing security/comfort items; such

as blanket, toy, under garments; - employing age appropriate distraction

techniques; and - preventing falls without using a safety

strap.

Security and comfort provides a safe environment for the child. Safety straps may be anxiety inducing for children.

2.10 Applying knowledge of the medications being administered, i.e. induction, maintenance, muscle relaxants, emergency drugs.

Perioperative Registered Nurses must respond immediately and competently to adverse events/reactions.

2.11 Assisting in establishing patient specific invasive and non-invasive monitoring including but not limited to: - temperature, pulse and respiration

(TPR); - blood pressure (BP); - electrocardiogram (ECG); - oxygen saturation ( SAO2); - end tidal carbon dioxide ( ETCO2); - central venous pressure (CVP),

pulmonary artery (PA) and arterial lines;

- fluid and electrolyte status; - urinary output; and - lab tests/results.

2.12 Providing personal protective equipment (PPE) for the health care team during the induction period

2.13 Confirming that contaminated designated single use items are discarded, (i.e. endotracheal tubes, needles, syringe).

The practice of reusing disposable medical devices introduces risks to the patient as well as the health care facility. Liability reverts to the user if the item is reprocessed.

2.14 Assisting to position the patient in a safe manner for the administration of a specific anesthetic, i.e. general, regional, etc.

Certain methods of anesthetic administration require particular positioning.

2.15 Moving an unconscious patient in collaboration with the anesthesia care provider and the health care team employing appropriate lifting/moving devices.

An inadequate number of personnel and/or insufficient equipment can result in patient and/or personnel injury.

2.16 Anticipating, prioritizing, and preparing for the management of anesthetic

emergency situations and responding collaboratively with the anaesthesia care

provider to complications and unexpected

The perioperative Registered Nurse’s response may assist in preventing complications or may prevent complications from deteriorating. Airway management difficulties are related to morbidity and mortality. Quick access to


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events including but not limited to: - aspiration; - rapid sequence induction; - difficult intubation; - airway obstruction and

bronchospasm; - malignant hyperthermia; - hypovolemia; - dysrhythmias and cardiac arrest; - defibrillation;

- external cardiac pacing; - acidosis, alkalosis; and - anaphylaxis.

2.17 Ensuring guidelines for the management of rare emergencies, such as malignant hyperthermia, anaphylaxis and pre-arrest arrhythmias are posted or immediately available.

advanced airway equipment is essential for the provision of safe anesthesia and improves the management of anesthetic emergencies. Enables the team to respond quickly and efficiently.

REFERENCES

Boyle, Heather J. (2005). Patient advocacy in the perioperative setting. AORN Journal, 82(2), 250-262.

Philips, N.M. (2007). Berry & Kohn’s operating room technique. (11th ed). Toronto: Mosby.

BIBLIOGRAPHY

Association of PeriOperative Registered Nurses. (2010). Standards Professional Practice. Perioperative Standards and, Recommended Practices. Denver: AORN.

Ball, K. A. (2009). Do-Not-Resuscitate Orders in Surgery: Decreasing the Confusion. AORN Journal,. 89 (1) 140-146. Canadian Anaesthesia Society (CAS) www.cas.ca CAS Practice of Anaesthesia Guidelines (2008) link on www.ornac.ca Canadian Patient Safety Institute (CPSI). www.patientsafetyinstitute.ca Doddamanegowda, B., Chetlan, & Hughes, R. (2008). Tracheal Intubation, tracheal tubes& Laryngeal Mask Airway. Journal of Perioperative Practice, 18 (3) 88-94. Faber, P & Klein, A. (2008). Theoretical & Practical Aspects of Anaethesia for Thoracic Surgery. Journal of Perioperative Practice, 18 (3) 121-129. Fuller, K. (2005). Surgical technology principles and practices. (4th ed). St. Louis: Elsevier. Hamlin, L., Richardson-Trench, M., Davies, M. (2009). Perioperative nursing: An introductory text. Sydney:

Elsevier. Hardcastle, T. (2009). Anesthesia for repair of cleft lip & palate. Journal of Perioperative Practice, 19 (1) 20-23.


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Middleton, P. (2009). Insertion techniques of the laryngeal mask airway: A literature review. Journal of PerioperativePractice, 19(1), 31-35.

Nunny, R. (2008). Inadvertent hypothermia: A literature review. Journal of Perioperative Practice, 18(4), 148-154. Peiris, K. & Frerk, C. (2008). Awake Intubation. Journal of Perioperative Practice, 18 (3), 96-104.

Poulikas, A. (2008). Preventing Unplanned Hypothermia. AORN Journal, 88 (3), 358-364. Provincial Infectious Diseases Advisory Committee (PIDAC). (April 30, 2006). Best practices for cleaning, disinfection and sterilization. Ontario. Retrieved April 26, 2009 from http://www.health.gov.on.ca/english/providers/program/infectious/pidac/pidac_fs.html Rothrock, J. (2010). Alexander’s care of the patient in surgery. (14th ed). Toronto: Mosby. Ryan, K & Johnson, S. (2009). Preventing DVT: a perioperative perspective. AORN Journal,

19 (2), 55-59. Schroeter, Kathryn. (2002). Ethics in perioperative practice. AORN Journal, 75(5), 941-949. Smith, B. & Rawling, P. (2008). Anesthetic Assistant Competencies: our experience. Journal of Perioperative

Practice , 18(5), 190-192.

Wicker, P &Smith, B. (2006). Checking the Anesthetic Machine. Journal of Perioperative practice,16 (12), 585-590

Postoperative Considerations

PRACTICE RATIONALE

The perioperative Registered Nurse is responsible for: 3.1 Assisting the anesthesia care provider

with reversal of anesthesia and extubation; and remaining with the patient until ready for transfer, being prepared to assist with suctioning, oxygenation and potential complications.

3.2 Assisting with the transfer of the patient

from the OR bed by: - using appropriate number of health

care team members; - transfer devices; and - applying principles of positioning.

Assists with safe emergence from anesthesia. Helps prevent injury. Availability of equipment and supplies ensures preparedness for potential emergencies. The patient is adequately supported. Prevents potential injury to patient and personnel.

3.3 Overseeing a safe transfer from the OR bed by: - locking the wheels; - securing and protecting the IV,

drains, tubes and other necessary

To prevent injury to the patient and equipment damage.


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equipment; - providing support to the head, arm

and legs; and - elevating the side rails.

3.4 Accompanying the patient from the OR

theatre to the receiving care unit with the completed chart and proper records.

3.5 Transferring care of the patient to the

appropriate health care professional. 3.6 Giving a concise verbal report of nursing

care provided to include, but not limited to: - name and age of patient; - pre-op diagnosis; - medical problems (i.e. diabetes); - pre-op medications given; - time of the next dose of antibiotic; - operative procedure done; - intake and output; - vital signs; - allergies; - drains(whether sutured or not); - foley catheter, nasogastric tube; - packing (type and amount/ sutured or

not); - any problems with anaesthesia not

reported by anaesthesia care provider;

- position on the operating bed and devices attached to the skin;

- presence of loose/capped teeth; - medications given (excluding

anaesthesia care provider’s) during surgery;

- physical limitations such as deafness, blindness, arthritis; - intraoperative complications;

- psychological disorders; - patient belongings; - special order(s) for PACU; - language barriers; and - existence of advanced directives.

Nursing intervention may be required during transport. Fluctuation in vital signs, airway obstruction, and vomiting may occur. The patient should be observed by someone familiar with his or her condition. Provides continuity of care from one health care professional to another. Accurate thorough reporting enables the patient to receive effective continuing care and decreases the risk of error.


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BIBLIOGRAPHY Association of PeriOperative Registered Nurses. (2010). Recommended practices for positioning the patient in the

perioperative practice. Perioperative Standards and Recommended Practices. Denver: Author. Fuller K.J. (2005). Surgical technology principles and practice (4th ed.). St. Louise: Elsevier. Hamlin, L., Richardson-Trench, M., Davies, M. (2009). Perioperative nursing: An introductory text. Sydney:

Elsevier. National Association of PeriAnesthesia Nurses of Canada (NAPAN). (2008). Standards for Practice. Pembroke:

Pappin Communications. Philips, N. (2007). Berry & Kohn’s Operating room technique (11th ed.). Toronto: Mosby. Rothrock, J., (2007). Alexander’s care of the patient in surgery. (13th ed). Toronto: Mosby The Royal College of Anaesthetist. Intraoperative care. Retrieved January 24, 2008 from

http://www.rcoa.ac.uk/docs/arb-section2.pdf Younker, J. (2008). Care of the Intubated Patient in the PACU: the ABCDE Approach. Journal of Perioperative Practice, 18(3), 116-120.

Local Anesthesia

PRACTICE RATIONALE

The perioperative Registered Nurse is responsible for: 4.1 Comprehensively assessing the patient

prior to transfer to a theatre for: - physiological systems risks, i.e.

injury, infection; and - psychological response to surgical

intervention, i.e. anxiety, pain; Sources of assessment data shall include but not be limited to: - the patient; - patient’s record; and - patient’s family/support.

Preoperative assessment is a key component in the assessment and management of risk. It enhances patient care and improves efficiency

4.2 Confirming that the surgeon/physician is available prior to administering any medications.

4.3 Monitoring the patient’s physiologic

status and safety during local anesthesia. This should be the only activity assigned to this nurse for the duration of the procedure. He or she should not perform

Patients can respond adversely to the medication. To ensure the patient receives a favourable analgesic/sedative response during the procedure. Continuously monitoring the patient’s physiological and physical status facilitates early detection of potential complications.


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circulating duties simultaneously. (Philips, 2007, p. 443).

4.4 Providing support and reassurance

throughout the perioperative experience. 4.5 Assessing the need for IV access in

collaboration with the surgeon. 4.6 Ensuring oxygen and suction are

available and in working order (turned on) if needed.

4.7 Monitoring of the patient and

documenting the following: - nursing interventions and patient

responses; - level of consciousness; - patient’s comfort level; - BP, heart rate and regularity,

respirations and O2 saturation (frequency dependent on patient’s condition and procedure);

- drug dosage and time of administration - effects of agents used;

- any adverse reaction to the drug administered;

- additional monitoring may be necessary including but not limited to skin temperature and color;

- oxygen administration; - intravenous infusion; and - other pertinent information.

4.8 Being clinically competent in the function

and use of the monitoring equipment to be used, the placement of connections, and the interpretation of data.

4.9 Notifying the surgeon when changes

occur in the patient’s physiological or psychological status.

4.10 Confirming the availability of emergency

equipment and supplies. 4.11 Assessing the patient’s postoperative

status and documenting appropriately.

Support and reassurance increases comfort levels and assists in reducing anxiety. Documentation establishes accountability, promotes quality nursing care, facilitates communication between Registered Nurses and other healthcare providers and conveys the contribution of nursing to care. Serious cardiac or respiratory complications can occur after administration of local anesthetic medication. Monitoring equipment provides the perioperative Registered Nurse with patient data to identify risks and/or complications during a procedure. Knowledge of the function and proper use of monitoring equipment is essential to provide safe patient care. Good communication is essential for optimal patient care. Administration of local anesthetic medications can result in sudden cardiac and respiratory complications.


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4.12 Transferring care of the patient to another

healthcare professional by providing a report of the patient’s status.

Proper reporting is required for continuity of patient care.

REFERENCES Philips, N. (2007). Berry & Kohn’s operating room technique. (11th ed). Toronto: Mosby.

BIBLIOGRAPHY

Association of Anaesthetists of Great Britain and Ireland. (2007). Guidelines for the management of severe local anesthetic toxicity. Retrieved January 15, 2008 from http://www.aagbi.org/publications/guidelines/doc/guidelines07.pdf

Association of Anaesthetists of Great Britain and Ireland. (Nov. 2001). Pre-operative assessment the role of the

anaesthetist. Retrieved January 16, 2008 from http://www.aagbi.org/publications/guidelines/doc/pre-operative01.pdf

Association of perioperative Registered Nurses. (2010). Recommended practices for managing the patient receiving

local anesthesia. Perioperative Standards and Recommended Practices. Denver: Author. Association of Registered Nurses of Newfoundland and Labrador (2010) Documentation Standards for Registered

Nurses Retrieved Nov 5, 2010 from http://www.arnnl.nf.ca/publication/DocumentationStandards2010.pdf

Canadian Anaesthesia Society (CAS) www.cas.ca Rothrock, J. (2010) Alexander’s care of the patient in surgery. (14th ed). Toronto: Mosby

Procedural/Conscious/Moderate Sedation, & Analgesia

PRACTICE RATIONALE

The perioperative Registered Nurse is responsible for: 5.1 Being cognizant that procedural

sedation/analgesia refers to a drug induced state that produces a condition in which the patient exhibits a depressed level of consciousness but retains the ability to maintain a patent airway independently and respond to verbal commands.

Patients requiring greater than moderate sedation/analgesia must be attended by an anesthesia care provider, surgeon or other physician.

The primary goal of procedural sedation/analgesia is to reduce the patient’s anxiety and discomfort level. Administration of procedural sedation by nurses is an advanced skill and requires training and certification by the healthcare facility. During deep sedation individuals cannot be easily aroused and the ability to independently maintain ventilatory function may be impaired.

5.2 Assessing each patient physiologically A preoperative assessment helps determine a


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before the procedure, including data from numerous sources, such as chart review, and consultation with other health care providers as appropriate. This assessment should include, but not be limited to: - chief complaint; - level of consciousness; - potential airway problems; - orientation and cognitive state; - emotional state; - communication ability; - patient’s perception and

understanding of the procedure and sedation/analgesia;

- history and physical examination; - current laboratory values; - current medications, including

alternative and/or complementary preparations;

- medication allergies/sensitivities; - current medical problems; - surgical history; - tobacco use and substance abuse

history; and - baseline information, including vital

signs, height, weight, and age. During the preoperative assessment visit, the patient shall be given written and verbal information on the procedure and on sedation/analgesia. The patient must be informed that they cannot drive or operate heavy machinery for 24 hours (or, as per health care facility policy) following sedation/analgesia.

5.3 Demonstrating the following skills and knowledge of: - proper patient selection and

screening; - anatomy and physiology; - total patient care parameters,

including but not limited to: respiratory rate, oxygen saturation, blood pressure, cardiac rate, and level of consciousness;

- pharmacology of medications used to induce and reverse sedation/analgesia;

- respiratory physiology, airway management, and the use of oxygen delivery devices;

- the function and use of monitoring equipment;

patient’s suitability for RN-monitored sedation/analgesia by identifying potential risk factors for undesirable outcomes. Written and verbal information reduces anxiety in patients and helps recovery. The monitoring methods for patients receiving procedural sedation, the medications administrated, and the interventions initiated must be within the scope of nursing practice. Monitors assist with the early detection of adverse incidents.


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- cardiac dysrhythmia interpretation; - possible complications and

contraindications related to the use of moderate sedation/analgesia medications; and

- age-appropriate needs and responses of patients.

5.4 Providing psychological support and

reassurance before and during the surgical procedure. The patient should be told what to expect and what is expected of him/her.

5.5 Remaining with the patient and having no

other responsibilities that would leave the patient unattended or compromise continuous monitoring during the procedure.

An additional perioperative Registered nurse must be present in the room and perform the circulating role during any procedure in which a patient receives procedural sedation/analgesia.

5.6 Developing a nursing care plan and

documenting the findings in the patient’s record.

5.7 Being clinically competent in the function

and use of the monitoring equipment to be used, the placement of connections, and the interpretation of data.

Ensuring the following equipment is available and ready for use in the room: - oxygen and delivery devices; - suction apparatus; - non-invasive blood pressure device; - electrocardiograph; and - pulse oximeter.

5.8 Inspecting equipment for proper function and replacing when necessary.

5.9 Maintaining competence in Basic Life

Support and having experience and knowledge in providing procedural sedation/analgesia. Ensuring that either an anesthesia care

Sedation and analgesic agents may cause hypersensitivity reactions, respiratory depression, hypotension, and impaired cardiovascular function. Support and reassurance increases comfort levels, assists in reducing anxiety and helps recovery. Continuous monitoring of the patient’s physiological and psychological status by a perioperative Registered Nurse leads to early detection of potential complications and increases the likelihood of positive outcomes. Enables the patient to receive effective continuing care and provides written communication to the healthcare team. Documentation provides evidence of continuity of care. Monitoring equipment provides the perioperative Registered Nurse with patient data to identify risks and/or complications during a procedure. Improves the management of anesthetic emergencies. Provides a safe environment for the patient. Improperly functioning equipment may jeopardize patient safety. The risk associated with procedural sedation may be low, but the outcome of adverse events can be life threatening.


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provider or a healthcare professional with ACLS skills are readily available during all procedures involving procedural sedation/analgesia.

5.10 Providing continuous monitoring of the

patient and documenting the following: - nursing interventions and patient

responses; - level of consciousness; - patient’s comfort level; - BP, heart rate and regularity; - respirations and O2 saturation; - body temperature; - skin temperature and colour; - drug dosage and time of

administration; - effects of agents used; - any adverse reaction to the drug

administered; - oxygen administration; - intravenous infusion; and - other pertinent information.

5.11 Ensuring an IV access line is established

to facilitate administration of conscious sedation/analgesia medications and emergency medications and fluids if needed.

5.12 Ensuring that an emergency cart with

resuscitative equipment and emergency drugs, including narcotic and sedative reversal medications are immediately accessible.

5.13 Understanding the usual dosages,

contraindications, interactions with other medications, onset and duration of action, desired effects, adverse reactions, and emergency management techniques; and monitoring for adverse reactions to medications and for physiological and psychological changes.

Assess and monitor the patient’s: - level of consciousness; - response to verbal command; - respiratory rate and effort; - oxygen saturation; - blood pressure;

Documentation establishes accountability, promotes quality nursing care, facilitates communication between Registered Nurses and other healthcare providers and conveys the contribution of nursing to care. It has become accepted that core data (heart rate, BP and peripheral oxygen saturation) should be recorded at intervals no longer than every five minutes and more frequently if the patient is unstable. (The Association of Anaesthetists of Great Britain and Ireland, 2007, p. 5) IV access provides a means for administering medications used for procedural sedation/analgesia, emergency medications and/or fluids. Medication overdoses or adverse reactions may cause respiratory depression, hypotension, or impaired cardiovascular function requiring immediate intervention and/or cardiopulmonary resuscitation. Being prepared decreases the response time during adverse reactions. To recognize normal and abnormal reactions to medications and respond appropriately. Provides a safe level of care and may predict and prevent potential adverse reactions.


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- cardiac rate and rhythm; - comfort level; - skin condition; and - tolerance to the procedure.

5.14 Notifying the surgeon when unfavourable changes occur in the patient’s physiological or psychological status.

5.15 Assessing the patient’s ability to retain

information before discharge.

Discharge criteria should include but not limited to: - adequate respiratory function; - stable vital signs; - return to pre-procedure level of

consciousness; - intact motor reflexes; - return of motor and sensory control; - absence of significant pain; and - satisfactory surgical site and dressing

condition (when present). A responsible adult must be available at discharge to accompany the patient home. (Rothrock, 2007, p 123).

5.16 Providing safe transport to PACU or to

another unit according to healthcare facility policy.

5.17 Reporting to the receiving nurse the type

and amount of drugs given and any adverse reaction noted, the IV site and type and amount of solution infused, intraoperative vital signs, the surgical procedure performed, and the type of dressing(if any). Also reported are any special postoperative orders, allergies and a general statement of the patient’s tolerance of the procedure.

Clear and concise communication is essential for optimal patient care. Medication used for sedation/analgesia often produces anterograde amnesia, which may be present even when consciousness appears otherwise normal. The patient may be transferred to the day-surgery and discharge area or returned directly to the hospital room. Allows the patient to receive effective continuing care while providing continuity of care from one healthcare provider to another.

REFERENCES

Association of perioperative Registered Nurses. (20010). Recommended practices for managing the patient receiving moderate sedation/analgesia. Perioperative standards and recommended practices. Denver: Author.

Association of Anaesthetists of Great Britain and Ireland. (Fourth ed.). (2007 March). Recommendations for

standards of monitoring during anesthesia and recovery, p. 5. Retrieved January 7, 2008 from http://www.aagbi.org/publications/guidelines/doc/standardsof monitoring07.pdf

Rothrock, J. (2010). Alexander’s care of the patient in Surgery (14th ed.). Toronto: Mosby.


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BIBLIOGRAPHY Association of Anaesthetists of Great Britain and Ireland. (2005). Day surgery. Retrieved January 16, 2008 from

http://www.aagbi.org/publications/guidelines/docs/daysurgery.pdf Association of Anaesthetists of Great Britain and Ireland. (Oct. 2, 2007). Managing patients undergoing sedation.

Retrieved January 16, 2008 from http://www.aagbi.org/publications/guidelines/docs/managing07.pdf Association of Anaesthetists of Great Britain and Ireland. (2007 June). Peri-operative management of The morbidly

obese patient. Retrieved January 7, 2008 from http://www.aagbi.org/publications/guidelines/docs/obesity07.pdf

Canadian Anaesthesia Society (CAS). www.cas.ca Johnston, M. & Liebelt, E. (2004). Acute pain management and sedation in children. Emergency Medicine: A

Comprehensive Study Guide. (6th ed). Retrieved January 7, 2008 from http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=940&FxId=80&Sc

Nicolaou, D. (2004). Procedural sedation and analgesia. Emergency Medicine: A Comprehensive Study Guide. (6th

ed). Retrieved January 7, 2008 from http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=940&FxId=80&Sc

Philips, N. (2007). Berry & Kohn’s operating room technique. (11th ed). Toronto: Mosby. Royal College of Nursing (02, Oct. 2007). Managing patients undergoing sedation. Retrieved January 7, 2008 from

http://www.rcn.org.uk/__data/assets/pdf_file/0007/78622/002436.pdf

Intravenous Regional Anesthesia (Bier Block)

PRACTICE RATIONALE

The perioperative Registered Nurse is responsible for: 6.1 Ensuring that the surgical site is marked

prior to the Block being administered. 6.2 Maintaining awareness of the patient’s

physiological status in conjunction with constant monitoring by an anesthetic care provider.

Adverse reactions to local anesthetic agents are potential complications.

6.3 In collaboration with the anesthetic care provider or physician, assisting with the placement of the pneumatic tourniquet cuff to the proximal position of the affected extremity.

6.4 Assisting the anesthetic care provider or physician by elevating the limb and wrapping it with an elastic wrap, i.e.

This achieves exsanguination.


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Esmarch. 6.5 Inflating the pneumatic tourniquet to an

acceptable level as requested by the anesthetic care provider or physician and assisting in the removal of the elastic wrap, i.e. Esmarch bandage.

Refer to Pneumatic Tourniquets, Application and Use in section 3.

6.6 Being cognizant, that premature loss of pneumatic pressure in the tourniquet can cause both a toxic reaction and a loss of anesthesia.

An inadvertent bolus of local anesthetic can cause a toxic reaction in the central nervous system (i.e. ringing in the ears, tingling, numbness, loss of consciousness, convulsions) and cardiac complications.

6.7 Assisting the anesthetic care provider or physician with the gradual deflation of the cuff.

Overdose or toxic reactions to the lidocaine are rare if the tourniquet has been inflated more than 20 minutes. The risk also is minimized by intermittently deflating the cuff for a few seconds at a time for several cycles when the surgical procedure is over. This method reduces the transient peak blood level of the local anesthetic in the central nervous system and heart. (Rothrock, 2007)

REFERENCES

Rothrock, J. (2007) Alexander’s care of the patient in surgery. (13th ed). Toronto: Mosby

BIBLIOGRAPHY

Association of PeriOperative Registered Nurses. (2010). Recommended practices for the use of the pneumatic tourniquet in the perioperative practice setting. Perioperative Standards and recommended practices. Denver: Author.

Litz, R. J.; Popp, M.; Stehr, S. N.; Koch, T. (2006). Successful resuscitation of a patient with ropivacaine-induced asystole after axillary plexus block using lipid infusion. [Case report] Anaesthesia, 61(8), 800-801. Philips, N. (2007). Berry & Kohn’s operating room technique. (11th ed). Toronto: Mosby. Sawyer, R. & Schroeder, H. (2002). Temporary bilateral blindness after acute lidocaine toxicity. Retrieved January

18, 2008 from http://www.anesthesia-analgesia.org/cgi/reprint/95/1/224 Smith, T. (2007). System toxic effects of local anesthetics. Retrieved January 18, 2008 from

http://docs.ksu.edu.sa/pdf/articles36/article360043.pdf Wilhelmi, B. & Weiner, L. (June 28, 2006) Hand, anesthesia: blocks. Retrieved January 18, 2008 from

http://www.emedicine.com/plastic/topic297.htm


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Regional Anesthesia – Spinal, Epidural and Peripheral Nerve Blocks

PRACTICE RATIONALE

The perioperative Registered Nurse is responsible for: 7.1 Recognizing that regional anesthesia can

be accomplished by injecting a local anesthetic anywhere along the pathway of a nerve from the spinal cord (spinal anesthesia) via epidural, and/or peripherally.

7.2 Being aware of the contraindications for spinal or epidural anesthesia such as abnormal bleeding and clotting times, patients receiving anticoagulants, and those with severe fluid loss. Contraindications to local anesthetic nerve blocks include: - patient refusal; - drug allergy; - coagulopathy; and - infection at the injection site (Spinal

Anesthesia, 2007, p. 2)

Provides a level of safety for the patient and prevents potential complications.

7.3 Preparing and monitoring the patient in the same manner as required for general anesthesia.

(See ORNAC Standards for Nursing Care of the Anesthetized Patient).

Prevention of complications requires patient assessment and preparation, knowledge of anatomy and physiology, and attention to detail. Continual monitoring leads to early detection of potential complications and increases the likelihood of positive outcomes.

7.4 Ensuring that resuscitative equipment and drugs immediately available.

Excessive or inappropriate doses and inadvertent high blocks can lead to total paralysis, cardiac and respiratory depression.

7.5 Assisting the anesthesia care provider by: - placing the appropriate monitors such

as pulse oximetry, ECG, and blood pressure;

- providing supplemental oxygen; - reassuring the patient; and - properly positioning the patient.

Provides a safe, comfortable environment.

7.6 Monitoring the patient for any substantial change in vital signs or untoward reactions until the patient is transferred to the OR, if the block is done in another area.

To allow adequate time for the local anesthetic to penetrate the peripheral nerve, blocks in the head area and upper or lower extremities are often completed in a preoperative holding area.


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7.7 Recognizing a change in position following a spinal anesthetic can direct the block up, down, or to one side of the spinal cord.

7.8 Being cognizant of physiological

responses that may occur following spinal anesthesia such as: - hypotension related to leakage of

cerebral spinal fluid (CSF); - total spinal anesthesia related to an

inadvertently high block; - positioning problems due to blockage

of pain and sensory inputs to a portion of the patient’s body; and

- post dural puncture headache (PDPH) believed to be related to leakage of CSF through the hole in the dura typically occurring when the patient assumes an upright position.

7.9 Recognizing the complications of

epidural anesthesia such as: - inadvertent dural puncture with the

epidural needle causing a PDPH; - subarachnoid injection caused by the

needle or catheter unintentionally inserted into the subarachnoid space;

- migration of the epidural catheter caused by patient movement; and

- vascular injection occurring inadvertently with the initial or subsequent dose.

7.10 Recognizing peripheral nerve blocks may

cause the following complications: - inadvertent intravascular injection; - overdose of local anesthetic; and - rarely, nerve damage from trauma

caused by the needle or compression from the volume of local anesthetic injected.

7.11 Being prepared for complications should

they arise and assisting the anesthetic care provider as required in emergency situations.

Positioning is crucial for a successful block. Epidural anesthesia may evoke several physiological responses that can result in major problems if not properly managed . Peripheral nerve blocks may evoke several physiological responses that can result in major problems if not properly managed Prompt treatment provides the best outcome for the patient.

REFERENCES

Spinal Anesthesia (10/12/2007) Retrieved January 22, 2008 from www.virtualbonecentre.com/treatments.asp?sid=111&title=spinal-anesthesia


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BIBLIOGRAPHY Association of perioperative Registered Nurses. (2010). Perioperative Standards and Recommended Practices.

Denver: Author. Dalens, B. (APA Manchester 2007). Development in peripheral nerve blockade. Retrieved January 22, 2008 from

http://www.apagbi.org.uk/docs/2.pdf Mariano, E. (Feb. 28, 2007). Nerve blocks: surgery without anesthesia presents alternatives. Retrieved January 22,

2008 from http://ts-si.org/content/view/2822/992/ Philips, N. (2007). Berry & Kohn’s operating room technique. (11th ed). Toronto: Mosby. Rothrock, J. (2010) Alexander’s care of the patient in surgery. (14th ed). Toronto: Mosby. Saha, S. & Turner, J. (January 2006). Risks associated with your anesthetic. Retrieved January 22, 2008 from

http://www.rcoa.ac.uk/docs/nerve-peripheral.pdf Wikipedia (Oct. 25, 2007). Local anesthesia. Retrieved January 22, 2008 from

http://en.wikipedia.org/wiki/local_anesthesia

Herbal Remedies

PRACTICE RATIONALE

The perioperative Registered Nurse is responsible for: 8.1 Assessing surgical patients for use of

herbal remedies, and over the counter drugs including but not limited to: dietary supplements, teas and weight loss remedies.

Herbal, over the counter drugs and prescribed medication interactions may interfere with the body’s ability to: absorb medications; potentiate cardiotonic medications; modify blood sugar in insulin dependent diabetics; modify the effects of prothrombopenic anticoagulants; and be incompatible with gastrointestinal medications.(Blumenthal, 2000)

8.2 Documenting the name of the remedies, dosage, frequency and duration of use on the patient’s health record.

Documentation is a form of communication.

8.3 Verbally communicating drug information to other members of the health care team.

Some herbal remedies can affect clotting time, act like MAO inhibitors, and interfere with blood glucose levels and electrolytes. Toxic effects of some preparations cause arrhythmias, hypertension, ECG changes and may need to be discontinued before surgery.

8.4 Requesting that a current list of herbal remedies, including common name, uses, side effects and precautions, be available to the health care team.

There are hundreds of these remedies available on the Canadian market. The expectation of the nurse to remember them all is unrealistic. The hospital pharmacist(s) may be available to


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8.5 Providing patient teaching regarding

herbal remedies and possible drug interactions.

8.6 Encouraging patients to disclose the use

of these remedies to the health care team.

assist in the creation of a list and keep it current. Patients may not think of herbal remedies as drugs. They may perceive herbal remedies as being natural therefore benign, and drugs as chemicals, not natural, and harmful. (Downey, 2002 ) There may be a perceived discomfort by patients with discussing the use of herbal remedies with the health care team. (Downey, 2002)

REFERENCES

Blumenthal, M. (2000). Interactions between herbs and conventional drugs: Introductory considerations. In F.

Chandler (Ed.), Herbs: Everyday reference for health professionals (pp. 9-20). Nepean ON: National Printers (Ottawa).

Downey, C. (2002). Complementary Medication Use: Perceptions and Practices of Pre-Surgical Women.

Unpublished master’s thesis, Queen’s University, Kingston, Ontario, Canada.

BIBLIOGRAPHY

Crowe, S., Lyons, B. (2004). Herbal medicine use by children presenting for ambulatory anaesthesia and surgery. Pediatric Anaesthesia, 14, 916-919.

McKenzie, A., Simpson, K (2005). Current management of patients taking herbal medicines: a survey of

anesthetic practice in the UK. European Journal of Anaesthesiology, 22, 597-602.

Trapskin, P., Smith, K. (2004). Herbal medications in the perioperative orthopaedic surgery patient. Orthopedics, 27(8), 819-822.

Additional Resources

Health Canada website- www.hc.gc-sc.ca HerbMed, www.herbmed.org Consumerlab, www.consumerlab.com USDA Agricultural Research Service Quackwatch, http://www.ars-grin.gov/duke/ National Council against Health Fraud, http://www.ncahf.org/


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Blood and Blood Products

The perioperative registered nurse is responsible for: PRACTICE RATIONALE

9.1 Assessing the patient for the potential

need for blood/blood products, verifying that crossmatch and typing have been done, and confirming that any requested blood products are available.

Blood replacement may be necessary during surgical procedures, i.e. cardiovascular, organ transplantation, trauma, orthopaedic. Blood typing and cross matching are necessary to determine compatibility between donor and recipient.

9.2 Verifying that written, informed consent/refusal for blood products is completed per Healthcare facility policy and procedure. Clearly document the refusal of blood transfusion in the patient’s medical record following Healthcare facility policy.

Because of religious/cultural beliefs, some patients will not accept allogenous blood but may accept Autotransfusion while others may refuse all blood transfusions. Patient’s have a right to refuse blood transfusions. Consent for blood transfusion is a medical responsibility (Transfusion Medicine, 2009).

9.3 Obtaining blood products from Transfusion Medicine according to Healthcare facility policy.

Patient safety measures must be strictly observed.

9.4 Ensuring that blood products are stored in a temperature controlled refrigerator approved for this use.

Red blood cell components must be stored at 1º – 6º C in a temperature controlled refrigerator with an alarm system, air circulating fan and continuous monitoring device (Canadian Blood Services, 2006, p. 17). Red blood cells (RBCs) deteriorate with fluctuations in temperature. Unrefrigerated blood allows increased risk of bacterial contamination.

9.5 Confirming that “all information associating the blood component with the intended recipient has been matched and verified in the presence of the recipient. This includes: - verifying ABO and RH (if

applicable) compatibility of the product and recipient;

- verifying that the unique patient identifiers applied to the product match those of the intended recipient; and

- verifying that the unique product identifiers on the product label match those on the accompanying transfusion service form/tag.”(Canadian Blood Services, 2006, p. 79)

The perioperative Registered Nurse or anesthesia care provider may administer blood products after confirmation of the patient’s identification, the label on the bag and the blood requisition form. This information shall be confirmed by two health care professionals per health care facility policy. The most common cause of ABO incompatible blood administration is improperly identified patients Transfusion medicine applies unique identifiers to each unit of product issued.


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9.6 Ensuring that if transfusion will not be initiated within 30 minutes of removal from the controlled temperature blood fridge, the unit shall be labeled and returned for disposal.

Blood is deemed to be safe if transfusion is initiated within 30 minutes of removal from a controlled refrigerated environment. It cannot be returned to Transfusion Medicine for reissue.

9.7 Ensuring an approved blood warmer is available and in working order.

Hypothermia due to rapid transfusion of large amount of cold blood can cause arrhythmias or cardiac arrest. Hemolysis may occur if temperature exceeds 43º C.

9.8 During transfusion, ensuring that a sterile pyrogen-free transfusion set with a filter is used and is changed as per manufacturer's recommendations.

Filters should be completely wet and the drip chamber 1/3 to ½ full prior to initiating the transfusion.

Vented tubing should not be used when administering blood components.

The administration set should be changed if there will be a delay of one or more hours between transfusing another unit.

9.9 Notifying Transfusion Medicine if more

blood is needed than initially anticipated. 9.10 Ensuring that a second intravenous line is

initiated for drug administration. Drugs should not be administered through the same IV as blood.

The transfusion filter prevents potentially harmful pyrogens from being transfused to the patient. These filters are intended to remove clots, cellular debris and coagulated protein. Vented tubing may introduce air into the bag. The filter can create an ideal environment for bacterial growth and contribute to sluggish flow slowing the transfusion. This allows time for Transfusion Medicine to prepare a specified number of units in advance decreasing the risk of rushing and jeopardizing patient safety. Drugs combined with blood may cause a reaction.

9.11 Being aware of the signs and symptoms of a transfusion reaction. Under anesthesia, these may be accompanied by temperature change, profound hypotension, blood in urine, diffuse oozing and/or skin rash.

9.12 If transfusion reaction is suspected, in

conjunction with the anesthesia care provider following the facilities policies and procedures related to the management of transfusion reactions.

Common chills and physical reactions are not seen in the anesthetized patient. The probability of a transfusion reaction increases in direct proportion to the number of units transfused.

REFERENCES Canadian Blood Services. (2006) Clinical guide to transfusion (4th ed.). Ottawa: Author. Transfusion Medicine. Informed consent for transfusion. Retrieved April 24, 2009 from http://www.transfusionmedicine.ca/


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BIBLIOGRAPHY

Blood Services. www.bloodservices.ca/ Canadian Society for Transfusion Medicine. (2007). Standards for Transfusion Medicine. (7th ed.). Canadian Standards Association. (2004). CSA Z902-04 Blood and Blood components. Toronto: Author. Diseases and Disorders: A Nursing Therapeutics Manual – 3rd Ed. (2007). Blood transfusion reaction. Retrieved

January 7, 2008 from http://online.statref.com/document/documentbodycontent.aspx?docid=36&fxid-62&scr

Merck Manual of Diagnosis and Therapy, 18th Ed. (2006). Transfusion medicine. Retrieved January 7, 2008 from

http://onlin.statref.com/document/documentbodycontent.aspx?docid=511&fxid-21&sc Philips, N.M. (2007). Berry & Kohn’s operating room technique. (11th ed). Toronto: Mosby. Rothrock, J. (2010). Alexander’s care of the patient in surgery. (14th ed). Toronto: Mosby.

Emergency Situations

10.1 Malignant Hyperthermia (MH) Malignant Hyperthermia (MH) is an uncommon hypermetabolic disorder usually triggered by potent halogenated inhalation anesthetic agents and depolarizing skeletal muscle relaxants.

PRACTICE RATIONALE

10.1.1 Treatment of MH requires the participation of all members of the health care team.

Treatment of MH requires that many interventions occur simultaneously to attain efficient management and expected outcomes.

10.1.2 The health care team should be familiar with the location and contents of a fully stocked MH emergency cart, the treatment protocol, and attend annual in-service education in dealing with MH.

Knowledge, skills, and equipment can prevent death of a patient from MH and its complications. Rapid, well coordinated responses contribute to desired patient outcomes.

10.1.3 A MH emergency cart with the recommended stock supply of thirty-six (36) vials of Dantrolene Sodium should be available, as well as sterile water with no preservative for reconstitution. A standard crash cart with emergency resuscitation drugs and equipment should also be available.

Since the incidence of MH is rare, the continuance of current knowledge and skills and proper equipment can prevent death of a patient from MH and its complications. Thirty-six vials of Dantrolene would be needed to treat and stabilize a 70 kg patient (Philips, 2007, p 639).


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10.1.4 Perioperative Registered Nurses shall be familiar with aspects of Dantrolene Sodium

including: - mechanism of action; - pharmacokinetics; - side effects; - preparation; and - special precautions.

Current information based on the health care facility's policy/protocol may reduce the effects of MH.

10.1.5 Management of patients susceptible to MH should include but not be limited to: - monitoring BP, ECG, respirations,

oximetry, end-tidal carbon dioxide, arterial blood gases, electrolytes and magnesium, urinary output and core body temperature;

- familiarity with non-triggering anesthetic agents;

- use of a clean or "purged" gas machine; and

- having a MH emergency cart available.

Elimination of triggering agents must be done to prevent the patient from having an MH crisis. All volatile inhalation anesthetic agents and “depolarizing” neuromuscular blocking agents (i.e. Succinylcholine) have been identified as triggering agents.

10.1.6 Recognition of the following early signs and symptoms of MH crisis: - increased CO2 production; - muscle rigidity (especially masseter

muscle); - unexplained sinus tachycardia; - tachypnea; - oxygen desaturation; - unstable blood pressure; - peripheral mottling, cyanosis; or

sweating; - fever(temperature rising 1-2 degrees

q5minutes); - cardiac arrythmias, ventricular or

atrial tachyarrythmias; - metabolic and respiratory acidosis; - increased serum concentrations of

potassium (K+), calcium (Ca+) and creatinine phosphakinase (CPK);

- hot soda lime in the CO2 absorbers of the anesthetic machine; and

- myoglobinuria (Rothrock).

Note: Not all of the signs and symptoms may be present. Increased CO2 is the most common symptom. Muscle rigidity is one of the earliest signs. Patient's jaw may be rigid and the mouth cannot be opened for intubation. Fever may occur late in the reaction and be very dramatic or may not occur at all. Cooling such areas as the axilla and groin may be sufficient. Excessive cooling can cause severe shivering which can precipitate ventricular tachycardia. When muscles break down, proteins are released into the bloodstream and are filtered out through the kidneys producing "cola" coloured urine.

10.1.7 The post anesthetic care unit or intensive care unit shall be notified in advance to expect the patient.

10.1.8 Monitor for at least 24 hours for

recurrence or late complications.

Further observation, monitoring, and treatment will be required. Advance notification allows for adequate preparation of essential equipment and supplies.


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10.1.9 MH crisis may be prevented by: - accurate preoperative diagnosis and

awareness of the disease by both patient and physician:

- avoid triggering agents; - prophylactic Dantrolene in certain

susceptible patients; and - intra-operative monitoring.

A positive muscle biopsy confirms the diagnosis of MH. However, a negative biopsy is not reliable enough to eliminate the diagnosis. (Buckley, 2006, p 9.)

REFERENCES

Buckley, D. (2006) Learning about Malignant Hyperthermia. Hamilton, ON: Hamilton Health Sciences. Malignant Hyperthermia Association of the United States (MHAUS). http://www.mhaus.org/ Philips, N.M. (2007). Berry & Kohn’s operating room technique. (11th ed). Toronto: Mosby.

Rothrock, J. (2007). Alexander’s care of the patient in surgery. (13th ed). Toronto. Mosby.

BIBLIOGRAPHY

Association of PeriOperative Registered Nurses. (2008). AORN malignant hyperthermia guideline. Perioperative Standards and Recommended Practices. Denver: Author.

Hommertzheim, R., Steinke, E. (2006) Home Study Program: Malignant Hyperthermia-The Perioperative nurse’s

role. AORN Journal, 83(1); 149-164. Spry, C. (2008). Essentials of Perioperative Nursing. (4th ed.). Maryland: Aspen Publishers. For additional information: MH hotline 1-800-644-9737 10.2 Latex Allergy Latex is produced from the rubber tree, Hevea brasiliensis, and contains a water soluble protein antigen that can cause a fatal allergic reaction. Latex allergies may produce local or systemic reactions that may affect patients and the health care team. Latex sensitivities may lead to true allergy, with the risk of anaphylaxis, therefore all reasonable attempts to reduce latex items from the operating room should be taken. PRACTICE RATIONALE

10.2.1 A current Policy and Procedure Protocol

to safely manage a patient with potential or actual latex allergy shall be available for the health care team.

A severe latex allergic response can be sudden and fatal. The aim is for latex avoidance, as a latex-free environment is not readily achievable

MHAUS HOTLINE (US and Canada) 1 800-644-9737


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10.2.2 Patients with latex allergies should: - be booked as the first case of the day,

if possible; - have an alert noted on the health

record; - have an alert noted on the OR

schedule; - wear an alert bracelet which is not

removed; and - carry an epinephrine syringe.

10.2.3 Surgeon offices, preoperative clinics, and

nursing units must have the information and consistent means to communicate the allergy in advance of surgery to prevent patient risk, delays and cancellations.

10.2.4 The healthcare team shall assess surgical

patients for the risk of latex sensitivity and potential allergy.

10.2.5 A current latex allergy protocol shall be

available including: - a list of sample admission assessment

questions; - list of signs and symptoms; - identification of high-risk groups; - preparation requirements for the

theatre in advance of admission; - documentation required; - equipment and supplies needed; and - actions for an anaphylactic latex

emergency.

10.2.6 Pediatric facilities should reduce the amount of latex as much as possible.

Significant time may be required to ensure the air ventilation system has removed all traces of airborne latex proteins when latex products have been used during the previous procedure. The aim is for latex avoidance, as a latex-free environment is not readily achievable. Advance notice for the perioperative team to safely prepare the environment is essential. Food allergies that may suggest a latex allergy include papain (meat tenderizer also present in papaya), kiwi fruit, avocado, bananas, papaya, chestnuts, potatoes, tomatoes, celery, peaches, stone fruit, molds and pollen. Patients with multiple true allergies are also at higher risk. Limited information is known about the latex-fruit possible cross reactivity. In addition to food allergies, questions to consider including in patient assessment include:

-do you have a confirmed allergy? -do you have spina bifida? -do you have hives, itchy rash, swelling after contact with rubber products i.e. balloons, condoms, mouth dams at dentist offices.

Further investigation is needed if the patient gives a positive response to any of these questions, in order to determine if the patient has a true latex allergy. Testing for IgE antibodies is used for latex allergy. High-risk groups include but are not limited to: - spina bifida patients; - health care workers; - atopic individuals (allergic to banana, kiwi,

avocados, chestnuts); and - patients with genitourinary tract anomalies. Research suggests the risk of latex allergy as high as 73% for spina bifida patients.

10.2.7 A latex allergy cart/box providing latex-free equipment shall: - be available;

The product list identifies articles that are latex-free and products that contain latex.


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- be restocked immediately after use; - contain the latex allergy protocol and

product list; and - have a designated person(s)

responsible for review and maintenance.

Common items in use such as tubing on blood pressure cuffs, connectors, cords on pulse oximeter, EKG leads and cords, donut, positioning devices, elastic bandages, tape, esmarch rubber bandage for tourniquet, stoppers in multidose vials, connecting tubing on insufflators, drains, and warming blankets may present an unsuspecting reaction.

10.2.8 Facilities should provide and encourage use of powder free latex gloves.

The less powder to carry the latex protein, the safer the environment. Gloves with latex protein <100ug/gm show little reactivity.

BIBLIOGRAPHY

Association of PeriOperative Registered Nurses, (2008). AORN latex guideline. Perioperative Standards and

Recommended Practices. Denver: Author. Phillips, N.M. (2007). Berry & Kohn’s operating room technique. (11th ed). Toronto: Mosby. Rothrock, J. (2007). Alexander’s care of the patient in surgery. (13th ed). Toronto: Mosby.

Additional Resources: Centre for Disease Control & Prevention http://www.cdc.gov/niosh/latexalt.html http://latexallergylinks.tripod.com www.healthline.co.uk/latex.html Spina Bifida Association, www.sbaa.org www.latexallergyresources.org- American Latex Allergy Association www.childsdoc.org Dr Patrick Birmingham – anesthesia .pdf 1999 10.3 Cardiac Arrest PRACTICE RATIONALE

10.3.1 Perioperative Registered Nurses shall

maintain competence in Basic Life Support (BLS) for Healthcare Providers according to provincial guidelines and Healthcare facility guidelines. Perioperative Registered Nurses shall attain and maintain competency to defibrillate if required by Healthcare facility protocols.

Early qualified action enhances chances of survival. Nurses may choose to upgrade their skill set to Advanced Life Support (ACLS) and/or Pediatric Advanced Life Support (PALS) to increase their comfort level in cardiac emergencies. Current knowledge and practice assists in the handling of sentinel events and in the safe management of the perioperative environment. Current knowledge of CPR/BCLS is necessary to assist theatre personnel with resuscitation.


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10.3.2 Nursing personnel should maintain knowledge of the healthcare facility’s current Code Blue policy. Under usual circumstances, the surgical team will manage a cardiac arrest within the surgical suite. In the event of inadequate resources, multiple arrests or other unusual circumstances, the Hospital Code Team may be accessed.

The dress code, traffic flow/patterns, and aseptic practices may lapse when a cardiac arrest occurs and additional health care facility members are required.

10.3.3 A Cardiac Arrest cart with defibrillator, resuscitation equipment and supplies shall be immediately available. This cart should be placed in the same strategic location at all times, when not in use.

10.3.4 The crash/code cart should be routinely

checked per the protocol established in the facility for completeness, medication expiration dates, and properly functioning equipment.

10.3.5 External defibrillating pads (hands free)

and defibrillating paddles with gel pads (hands on) should be appropriately connected/available on the crash cart defibrillator. Sterile internal paddles should be available according to healthcare facility policy.

10.3.6 A resuscitation protocol should be

established and understood by all members of the Healthcare Team. Periodic practice sessions (mock code) for delegated duties should be scheduled as part of the safety program.

Immediate response/defibrillation offers a greater chance of survival. Perioperative Registered Nurses shall be familiar with the location of all supplies and equipment to enhance their ability to assist and use all items within their scope of practice.

10.3.7 During a cardiac arrest, if circumstances allow, the scrub nurse shall: - protect the integrity of the sterile

field whenever possible; - track sponges, needles and

instruments; and - complete closing counts as quickly as

possible.

Sterility is secondary to resuscitation efforts. Health care facility’s written policies and procedures for counts are followed during emergency situations.

10.3.8 Documentation of a cardiac arrest should include, but not be limited to: - time of arrest; - time the code was called; - time of arrival of code members; - time CPR was initiated and by

whom;

Document Cardiac Arrest as per facility policy.


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- time(s) of medication(s) and dosage(s);

- medications administered by; - infusion/transfusions; and - patient outcome.

10.3.9 Spiritual/supportive care should be

arranged for the family. 10.3.10 Critical Incident Management should be

offered to all team members involved in a code situation.

10.3.11 Routine preventative maintenance on the

defibrillator will be completed and documented by healthcare facility biomedical department.

Healthcare team members should be given time to express their feelings and debrief.

BIBLIOGRAPHY

Phillips, N.M. (2007). Berry & Kohn’s operating room technique. (11th ed). Toronto: Mosby.

Rothrock, J. (2007). Alexander’s care of the patient in surgery. (13th ed). Toronto: Mosby. www.heartandstroke.ca 10.4. Disseminated Intravascular Coagulation (DIC) Disseminated Intravascular Coagulation (DIC) is not a disease but a complication of a variety of conditions that can initiate activation of the coagulation process (Porth, 2007). DIC manifests on a continuum that begins with activation of either the intrinsic or the extrinsic coagulation pathways and results in multiple thrombi that lead to vessel occlusion, tissue ischemia, and organ failure. All available coagulation proteins and platelets are consumed by the thrombi and the result is bleeding in the form of petechiae, purpura, oozing from tissues, or massive hemorrhage due to an imbalance between coagulation, anticoagulation and fibrinolysis (Porth, 2007, p.207-8; Sivula, et al, 2005).

PRACTICE RATIONALE

10.4.1 Treatment of DIC requires the participation of all members of the health care team.

Treatment of DIC requires that many interventions occur simultaneously to attain efficient management and expected outcomes.

10.4.2 The Perioperative Registered Nurse should:

- recognize the risk factors for DIC; - understand potential complications; - formulate potential nursing

diagnosis; - anticipate the needs of the patient and

if the surgical team(the common and probable treatment protocols); and

Knowledge about DIC and relevant nursing skills, may prevent the condition from causing the death of a patient. Risk factors associated with DIC include but are not limited to:

- Endothelial damage caused by viruses, infection, temperature extremes, stasis of blood, or immune mechanisms i.e.:


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- expedite the care sequence to maximize patient outcomes (by knowing the immediate location, and protocols for use of required medications, blood products, and necessary equipment).

- trauma; - burns; - gram-negative Sepsis; - hypoxia; - acidosis; - shock; and - vasculitis

- Release of tissue factors from: - obstetrical complications (includes: necrotic fetal tissue; necrotic placental tissue; or amniotic fluid emboli. This is the cause of 50% of all DIC cases); - trauma; - complications from cancer; - bacterial sepsis; - immunological disorders; - severe toxic reactions; - hematological disorders –iatrogenic and non-iatrogenic; and - cardiac surgery.

10.4.3 Nursing personnel shall maintain

knowledge of the health care facility’s current cardiac arrest code policy.

Current knowledge and practice assists in the handling of sentinel events and in the safe management of the perioperative environment.

10.4.4 Seek resources and/or in-service education regarding DIC.

REFERENCES Porth, C.M., (2007). Essentials of Pathophysiology. (2nd ed.). Philadelphia: Lippincott, Williams, & Wilkins. Porth, C.M., (2005). Pathophysiology Concepts of Altered Health States. (7th ed.). Philadelphia: Lippincott,

Williams, & Wilkins. Sivula, M., Yallgren, M., Pettila, V. (2005). Modified score for disseminated intravascular coagulation in the

critically ill. Intensive Care Medicine, 31, 1209-1214. Toh, C.H. and Dennis, M. (2003). Disseminated intravascular coagulation: old disease, new hope. (Clinical review).

British Medical Journal, October 2003, 974. Zeerleder, S. and Wuillemin, W. (2005). Disseminated intravascular coagulation in sepsis. Chest, 128(4), 2864-

2875.

BIBLIOGRAPHY

Jones, K.J., adapted by D’Onofrio, L. (2006). Nursing management haematological problems in Lewis, S.M., Heitkemper, M.M., & Dirksen, S.R. (2006). Medical –Surgical Nursing in Canada. Toronto: Elsevier Mosby.

Pillitteri, A. (2003). Maternal and Child Health Nursing. Philadelphia: Lippincott, Williams, & Wilkins.


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White, A. (2006). Emergency care for patients with HELLP Syndrome. Advanced Emergency Nursing Journal, 28(4), 338-345.

10.5 Intraoperative Death PRACTICE RATIONALE

10.5.1 Perioperative Registered nursing

personnel shall provide nursing care to support the patient to a dignified death.

Notification of manager or designate shall take place as soon as possible (Phillips, 2007, p123).

Provide a continuum of care Cardiac arrest, standstill or fibrillation may occur in patients undergoing surgical procedures due to hazards of surgery including but not limited to unavoidable reactions to anesthesia such as hypoxia, or poor ventilation, blood loss, shock (Rothrock, 2007, p 42). Provides the department with notification to assist with the process of after death care, arrangement of viewing by family if requested, assists with appropriate transfer of patient, assists with following of facility, local, provincial or federal regulations.

10.5.2 A current and dated procedure/policy for the management of death and care of the body shall be available and may include: - provincial and health care facility

regulations; - notification of the authorities, such as

the Coroner, administration, and the healthcare facility unit;

- preparation of the body according to the Medical Examiner/coroner’s wishes;

- documentation required including time of death;

- documentation if religious rites were performed

- removal of the body, records, and belongings;

- a list of devices that should remain in place for potential medical investigations;

- provisions of a private room in the surgical suite for family viewing of their loved one’s body; and

- emotional support by the health care team members to family during viewing

- be sure identification of the patient is correct; and

- completion of an incident report as required by facility.

Medical examiner/coroner may wish to view patient with all lines/devices attached Support to family is essential. Never leave family members alone while viewing the body


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10.5.3 All surgical items/instrumentation shall be removed from the patient and a final count be performed unless otherwise instructed by the medical examiner/coroner.

10.5.4 Foreign bodies removed during surgery

shall be handled via facility laboratory/histology departments or may be handled as forensic evidence.

Fulfills surgical counting policies & procedures dependent upon facility. May provide information for the coroner. Data collection begins prior to the operating room. Patients who are critically injured may be taken directly to the operating room. (Phillips, 2007, p 119). Law enforcement or coroner may request/require specimens, examination of body, or removal of evidence and/or body.

10.5.5 Nursing personnel should have knowledge of facility protocol for organ & tissue donation and advanced directives.

10.5.6 Healthcare team members should be

given time to express their feelings and deal with a death within the surgical suite. Critical incident debriefing should be considered.

To preserve organs &/or tissue and have appropriate knowledge of organ and tissue donation procurement processes, assist in retrieval procedures and appropriate perioperative documentation. (Rothrock, 2007, p1197) Death may be a result of surgery and debriefing is a means of providing support to members of the health care team. Allows staff to discuss the process, grieve, & relieve personal stress related to the incident.

REFERENCES

Rothrock, J. (2007). Alexander’s Care of the Patient in Surgery, (13th ed.). Toronto: .Mosby. Philips, N. (2007). Berry & Kohn’s Operating Room Technique, (11th ed.). Toronto: .Mosby.

BIBLIOGRAPHY Association of PeriOperative Registered Nurses, (2008). Perioperative Standards and Recommended Practices.

AORN: Author. Becker, Gerhild et all, (2007). End-of-Life Care in Hospital: Current Practice and Potentials for Improvement.

Journal of Pain and Symptom Management, 33(6), 711-719. Ewanchuk, Mark & Brindley, Peter G. (2006). Ethics Review: Perioperative do-not-resuscitate Orders doing

“nothing” when “something” can be done. Critical Care, 10, 219 Fallat, Mary E. & Deshpande, Jayant K. (2004). Do-Not-Resuscitate Orders for Pediatric Patients Who Require

anesthesia and Surgery. American Academy of Pediatrics, 114 (6), 1686-1692. Mulley, AG, (2007). Do You Know All your Medical Options? A new approach to getting the information you

need. Bottom Line Health, 21(9), 5-6. Porteous, Joan (2005). Don’t Tip the Scales! Care for patients involved in forensic evidence gathering, Canadian Operating Room Nursing Journal, 23(3). Woodhead, K., Wicker, P. (2005). A textbook of Perioperative Care. Elsevier: Toronto


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Promoting Excellence

OPERATING ROOM NURSES ASSOCIATION OF CANADA (ORNAC)

Glossary

The definitions have come from multiple sources and are applicable to Perioperative Registered Nursing Practice and the environment within the context of each section.


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Glossary

Revision Date: June 2009 of 334

A AAAANI: American Academy of Allergy, Asthma & Immunology. AANA: American Association of Nurse Anesthetists. AAMI: Association for the Advancement of Medical Instrumentation. Accountability: Is answerable for activities and/or outcomes. Accountable is used to denote liability for individual activities, a group of activities, and those activities delegated. ACAAI: American College of Allergy, Asthma and Immunology. Accreditation Canada: Formerly known as CCHSA provides guidance to reach standards of excellence. Mission is to drive quality in healthcare via accreditation process, it is a national non-profit organization. www.accreditation-canada.ca ACORN: Australian College of Operating Room Nurses. www.acorn.org.au Active communication: An affirmation, orally or by some action, that the patient, procedure, and site are correct. Active communication involves everyone's participation. Active electrode: The electrosurgical accessory that directs flow of electrical current to the operative site. Active electrode monitoring: A dynamic process of searching for insulation failures and capacitive coupling during monopolar surgery. If the monitor detects an unsafe level of stray energy, it signals the generator to deactivate. Advanced Nursing Practice: The scope of Advanced Nursing Practice focuses on a specialty clinical service (i.e. Perioperative), providing support to clients and the healthcare team, as a consultant, researcher, administrator, educator, and clinical practitioner. Advanced Practice Nurses include Nurses Practitioners (NP) and Clinical Nurse Specialists (CNS). Administration: A process of senior management, which provides the structure/framework, facilities, policies, and business operations to support human, materials, and fiscal resources to work toward predetermined goals and outcomes. Adverse Drug Event: Injury as a result of medical intervention related to a medication. The onset of the adverse reaction may be sudden or develop over time. Adverse event: An untoward incident, therapeutic misadventure, iatrogenic injury, or other wrongful occurrence directly associated with patient care. Not all adverse events are preventable, and they can be classified by severity - significant, serious, life threatening, or fatal. Adverse Medical Event: Broad term to describe unexpected events as a result of medical intervention. The event maybe related to medication, surgical technique, and/or related to the use of technology. Advocacy: The unique position of the perioperative Registered Nurse as a member of the health care team to speak on behalf of patients and interpret individual needs and responses to others who participate in their care. AER: Automated Endoscope Reprocessor. Aeration: Method by which absorbed ethylene oxide is removed from EtO-sterilized items by circulating warm air in an enclosed cabinet specifically designed for this purpose.


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Glossary


Aerosol: Suspension of ultramicroscopic solid or liquid particles in air or gas: a spray (IAHCSMM, 2007, p. 464). Aerosolization: the suspension of microscopic particles in air or gas. AfPP: Association for Perioperative Practice (United Kingdom). Prior to 2005known as National Association of Theatre Nurses (NATN). www.afpp.org.uk Airborne precautions: Precautions that reduce the risk of an airborne transmission of infectious airborne droplet nuclei. (i.e. small particle residue 5mm or smaller). Air-removal test: A diagnostic test to determine the adequacy of air removal from the chamber of a prevacuum steam sterilizer. The air removal test is not a test for sterilization. (i.e. Bowie-Dick test) AJIC: American Journal of Infection Control. Allograft: A graft of tissue between individuals of the same species, donors, may be cadaveric, living related, or living unrelated. Alcohol-based preparations: Products used for hand antisepsis that are increasingly being used as an alternative to the traditional surgical hand scrub using detergent-based antiseptic agents. Formulations include foams, gels and liquid rinses. These products do not remove soil; therefore, application must be preceded by a soap and water wash when used by surgical team members. A.L.E.R.T. Inc.: Previously known as American Latex Allergy Association. A national non profit organization providing information about latex allergy and support to individuals with latex allergy. Allogenous: Having different genetic constitution but from same species. (Taber’s 2005). Ambient air: The surrounding environmental air. Aneroid gauge: A pressure registering system that does not use mercury (Hg): it uses a mechanical amplifier system to transmit the motion of metal bellows to the indicator needle of the dial. ANSI: American National Standards Institute, www.ansi.org AORN: Association of PeriOperative Registered Nurses, Inc. Home office is in Denver, Colorado. A professional perioperative group for registered nurses in the United States of America. www.aorn.org AORNJ: Association of PeriOperative Registered Nurses Journal. APIC: Association for Professionals in Infection Control and Epidemiology. ARO: Antibiotic Resistant Organisms. Arterial calcification: Calcification of the arteries renders the vessels incompressible by the inflated tourniquet cuff; a bloodless field cannot be obtained. This problem also occurs in rheumatoid arthritis patients on steroid therapy because steroid induced vascular calcification contributes to arterial occlusion. ASA: American Society of Anesthesiologists. Aseptic technique: Conditions and procedures used to exclude the introduction of microbial contamination. Assessment: A continuous activity to collect and document data about the patient's health status. ASPAN: American Society of Perianesthesia Nurses.


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Glossary


Autogenous: Self producing; originating within the body (Taber’s 2005). Autotransfusion: “a method of returning the patient’s own extravasated blood to the circulation” (Taber’s 2005, p. 207).

B

Bariatric: overweight, obese, large, heavy & is a branch of medicine dealing with cause, prevention, & treatment of obesity; (Canadian Association of Bariatric Physicians & surgeon (CABPS). http://www.cabps.ca) BCORNG: British Columbia Operating Room Nurses Group. Best Practice: evidence-based, proven nursing practices which assist in the provision of optimal outcomes or “best” result. Bibliography: “cites works for background or for further reading a may include descriptive notes” (APA, 2001, p. 215). Bioburden: Contamination of the environment, supplies, and/or equipment with microorganisms. Biofilm: a group, groups or collections of microorganisms which adhere to the surfaces of items such as instruments causing the formation of a layer or film. As the microorganisms multiply the film may be come slimy and may be very difficult to remove. Biohazardous: A biological agent that is hazardous to humans or the environment. Biological Indicator (BI): A sterilization process monitoring device consisting of a standardized, viable population of microorganisms (usually bacterial spores) known to have a high resistance to the mode of sterilization being monitored. BJPN: please see JPP BMI: Body Mass Index a scientific formula used to calculate body mass, MBI=weight (Kg) /height (m)2 for example a BMI of ≥30 is considered obese Brightness ratio: For any 2 surfaces in the field of vision, the ratio of the luminance of one surface to the luminance of the other surface, expressed as a percentage. BSE: Bovine Spongiform Encephalopathy. Commonly referred to as Mad Cow Disease. A fatal, slow progressive degenerative disease caused by a prion protein which affects the Central Nervous System of adult cattle. Body Piercings: the practice of adorning the body with jewelry that penetrates the flesh.

C

Calibration: A method of measuring the accuracy of the tourniquet pressure display. To standardize (as a measuring instrument), by determining the deviation from a standard, in order to ascertain the proper correction factors. Calibration kit: A method of measuring the accuracy of the tourniquet pressure display. Capacitive-Coupled Return Electrode: A large non-adhesive return electrode placed close to and forming a


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Glossary


capacitor with the patient, returning electrical current from the patient back to the electrosurgical unit (ESU). Canadian Blood Services: a national not for profit organization which manages and supplies blood & blood products in all provinces and Territories outside of Quebec, www.blood.ca CAS: Canadian Anesthesia Society. Cautery : See Electrosurgical Unit (ESU). CCDT: Canadian Council for Donation and Transplantation; mandate is to provide advice to Federal, Provincial & Territorial Conference of the Deputy Ministers of Health in order to improve organ & tissue donation & transplantation in Canada. Http://www.ccdt.ca/ CCHSA: Canadian Council of Hospital Services Accreditation. Is now known as Accreditation Canada. www.cchsa.ca CDC: Centers for Disease Control and Prevention, in the United States of America. www.cdc.gov Canadian Standards Association (CSA): An organization that develops and publishes standards for many devices and operational procedures. Volunteers help develop the Standards. The Standards are reviewed every five years. (ORNAC members participate in development, revisions, and support the Standards). www.csa.ca Chemical burns: These burns are caused by solution seeping under the tourniquet cuff or when antiseptic solutions pool under the patient during skin prep, and remain in contact with the patient’s skin. Chemical disinfectant/germicide: A generic term for a government-registered agent that destroys microorganisms. Germicides are classified as sporicides, general disinfectants, hospital disinfectants, sanitizers, and others. Chemical Indicator (CI): A sterilization monitoring assistive device used to monitor certain parameters of a sterilization process by means of a characteristic color change. (e.g., chemically treated paper, pellet sealed in a glass tube, pressure-sensitive tape.) CHICA: Community and Hospital Infection Control Association. Is a national multidisciplinary volunteer organization of Infection Control Professionals (ICP), http://www.chica.ca CIDPC: Centre for Infectious Disease Prevention and Control- a division of Health Canada &. CTO-cells, Tissue & Organs CIHI: Canadian Institute of Health Information. http://secure.cihi.ca Circulating Nurse: A Perioperative Registered Nurse who provides leadership and coordinates the individual care of the patient and needs of the surgical team by: disseminating information; planning; organizing; delegating; implementing; coordinating; and evaluating the perioperative activities. This term may be reduced to "Circulator". CJD: Creutzfeldt-Jakob Disease http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc02vol28/28s5/index.html Cleaning: The removal of soil. Note: Soil includes, but is not limited to, the bioburden plus the patient-derived cells, secretions, or excretions. Clinical Nurse Specialist: “A registered nurse who holds a master’s or doctoral degree in nursing with experience in a clinical nursing specialty; uses in-depth knowledge and skills, advanced judgment and clinical experience in a nursing specialty to assist in providing solutions for complex health-care issues” (CNA, 2008, p. 40).


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Glossary


Clostridium Difficile (CDiffe): A bacterium causing diarrhea being found with increasing frequency in our population. CNA: Canadian Nurses Association. A federation of provincial and territorial registered nurses associations acting as the “voice of RN’s in Canada”. www.cna-nurses.ca CNPS: A not for profit society, owned & operated by nurses offering legal liability protection to registered nurses in provinces & territories, http://www.cnps.ca Collaborate: Advise, consult, cooperate, support, and willingly assist others in assessing, planning, implementing, and evaluating activities. Competence: The demonstration of the knowledge, skills, abilities, attitudes, and judgement required in the professional care of patients by the perioperative Registered Nurse. The perioperative Registered Nurse functions with care and regard for the welfare of the patient and in the best interest of the public, perioperative Registered Nurses, and the nursing profession. Competency: A statement of the combined knowledge, skills, attitudes, and judgment derived from the nursing roles and functions within a specified context to meet a specified level of performance expectation. Confine and contain: A principle that recommends prompt cleanup of items contaminated with blood, tissue or body fluids. Contact precautions: Precautions designed to reduce the risk of transmission of epidemiologically important microorganisms by direct or indirect contact. Container: See rigid sterilization container. Contaminated: The presence of potentially infectious pathogenic microorganisms on animate or inanimate objects. CORL: Canadian Operating Room Leadership Network. www.operatingroomleaders.com CORNJ: Canadian Operating Room Nursing Journal. A peer reviewed quarterly publication of ORNAC since 2002. First published in 1983. www.ornac.ca CORNQ/CIIS: Corporation of Operating Room Nurses of Quebec. CORR: Canadian Organ Replacement Registry. CPR: Cardiopulmonary resuscitation. CPSI: Canadian Patient Safety Institute. www.patientsafetyinstitite.ca CRT: Cathode - ray tubes. Credential: Something that gives a basis for credit or confidence such as letters or a certificate showing ones right to position or authority. Creutzfeldt-Jakob Disease (CJD): A fatal central nervous system degenerative disorder of humans. It is one of the Transmissible Spongiform Encephalopathy’s (TSE). Classic CJD has 3 known types: 1. Inherited 2. Iatrogenic

3. Sporadic


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Criminal coroner’s case: A situation where police may act under the authority of the coroner. Under the Coroner’s Act, coroners have broad powers of entry and inspection and the Act authorizes the delegation of these powers to police officers. Critical item: Instruments and devices that enter sterile tissues, including the vascular system. Critical items present a high risk of infection if the item is contaminated with any spores. Reprocessing critical items involves meticulous cleaning followed by sterilization. CSGNA: Canadian Society of Gastroenterology Nurses and Associates. www.csgna.com CTO: cells, tissues and organs

D Daily exposure: The amount of noise, chemical and gas to which a worker is exposed during the workday. DCD: Donation after Cardiac Death. Decibel: A unit for measuring the relative loudness of sounds. Decontamination: The process of cleaning, followed by the inactivation of pathogenic microorganisms, in order to render an object safe for handling. Diligence: Steady, earnest and energetic effort. Disinfection: A process that destroys some forms of microorganisms excluding bacterial spores; a process that kills most forms of microorganisms on inanimate surfaces. Dispersive electrode: A conductive plate or pad that recovers the therapeutic current from the patient during electrosurgery, disperses it over a wide surface area, and returns it to the electrosurgical generator. The Dissector: Quarterly Perioperative Nursing Journal of the New Zealand Perioperative Nurses College, http://www.nzno.nz/groups/colleges/perioperativenursescollege Dispute resolution: A process to facilitate a positive and effective resolution to a conflict. Droplet Precautions: Precautions that reduce the risk of large particle droplet (i.e., 5mm or larger) transmission of infectious agents. Due diligence: The attention and care legally expected or required. Dust cover: An optimal, unsterile cover used to help protect clean or sterile packages during routine storage, handling, and transportation.

E

Electrosurgery: The cutting and coagulation of body tissue with a high radio frequency current.


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Electrosurgical Unit (ESU): A machine used to deliver a high frequency current to cut and to coagulate body tissue. Emergency: An unexpected situation in which there is a pressing threat to patient life or health. Note: For the purpose of this Standard, an emergency situation is one so pressing as to warrant the omission of specified requirements of this Standard, as detailed in the Risk Management policy of the health care facility. Emergency sterilization: A special steam sterilization cycle designed for the unplanned sterilization of unwrapped surgical goods. Note: Cycles currently employed for emergency sterilization are gravity displacement, dynamic air removal, and a cycle that may be available on some steam sterilizers that is designed to permit the use of a single wrapper on the instrument tray. Emulator: "Emulating indicators are indicators designed to react to all critical parameters over a specified range of sterilization cycles, for which the stated value are based on the settings of the selected cycles. (ISO11140-1, sub clause 4.6) " End of procedure cleaning: Cleaning that is performed at the end of one surgical procedure and before the start of another surgical procedure in the same room. Endogenous: Substance which arises from within an organism, cell or tissue ECRI: Emergency Care Research Institute. www.ecri.org EORNA: European Operating Room Nurses Association. This group is a member of IFPN, officially named EORNA in 1992 and is a federation of 23 countries. http://www.eorna.eu/ Ergonomic: The science concerned with fitting a job to a person’s anatomical, physiological and psychological characteristics in a way that enhances human efficiency and well-being. ESBL: Extended Spectrum Beta-Lactamase (ESBL), organisms are bacteria found in the bowel, urine, blood, skin wounds or sputum. Esmarch bandage: An elastic bandage applied around an extremity from distal to proximal in order to expel blood from it. The limb is often elevated as the elastic bandage is applied. Used to control bleeding and exsanguination prior to tourniquet use. ESU: Electrosurgical Unit. Commonly called a “cautery”. Expiry Date: A date marked on a product or supply noting it is no longer guaranteed or “in Date” after the date marked. Best before, similar to food labels. For example sutures commonly have expiry dates. Exogenous: From a source other than the patient (e.g., personnel, equipment, the environment, instruments, supplies). Exposure time: Time during which the sterilizer chamber is maintained within a specified range for temperature, sterilant concentration, pressure, and humidity. Expanded Nursing Practice: “ An umbrella term for an advanced level of clinical nursing practice that maximizes the use of graduate educational preparation, in-depth nursing knowledge and experience in meeting the health needs of individuals, families, groups, communities and populations” (CNA, 2008, P. 40). External chemical Indicator: Are used to provide healthcare facilities & workers with the knowledge a package/container has been in contact with a sterilization process such as autoclave tape or tags which turn colour.


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Event-related: Storage and transportation practice that operates on the principle that a properly packaged item that has successfully undergone a validated sterilization process is considered sterile until an event occurs that could breach the protection provided by the packaging (e.g., wetting, tearing, or dropping).

Evidence: “Information on which to base proof of/or establish truth of a lie” In law, evidence is demonstrative or physical and cannot be introduced without a witness or something physical that a judge and jury can observe. Eckert,W., Wright,R. (1997) Scientific Evidence in Court. CRC Press Inc. Exsanguination: The process of removing / losing large volumes of blood.

F

Fatal-Familial Insomnia (FFI): A TSE, one of the fatal degenerative brain diseases. FIFO: A form dated stock rotation, First In First Out, employed in areas of storage such as processing, operating rooms, warehouses Filter: A component of a rigid sterilization container system that allows the passage of air and sterilant during sterilization yet provides a barrier to bacterial penetration. Note: The filter media may be removable (either reusable or single-use), or it may be permanently affixed to the container. Flash sterilization: See emergency sterilization. Fluoroscopy: The observation of the internal features of an object by means of the fluorescence produced on a screen by x-rays transmitted through the object. Forensic documentation: Written or diagrammatic record of injuries to include wound measurement, location and pattern of injuries.

G Gasket: A pliable strip that serves as a seal between the lid and the base of a rigid sterilization container. Generator: The machine that produces radio frequency waves (e.g., cautery unit, power unit). Geobacillus stearothermophilus: A nonpathogenic microorganism used for biological testing (challenging) steam sterilizers. Gerstmann-Straussler-Scheinker (GSS): This is a rare type of inherited human TSE. Glare: Brightness within the field of vision that causes eye fatigue or loss in visual performance. Gravity displacement: A sterilization system in which incoming steam displaces residual air by gravity as opposed to vacuum pumps through a port or drains that is situated at the lowest point of the sterilizer chamber.

H Hands free transfer: Instrument transfer between scrub perioperative Registered Nurse and surgeon/delegate such that neither person touches the same sharp instrument at the same time.


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Hand hygiene: decontamination of the hands by one of two methods- hand washing with either an antimicrobial or plain soap and water, or use of an antiseptic hand rub. HARP: Healing Arts Radiation Protection Act. HBV: Hepatitis B virus. HCV: Hepatitis C virus. Health Canada: Is the federal department responsible for helping Canadians improve, and maintain their health. http://www.hc-sc.gc.ca/ Health care facility: A facility where people are accommodated on the basis of medical and/or nursing need, including but not restricted to public and private hospitals, nursing homes, extended care facilities, long-term care facilities, clinics, medical and dental offices, and health units in industry. Health care personnel: Individuals directly involved with patient care. Health care professional : an educated person licensed/registered by a regulatory body to practice within a defined scope of practice. HEPA filter: A high efficiency particulate air filter. The industry minimum standards, as defined by the Institute of Environmental Sciences (IES) for HEPA filters is 99.97% efficiency in capturing particles of 0.3 um and larger. Three particles out of 10,000 pass through the filter. High filtration mask: Surgical masks that filter 1 - 5 microns in diameter nuclei with 95% efficiency. H.L.D.: High level disinfection. High Level Disinfection: Level of disinfection required when processing semicritical items. High-level disinfection processes destroy vegetative bacteria, myobacteria, fungi and enveloped (lipid) viruses, but not necessarily bacterial spores. High level disinfectant chemicals (also called chemisterilants) must be capable of sterilization when contact time is extended. Items must be thoroughly cleaned prior to high level disinfection. High risk: Patients at risk if the aspect of care is not provided correctly and in a timely manner. H.I.R.O.C.: Hospital Insurance Reciprocal of Canada. HIV: Human immunodeficiency virus causing AIDS. Hole: An aperture; a perforation. HVAC: Heat, ventilation and air-conditioning Hydrodissection and irrigation: Hydrodissection assists with visualization of the operative area through irrigation. Irrigation can be passed through irrigating channels built into the endoscope or through pump irrigation systems. Some systems incorporate electrosurgical capabilities as well. Hyperemia: A normal circulatory response involving a higher-than-normal blood flow to an ischemic or anoxic body area; after tourniquet release, hyperemia refers to the flow of blood back into the exsanginuated limb. Hypothermia: A decrease in core body temperature to a level below the normothermic range.


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I IAHCSMM: International Association of Healthcare Central Service Materials Management, the primary goal is to put members on the path to quality & professional excellence; has been in existence for over 50 years. http://www.iahcsmm.org/ ICN: International Council of Nurses. www.icn.ch ICP: Infection Control Professional refer to CHICA. Ideal body weight: Male; 49.9 + 0.89kg/cm above 152.4 cm height. Female; 45.4kg + 0.89 kg/cm above 152.4 cm height (Schneider, 2008). IFPN: International Federation of Perioperative Nurses. IHI: Institute for Healthcare Improvement. This is an independent not for profit organization working to improve healthcare globally.http://www.ihi.org/ Illumination level: The amount of light falling on a surface. Implantable devices: Devices placed into a surgically or naturally formed cavity of the human body if it is intended to remain there for a period of 30 days or more. Implementation: The phase of the nursing process in which the nurse initiates and completes the action necessary to accomplish definite goals. Incident: An unintended event, no matter how trivial, that could potentially have harmed, or actually harmed a patient. A clinical incident is an occurrence inconsistent with accepted professional standards of patient care or routine organizational policies and procedures. Incident reporting: A process to document occurrences inconsistent with routine hospital operation, policies or procedures, or patient care. Infectious waste: Medical waste (e.g., blood, body fluids, and sharps) that is capable of producing infectious diseases. Informed consent: is a process. A consent granted by a patient or family member, if required, for treatment after the following was explained by the attending physician:

- the condition for which the treatment is proposed; - the nature of the proposed treatment; - reasonable alternative treatments; and - the material risks, expected benefits, likely effects and side-effects of the proposed treatment and

of alternative treatments, including no treatment. The patient and/or family have an opportunity to ask questions and receive answers about the proposed treatment before consent is granted. Initial count: The surgical count done immediately prior to the start of the procedure by the perioperative scrub and registered circulating perioperative nurse concurrently. Injuries: Specific aspects of injuries to reflect cause and effect. Inservice: A planned education session conducted within an agency and directed towards personnel development, job enhancement, and functional requirements.


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Integrator: Integrating indicators are indicators designed to react to all critical parameters over a specified range of sterilization cycles. Intermediate Level Disinfection: Level of disinfection required for some semi-critical items. Intermediate disinfectants kill vegetative bacteria, most viruses and most fungus but not resistant bacterial spores. Internal Chemical Indicator: A device placed inside a package for sterilization to verify the process has reached inside the container package, for example a Class V Integrator. Comes in various levels difficulty from 1-6. Instruments: Surgical tools or devices designed to perform a specific function, such as cutting, dissecting, grasping, holding, retracting, or suturing. Insulation failure: Damage to the insulation of the active electrode that provides an alternate pathway for the current to leave that electrode as it completes the circuit to the dispersive electrode. Intraoperative: Begins when the patient is transferred to the operating room bed and ends when he or she is admitted to the postanaesthesia area. Invasive procedures: The surgical entry into tissues, cavities, or organs or repair of major traumatic injuries. Ionizing radiation: Electromagnetic radiation (e.g., x-rays, gamma rays) that yields ions as it passes through tissue. ISMP: The Institute for Safe Medication Practices Canada (ISMP), is an independent Canadian non-profit agency established for the collection & analysis of medication error reports & developing recommendations to enhance patient safety. http://www.ismp-canada.org/ ISO: International Standards Organization.

J JACHO: Joint Commission on Accreditation of Healthcare Organizations in the United States & has an international section as well. www.jacho.org Journal of Perioperative Practice (JPP): Is the official perioperative nursing monthly journal of the Association for Perioperative Practice (AfPP) formerly known as the National Association of Theatre Nurses (NATN) and the British Journal of Perioperative Nursing (BJPN) Joint Commission: works to improve the safety & quality of care provided to the public of the USA via accreditaion and support to improve performance. www.jointcommision.com

K KURU: A type of human TSE, which occurred in epidemic form in the FORE people Papua New Guinea in the 1950’s and was linked to ritualistic cannibalism.

L LC: Laser committee.


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LCD: Liquid crystal display. LCDC: Laboratory Centre for Disease Control. Canadian government national centre for control of human disease. Laser: A device that produces an intense, coherent, directional beam of light by stimulating electronic or molecular transitions to lower energy levels. An acronym for "light amplification by stimulated emission of radiation". Laser Safety Officer (LSO): Person responsible for effecting the knowledgeable evaluation of laser hazards and is authorized and responsible for monitoring and overseeing the control of such laser hazards. Laundering: The sequence of activities (including preparation, washing, and drying) undertaken to make a new or soiled reusable textile clean, dry and fit for service. Latex: The milky cytosol tree sap acquired by tapping the commercial rubber tree, Hevea brasiliensis, which is grown on large plantations in Africa and Central Asia. Also known as natural rubber latex (NRL). Latex allergy: (Type I IgE-mediated/immediate hypersensitivity response): A systemic or local allergic response to various latex proteins to which the individual has been sensitized. Leaded apron: A leaded-rubber material worn to protect personnel from scattered radiation. Legal aspects: Established legal policies, procedures, and precedents related to such activities as documentation, informed consents, patient identification, controlled drugs, unusual incidents, negligence, and other such activities. Light cord: A cable of fiberoptic filaments used to transport light to the surgical field. Limb occlusion pressure (LOP): The minimum pneumatic pressure needed at a specific time in a given tourniquet cuff applied to a specific patient’s limb, to stop the flow of arterial blood into that limb distal to that tourniquet cuff. Limb paralysis: Also referred to as nerve paralysis or tourniquet paralysis syndrome. This usually occurs when there is compression at the nerve site, unequal pressure of the tourniquet or ischemia distal to the tourniquet. Patient injury results in short term or long term paralysis of the affected limb. Liquid: A substance that flows readily in its natural state; neither solid nor gaseous. LOP: Limb occlusion pressure. LSO: Laser safety officer. Lumen: The cavity within a tubular structure.

Low level disinfection: Level of disinfection required when processing noncritical items or some environmental surfaces. Low level disinfectants kill most vegetative bacteria and some fungi as well as enveloped (lipid) viruses (e.g. Hepatitis B, C, Hantavirus and HIV). Low level disinfectants do not kill mycobacterium or bacterial spores. Low level disinfectants- detergents are used to clean environmental surfaces.

M

Malignant Hyperthermia (MH): A severe form of pyrexia that usually occurs with the use of muscle relaxants &/or inhalation agent. Common triggers succinylcholine and halothane. This inherited condition progresses very rapidly and if untreated may be fatal. May be referred to as Malignant Hyperpyrexia.


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Management: A process of leadership within the broad framework of administration, which executes policies, advises and supports administration, and facilitates collaboration. Materials: Specific operating room equipment, supplies and instruments. ME: Mistaken entry, as in documentation. MEC: Minimum Effective Concentration lowest level of concentration of an active ingredient required to meet the label claim of a reusable HLD/sterilant. Medical device: Any instrument, apparatus, appliance, material or other article, whether used alone or in combination, including the software necessary for its proper application intended by the manufacturer to be used for human beings for the purpose of:

diagnosis, prevention, monitoring, treatment or alleviation of disease; diagnosis, monitoring, treatment, alleviation of or compensation for an injury or handicap; investigation, replacement or modification of the anatomy or of a physiological process; or control or conception,

and which does not achieve its principal intended action in or on the human body by pharmacological, immunological or metabolic means, but which may be assisted in its function by such means. Note: For the purposes of this Standard, this term also encompasses medical device sets. Medical error: An error made when something planned as part of medical care does not occur, or when a wrong plan is implemented. The four types of medical errors include:

diagnostic - failures or delays in diagnoses or in ordering diagnostic tests; treatment - technical errors in performing a procedure or administering a treatment; preventive - failure to provide preventive treatments; or other (e.g., improper medical staff behavior, laboratory errors, equipment failures, communication).

Medication error: An error in the processing, ordering, delivery, or administration of a medication. Memory: Tendency of a textile or single use product to retain the shape and folds it had in the sterilized package. Note: High memory will cause an opened textile or single use product to spring back to its original package shape, and this may allow contamination of the sterile field. Mentor: A trusted counselor or teacher to another person. MHAUS: Malignant Hyperthermia Association of United States. www.mhaus.org Microorganisms: Living organisms of microscopic size. The term is generally used in this Standard to refer to bacteria, fungi, viruses, and bacterial spores. Microprocessor: A very small silicon chip used in computers; the central processing unit. Mini-laparotomy: a surgical procedure typically using laparoscopic instruments in conjunction with a small abdominal inscision. Often refered to as a mini-lap. Minimum effective pressure: The minimum pressure needed in a tourniquet cuff to stop blood flow past the cuff for a time period suitably long for the performance of a surgical procedure. For each usage of a tourniquet system, the Minimum Effective Pressure is typically determined by first measuring the Limb Occlusion Pressure (see definition) and then adding to it a safety margin of between 70-90 mmHg to account for intraoperative variations which may occur over the time period.


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Minimally Invasive Surgery (MIS): Surgery performed through cannulas using telescopes, cameras, and video monitoring devices. Miscellaneous items: Includes, but not limited to: delicate instrument tip protectors; clip cartridges; ligaclip bars; vessel loops, clamps, inserts; umbilical and hernia tapes; ESU (cautery ) pencils, blades, and scraper/scratch pads; wing nuts; screws; small endodscopic parts (i.e. trocar sealing caps, washers, O-rings, springs, caps); and any other small items in a surgical count that have the potential for being retained in a surgical wound. Monitoring: Clinical observation that is individualized to patient needs and based on data obtained from pre-procedure patient assessments. The objective of monitoring patients who receive conscious sedation/analgesia is to improve patient outcomes. Monitoring includes the use of mechanical devices and direct observation. Morbidly Obese: Body mass index (BMI) greater than 30 (Schneider, 2008). MORNA: Manitoba Operating Room Nurses Association. MRSA: Methicillin Resistant Staphylococcus Aureus, which is resistant to methicillain, penicillin, and as well as other antibiotics.

N N95 Mask: N95 refers to the rating given by NIOSH to a mask. The N notes the mask is not oil resistant. The mask filters 95% of non-oil particles of 0.3 microns. N & LORNA: Newfoundland and Labrador Operating Room Nurses Association.

N.A.T.N.: National Association of Theatre Nurses, now known as the Association for Perioperative Practice (AfPP). NBORN: New Brunswick Operating Room Nurses. NDD: Neurological Determination of Death Near miss: An occurrence that could have resulted in an accident, injury, or illness but did not by chance, skillful management, or timely intervention. Necrotizing Fasciitis: A rapid progressive, inflammatory, bacterial infection often located in the deep fascia which is usually caused by Streptococcus A. Commonly called “Flesh Eating Disease”. Needs: Those physical, emotional, spiritual, and intellectual needs required and common to all human beings regardless of their culture, race, sex, or age (patient, personnel, physician, student). Basic human needs must be either supplied or relieved. Nerve injury: A tourniquet-related complication ranging from complete nerve loss to mild transient neuroproxia; caused by pressure at the edge of the tourniquet cuff, ischemia distal to or under the tourniquet cuff, or compression of a nerve segment resulting in nerve lesions. NIAID: National Institute of Allergy ad Infectious Diseases. Falls under the Institute of Health of United States government. http://www3.niaid.nih.gov/ NIOSH: National Institute for Occupational Safety and Health in the United States of America.


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Noise: Sound energy in the workplace. Non-critical item: Those that either touch only intact skin, but not mucous membrane or do not directly touch the patient. Reprocessing of noncritical items involves cleaning and/or low-level disinfection. Non-porous: not permeable by air, steam, water Nosocomial: Hospital acquired infections. Nurse Practitioner: “A registered nurse with additional educational preparation and experience who possesses and demonstrates the competencies to autonomously diagnose, order and interpret diagnostic tests, prescribe pharmaceuticals and perform specific procedures within the legislated scope of practice” (CNA, 2006). Nursing: Art and science in the application of the nursing process, performed with a caring attitude while assisting patients to meet their needs in health, sickness, and for a dignified death. Nursing actions: Professional activities which include leading, facilitating, teaching, supporting, counseling, informing, and providing physical and supportive care (comfort measures, maintenance, prevention, diagnostic, and therapeutic). Nursing intervention: Those activities performed by the nurse to meet expected patient outcomes. Nursing process: A systematic approach to nursing practice utilizing problem solving techniques. The major components of the nursing process are assessment, planning, implementation, and evaluation which are continuous throughout the perioperative phases.

ASSESSMENT: The initial phase of the nursing process which identifies the patient's existing needs and problems.

These steps include: - collection of data;

- analysis of data; and - nursing diagnosis - a concise statement which is a product of the assessment phase identifying the individual's existing and/or potential health needs within the scope of nursing practice. PLANNING:

The phase of the nursing process which involves setting goals, judging priorities,designing methods to resolve problems, and confirming the plans with the patient. Nursing Care Plan (NCP) - a written document indicating the requirements, resources, and nursing

interventions, which will meet the unique needs of patients psychologically and physically, from admission through to discharge from the operating room. IMPLEMENTATION:

The phase of the nursing process in which the Registered Nurse initiates and completes patient care actions necessary to accomplish defined goals and resolve problems in cooperation with other health care team activities.

EVALUATION: The phase of the nursing process in which the Registered Nurse determines in a progressive, ongoing manner, the patient's responses and outcomes to activities of health care team members.

O

Obese: BMI 30-35 (Schneider, 2008). OPA: ortho-phthalaldehyde - a high level disinfectant.


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Open-gloving method: A method of donning sterile gloves in which the everted cuff of each glove allows the gowned person to touch the inner side of the glove with ungloved fingers and the outer side of the glove with gloved fingers. Operating room theatre: A room within the operating room suite designed and equipped for the purpose of performing surgical operations. This term may be reduced to "Operating Room", "Theatre" or "OR". Organization: A business, company, or facility that is involved in manufacturing, distributing, transporting, processing, or using a medical device (e.g. health care facility, manufacturer, distributor). ORNAA: Operating Room Nurses Association of Alberta. ORNAC: Operating Room Nurses Association of Canada. www.ornac.ca ORNANS: Operating Room Nurses Association of Nova Scotia. ORNAO: PeriOperative Registered Nurses Association of Ontario. ORNPEI: Operating Room Nurses Prince Edward Island. Out count: The final surgical count performed at the end of the procedure by the perioperative scrub and registered circulating perioperative nurse concurrently. The results of this count are reported to the surgeon. Over weight: BMI 25-30 (Schneider, 2008).

P PACS: picture archiving and communication systems (PACS) used in medical imaging. These are computers or networks that store, retrieve, distribute and display medical images. PACU: Post-Anesthetic Care Unit (Recovery Room). Particulate: A formed element or discrete body within a surrounding liquid or semi-liquid material. Passive communication: Occurs when there is no response to a question. There is an assumption on the part of communicator that their statement has been accepted. Patient: Person requiring care in the surgical suite. Peak sound level: The maximum instantaneous sound level. Perioperative: Surrounding the operative and other invasive experience (i.e., before, during, and after). Perioperative nursing care: The nursing activities that address the needs of patients, their families, and significant others that occur preoperatively, intraoperatively, and postoperatively. Perioperative Nurses College of New Zealand (NZNO): is special interest group under the New Zealand nurses Organization. http://www.nzno.org.nz/Groups/Colleges/PerioperativeNursesCollege.aspx Perioperative Registered Nurse: A Registered Nurse whose primary professional focus is patient care during the perioperative phase of surgical intervention until admission to the post anesthetic care unit:

- a Registered Nurse who provides administration of the surgical suite;


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- a Registered Nurse who teaches theory and skills to student nurses and/or staff in the perioperative setting; and

- a Registered Nurse who supports, participates in, and initiates research. Perioperative registered nursing practice: Those nursing activities performed by the professional nurse in the preoperative, intraoperative, and postoperative phases of the patient's surgical experience. Perioperative nursing services: Services extended to a variety of other groups to enhance the care ultimately provided to the patient. These groups include, but are not limited to hospitals, clinics, schools and colleges of nursing, physicians, other nurses, insurers, and medical device and pharmaceutical manufacturers. Perioperative Period: Time commencing with the decision for surgical intervention and ending with a follow-up home/ clinic evaluation. This period includes the preoperative, intraoperative, and postoperative phases. Personal protective equipment (PPE): Specialized equipment or clothing used by health care workers to protect themselves from direct exposure to patients' blood, tissue, or body fluids. Personal protective equipment may include gloves, gowns, fluid-resistant aprons, head and foot coverings, face shields or masks, eye protection, and ventilation devices (e.g., mouth pieces, respirator bags, pocket masks). PIDAC: refers to the best practices document developed by the Ontario Provincial Infectious Disease Advisory Committee. http://www.health.gov.on.ca/english/providers/program/infectious/pidac/pidac_fs.html Pneumatic: Pertaining to gas or air; filled with compressed gas (or air). Policy: A specified requirement developed by the healthcare facility. Personnel and physicians shall follow facility policies. Porous: permeable by air, steam, water. Positioning device: Any device or piece of equipment used for positioning the patient and/or providing maximum anatomic exposure. Devices include, but are not limited:

- support devices for head, arms, chest, iliac crests, and lumbar areas; - pads in a variety of sizes and shapes for pressure points (e.g., head, elbows, knees, ankles, heels, sacral

areas); - securing devices (e.g., safety belts, tapes, kidney rests, vacuum pack positioning devices); - procedure bed equipment (e.g., headrest/holders, overhead arm supports, stirrups, foot boards); and - specialty surgical beds (e.g., fracture tables, ophthalmology carts/stretcher chairs).

Postoperative: Begins with admission to the postanaesthesia care area and ends with a resolution of surgical sequelae. Post Tourniquet Syndrome (PTS): This tourniquet complication is a result of postoperative swelling in the extremity. It is caused by a combination of hyperemia and reactive hyperemia; edema, hematomas, and excessive wound bleeding contribute to further swelling. This occurs most often in patients whose tourniquet cuff pressure is insufficient to prevent arterial inflow while preventing venous outflow. Potentially infectious material: Blood; all body fluids, secretions, and excretions except sweat, regardless of whether they contain visible blood; non-intact skin; mucous membranes; and airborne, droplet, and contact-transmitted epidemiologically important pathogens. PPM: parts per million. Precautions: Interventions implemented to reduce the risk of transmission of microorganisms from patient to patient, patient to Health Care Worker (HCW) and HCW to patient.


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Preceptor: A nurse who gives personal instruction, training, support, and supervision to a nursing student or a nurse who is new to the area. Professional Nurse: A formally educated nurse licensed/registered to perform within a define scope of practice by a recognized regulatory body. i.e. a Registered Nurse; Licensed Practical Nurse; Registered Practical Nurse. Each provincial or territorial nursing regulatory body in Canada is responsible for ensuring that the individuals it registers as nurses meet an acceptable level of competence before beginning to practise. (CNA, 2009 retrieved April 5, 2009 from www.can-aiic.ca Preoperative: Begins when the decision for surgical intervention is made and ends with the transfer of the patient to the operating room bed. Prion: Protienaceous infectious particle which is able to initiate infections without the traditional inflammatory response. Incubation ranges from months – 40 years. They are smaller than viruses and contain no nucleic acid. Prion protein: A protein that is present in many organs and tissues including the brain, spinal cord and eye of healthy humans and animals. The TSE agent is believed to be an abnormal form of a prion protein which causes surrounding prion proteins to change their configuration. Procedure: A specific mode or way of performing tasks in a sequential manner. Procedures are often developed as a guideline to implement policies. Process: Activities of the nurse or the process of nursing. Meeting the needs of the patient in a caring manner and conforming to established standards of nursing practice. Includes those functions carried out by practitioners, such as assessment, planning, treatments, indications for procedures/treatments, technical aspects of performing treatment, and management of complications. Pyrogen: A waste product of bacterial metabolism and growth which produces a fever, is toxic to patients and is not destroyed in the sterilization process.

R Rapid Read Out Incubator: at the time of printing this is the only incubator system from 3M which provides a reading of a Biological Indicator after 1 hour (gravity cycle) and 3 hours (vacuum cycle). Recall: Voluntary process of corrective action or removal of items from the market. Receiving: The activities that take place once the device arrives at the health care facility, including examination and inventory, and preparations for the processing, storage or disposal of the device. Reference: Sources used in the research and preparation of a document. Direct quotes include page number. Summarized information includes author and date. (APA, 2001). Reflectance: The ratio of the light reflected from a surface to that falling on the surface, expressed as a percentage. Regulated Medical Waste: Waste that is generated by human or animal health care facilities; medical research and medical teaching establishments; clinical testing; or research laboratories. Includes anatomical waste; microbiology laboratory waste; blood and body fluids; and sharps waste. (Code of Practice for Management of Biomedical Waste in Canada, 1992). Reprocessing: The steps performed to prepare a used medical device for reuse.


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Responsibility: Being depended on for completion of an activity or group of activities including those delegated to other persons. Reusable: Any product or piece of equipment intended by the manufacturer for multiple uses. The manufacturer is to provide instructions for reprocessing, care and maintenance as appropriate to each item. R.H.P.A.: Regulated Health Professions Act. Legislation in the Province of Ontario that defines the scope of practice and regulations for practice of twenty-four health disciplines, including nursing. Rigid sterilization container: A box or tray made of a rigid material that is designed to contain items for sterilization. Specific containers are developed for regular steam sterilization and another specific for emergency (flash) sterilization. RMW: Regulated Medical Waste. RNFA: Registered Nurse First Assist of Canada Network. Refer to Section 1 for more information. Roentgen equivalent man (rem): A unit equivalent dose derived by multiplying rads by quality factors for the relative biologic effects of a type of radiation. Rem is a measurement used in occupational monitoring: 1 rem = 1 R = 1 rad; 1 milliroentgen (mR) = 1/1000 rem. Role: Expected behavior patterns. Root cause analysis: A process performed after an adverse event already has occurred to identify basic and contributing causal factors underlying variations in performance associated with near misses, adverse events, and sentinel events. Root cause analysis seeks to find common causes to improve performance. Routine Precautions (RP): A set of procedures and protocols for consistently treating all body substances from every patient as potentially infectious. RSV: respiratory syncytial virus.

S Safe Surgery Checklist: Is part of the WHO World Alliance Challenge to improve surgery globally. The 3 part checklist is a result of the work to improve the safety of surgery. WHO has declared surgery can cause harm! http://www.who.int/patientsafety/safesurgery/ss_checklist/en/index.html Safer Heathcare Now! (SHN): Is a campaign aimed at improving the safety of Canadian patient care, sharing the knowledge, implementing & learning. Campaign was launched by CPSI. http://www.saferhealthcarenow.ca SARS: Sudden Acute Respiratory Syndrome. A viral respiratory illness first reported in 2003. SATS: South African Theatre Nurses, at the time of printing a founding member of IFPN, www.theatresisters.co.za Scatter radiation: Radiation is scattered when an X-ray beam strikes a patient's body, as it passes through the patient's body, and as it strikes surrounding structures (e.g., walls, OR furniture). Scope of Nursing Practice: The activities that nurses are educated and authorized to perform, as established through legislated definitions of nursing practice, complemented by standards, guidelines and policy positions issued by professional nursing bodies (CNA, 2008, p. 41)


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Scrub Nurse: A Perioperative Registered Nurse who performs a surgical scrub, gowns, gloves, uses anticipatory skills, and manages the sterile field and equipment in assisting the surgical team to perform the surgical procedure and to meet individual patient needs. Semi-critical items: Devices that come in contact with non-intact skin or mucous membrane but ordinarily do not penetrate them. Reprocessing semi-critical items involves meticulous cleaning followed by high-level disinfection. Depending on the type of item and the intended use, intermediate level disinfection may be acceptable. SENS: Safety engineered needles. Sensitization: The development of immunological memory in response to exposure to an antigen. Sentinel event: Unexpected occurrences involving death or serious physical or psychological injury or risk. May include loss of limb or function (i.e., sensory, motor, physiologic, intellectual impairment) not previously present which requires continued treatment or lifestyle change. Sequential compression device (SCD): also known as pneumatic compression devices (PCD). Placed on lower extremities to facilitate deep vein thrombosis prevention by reducing the pooling of blood and aiding in flow. Sequentially compress sections of the lower extremities. SGNA: Society for Gastroenterology Nurses and Associates of the United States of America. www.sgna.org Sharps: Items containing a sharp point(s) or edge(s) such as suture needles, hypodermic needles, scalpel blades, electrosurgical tips/blades, safety pins and instruments with sharp edges or points. SHEA: Society for Healthcare Epidemiology of America Shelf life: The length of time that a sterilized item will remain sterile. Factors affecting the maintenance of sterility include the quality of the wrap, packaging material, or rigid container, the sealing method, the handling, and the storage and transport practices. The shelf life of a chemical is the length of time after production or after mixing, that the chemical is expected to be effective. Shield or Shielding: Radiation absorbing material or materials used to reduce the absorbed dose, or absorbed dose rate imparted to an object. Sodium Hypochlorite: Common name is bleach. A caustic agent frequently used for cleaning/disinfecting. Sodium Hydroxide: NaOH is soda lye, another caustic agent which may be used as a cleaning/disinfecting. SORNG: Saskatchewan Operating Room Nurses Group. Spaulding classification: Dr. Spaulding devised classification system for medical devices. It has 3 levels, critical, semi-critical & no critical. It is recognized as the internationally accepted norm or practice when employing the use of disinfection or sterilization. Specialized Practice: “Practice that concentrates on a particular aspect of nursing, related to the client’s age (e.g., paediatrics, gerontology), the client’s problem (e.g., pain management, bereavement), the diagnostic group (e.g., orthopaedics, vascular surgery), the practice setting (e.g., home care, emergency) or the type of care (e.g., primary health care, palliative care, critical care)” (CNA, 2008, p. 41). Sponges: Includes all sizes and shapes of absorbent dissecting material (i.e., pledgettes, peanuts, etc). All sponges must have radiopaque markers and/or tab.

SSI: Surgical Site Infection.


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SSSL: Safe Surgery Saves Lives, campaign from WHO challenging the world to make global surgery safer. http://www.who.int/patientsafety/safesurgery/ Standard: An established norm determined by opinion, general agreement, authority, research, and/or theory that are measurable by established criteria. An agreed upon level of excellence. Standard Precautions: The primary strategy for successful prevention or control of nosocomial infection; reduction of worker exposure to infection; precautions used for care of all patients regardless of their diagnosis or presumed infectious status. Refer to Routine Practices. Previously called “Universal precautions”. Sterile: Free from viable microorganisms. Sterile field: An area immediately around a patient that has been prepared for a surgical procedure, including the scrubbed team members, the furniture, and fixtures. Sterile medical device: A device that is free from viable microorganisms. Sterile storage area: A controlled storage area used to store clean and sterile medical devices. Sterilization: A validated process used to render a product free from viable microorganisms. Note: In a sterilization process, the nature of microbial death is described by a mathematical function. Therefore, the presence of microorganisms on any individual device can be expressed in terms of probability. While this probability may be reduced to a very low number, it can never be reduced to zero. Sterilization: The chemical process: Chemical sterilization processes are used when items are not compatible with heat or steam. Chemical sterilization is achieved by EO, hydrogen peroxide plasma/vapor, or by gas (peracetic acid) vapor/plasma processes. Sterilization: The physical process: Saturated steam under pressure shall be used for instruments compatible with heat and moisture. Sterilizer: A processing unit that cleans by a spray-force action known as impingement. This machine combines a vigorous agitation bath with jet-stream air to create under-water turbulence. A sterilization cycle follows the washing cycle. Strike-through: An event whereby sterile drapes or packages become contaminated with microorganisms due to soaking through or forcing through of moisture or air. Subungual: Under the nail (e.g., finger). SUMeDs: Single Use Medical Devices. May also be referred to as SUDs Superficial: Superheating: Uncontrolled, and possibly damaging, heat rise in a package that is being steam-sterilized, usually as a result of insufficient moisture in the package materials or contents. Note: In addition to damaging materials, superheating can result in the failure of sterilization, as effective sterilization relies on the presence of moisture. Surgical attire: Surgical apparel worn within the semirestricted and restricted areas of the Surgical Suite which includes the two-piece pantsuit, cover jackets, head coverings, shoes, masks, protective eyewear, and other protective barriers.


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Surgical Conscience: professional behavior in the surgical setting that demonstrates an understanding consistent application of the principles of asepsis; being unable to note a break in technique and not ignore it. Surgical gown: A sterile textile gown that is worn by health care providers who are performing sterile procedures. Note: Surgical gowns are recognized as Class 1 medical devices, according to the Medical Device Regulations of the Canada Health Act. Surgical hand scrub: The process of removing as many microorganisms as possible from the hands and forearms by mechanical washing and chemical antisepsis before participating in a surgical procedure. Surgical plume: Smoke produced by combustion of human tissue which is a health hazard containing organisms, body fluids and carcinogens. i.e. Electrosurgery, Laser Surgery. Surgical Suite: An area including the operating rooms, post anesthetic recovery room and support facilities. Systems approach: A method to assess the structural and functional ways in which an organization operates and how the people interact.

T Tamper-evident device: A seal or disposable "lock" designed so that it cannot be resealed after opening, which is used to indicate whether a container has been intentionally or accidentally opened and therefore exposed to potential contamination prior to use. The device is generally secured on the container latching mechanism. TB: Tuberculosis. A disease caused by bacteria usually attacking the lungs, which is spread via the airborne route from person to person. Telerobotic surgery: Minimally invasive surgery technique that utilizes advanced information technology to offer treatments and procedures over long distances. Terminal cleaning: Cleaning that is performed at the completion of surgical practice settings' daily surgery schedules. Terminal cleaning is performed in surgical procedure rooms and scrub/utility areas, which include, but are not limited to, surgical lights and external tracks, fixed and ceiling-mounted equipment, all furniture (including wheels and casters), equipment, handles of cabinets and push plates, ventilation faceplates, horizontal surfaces (e.g., tops of counters, autoclaves, fixed shelving), the entire floor, kick buckets, and scrub sinks. Third party reprocessor: A facility licensed by Health Canada or the US Food and Drug Administration (FDA) to reprocess single-use medical devices to the same quality system requirements as the original manufacturer. Toxic reaction: A reaction which may occurs in intravenous regional anesthesia (i.e., Bier block) procedures. The major danger is an inadvertent bolus of local anesthetic entering the general circulation. This condition results from accidental or sudden deflation of the tourniquet, from deflation soon after injection of local anesthetic, or if the bolus is released too rapidly at the end of the procedure. During the procedure, minor toxicity symptoms could indicate leakage due to under inflation of the tourniquet cuff. Transfer: The process of preparing and moving a clean device from one organization to another. It includes sending, transporting, and receiving. Transmission based precautions: Second tier of precautions designed to be used with patients known or suspected to be infected or colonized with highly transmissible or epidemiologically important pathogens for which additional precautions are needed to prevent transmission in the practice setting.


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Transmissible Spongiform Encephalopathy (TSE): Also known as prion diseases are fatal degenerative brain diseases. The TSE agents are hardy, remain infectious for years in a dried state, and resist all routine sterilization and disinfection procedures commonly used in health care facilities. Examples of human TSE are: GSS, FFI, Kuru, and CJD. Transportation: Movement of medical devices between an off-site facility and a health care facility. Note: This includes movement of medical devices between health care facilities. TURP: Transurethral resection of prostate.

U ULPA filter: An ultra low penetration air filter, used for the capture of submicronic particles. The Institute of Environmental Sciences (IES) for ULPA filters specifies an efficiency of 99.9999% for particle diameters of 0.12 um; one particle out of every 100,000 passes through. Research has shown that pathogens such as HIV, HPV, and HBV particles are found attached to droplet nuclei, and that the total size of the particle is significantly larger than the 0.1um particles that an ULPA filter is designed to capture. Ultrasonic technology: Ultrasonic technology allows for the cutting and coagulation via the use of sound waves. Ultrasonic energy begins with an electrical current that generates a signal that is sent to a handpiece. A transducer converts the energy to a mechanical motion in the handpiece. The tip of the handpiece when in contact with tissue coagulates vessels. No tissue plume is generated and damage to adjacent tissue is limited. Examples of ultrasonic systems are the Harmonic Scalpel®, Ultrasonix®. Universal Precautions: Refer to Routine Practices. Unlicensed Assistive Personnel (UAP): Individuals trained to assist registered nurses in providing patient care activities as delegated by registered nurses. Assistive personnel include, but are not limited to, aides/assistants, orderlies, technicians and technologists. Unregulated support staff: Staff members who are not regulated in their role by Provincial/National legislation, who work under the supervision of a healthcare professional. The public has no recourse for lodging complaints except directly to the employer. Used items: Items that are opened for surgical procedures that may or may not have come in contact with the patient’s blood, tissue or body fluids. User-centered design: A system designed to devise methods to avoid errors. Strategies are directed at the design of individual devices so they can be used reliably and safely. UV: Ultraviolet.

V

Validation: Documented procedure for obtaining, recording, and interpreting the results required to establish that a process will consistently yield product complying with predetermined specifications. Valve: A mechanical component of a rigid sterilization container system that opens during sterilization to allow air evacuation and sterilant penetration and closes after sterilization to prevent contamination.


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vCJD: Variant Creutzfeldt-Jakob Disease. A new prion disease in humans linked to eating beef products from cattle infected with BSE. First reported case in Canada was 2002. It is a progressive fatal disease affecting the central nervous system. VRE: Vancomycin Resistant Enterococcus which is resistant to Vancomycin and other microbial agents.

W Weight: A measurement used for textiles, expressed in grams per square meter. WHMIS: Workers' Hazardous Material Information System. A federal program administered by Health Canada, Environmental & Workplace Health, http://www.hc-gc.ca/ewh-semt/occup-travel/whmis-simdut/index-eng.php WHO: World Health Organization is the United Nations specialized agency for health. www.who.int Wrap: To enclose and fasten securely as a package. Wrong level/part surgery: A surgical procedure that is performed on the correct site, but at the wrong level or part of the operative field. For example, performing a lumbar laminectomy on an unintended intervertebral level with identified pathology. In this type of error, the correct part of the body is prepped and draped, but the surgical procedure is performed on the wrong level of the patient’s anatomy. Wrong patient surgery: An error includes procedures that are performed on the wrong patient; a patient not correctly identified prior to surgery. Wrong side surgery: A surgical procedure that involves operating on the wrong extremity or wrong side of the body. Wrong site surgery: A broad term that encompasses all surgical procedures that are performed on the wrong body part or the wrong patient.

X X-rays: Electronically generated electromagnetic radiation of maximum photon energy not less than 5,000 electron volts. X-ray machine: Electrically powered device, the principal purpose of which is the production of x-rays. X-ray source: Any device or that portion of any device that emits x-rays, whether or not the device is an x-ray machine.


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REFERENCES

American Psychological Association (APA) (2001). Publication Manual (5th. Ed.). Washington: Author. Canadian Nurses Association (2008). Advanced Nursing Practice A national Framework. Ottawa: Author. Canadian Nurses Association (2006). Practice Framework for Nurse practitioners. Ottawa: Author. Canadian Association of Bariatric Physicians & surgeon (CABPS). http://www.cabps.ca Schneider, M. (2008). Anesthesia safeguards for the obese. Out Patient Surgery. March 2008, p. 5. Taber’s Cyclopedic Medical dictionary (2005). Philadelphia: F A Davis Co.


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Standards, Guidelines and Position Statements for Perioperative Registered Nursing Practice

Revision Date: June 2009 Evaluation Form 9th Edition of 334

Evaluation Form Standards, Guidelines and Position Statements for

Perioperative Registered Nursing Practice The ORNAC Standards Committee would like your feedback on this edition of the Standards. Please complete this form and send it to the ORNAC president Thank you in advance for your participation. 1. Comments on the revised, bound, format. 2. Is information presented in logical order? (if not, give example of where information

should be moved). 3. Areas requiring correction (including typo errors). 4. Material/information you wish to see added in future editions/revisions. Comments: please use other side of page.

The name and address of the current President is available at the ORNAC web site www.ornac.ca


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Canadian Standards Association - Standards for Sterilization and Infection Control in Health Care Facilities

General standards and guides – for all facilities Number Title Intended forZ314.8 Decontamination of Reusable Medical

Devices Sterile processing departments; clinical areas and ORs (covers all activities from point-of-use to cleaning, disinfection and preparation for sterilization)

Z314.10 (2009)

Selection, Use, Maintenance & Laundering of Reusable Textile Wrappers, Surgical Gowns and Drapes for Health Care Facilities

Laundries and purchasing departments in facilities that use or process reusable textiles.

Z314.14 Selection and Use of Rigid Sterilization Containers

Sterile processing departments and other area where rigid sterilization containers, organizing trays, etc. are used.

Z314.15 Warehousing, Storage and Transportation of Clean and Sterile Medical Devices

Material managers, sterile processing departments and infection prevention and control personnel in facilities that store and pick medical devices outside of controlled sterile supply areas.

Z314.22 Management of Loaned, Shared and Leased Medical Devices

Sterile processing departments and operating rooms (Standard outlines requirements and responsibilities for the safe and effective use of loaners).

PLUS 1112 Handbook on Infection Prevention and Control in Office-Based Health Care and Allied Services

Smaller health care facilities that want guidance consistent with the hospital sterilization standards.

Z14161 Sterilization of Health Care Products - Biological Indicators - Guidance for the Selection, Use and Interpretation of Results

Health care facility departments and staff that purchase or use biological indicators.

Z15882 Sterilization of Health Care Products - Chemical Indicators - Guidance for Selection, Use and Interpretation of Results

Health care facility departments and staff that purchase or use chemical indicators.

Z317.13 Infection Control During Construction or Renovation and Maintenance of Health Care Facilities

Hospital engineers, architects, contractors and infection prevention and control personnel in facilities undergoing construction or renovation.


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Additional standards for steam sterilization Number Title Intended forZ314.3 Effective Sterilization in Health Care

Facilities by the Steam Process Sterile processing departments that perform steam sterilization

Z314.7 Steam Sterilizers for Health Care Facilities Hospital engineering departments

Additional standards for ethylene oxide (EtO) sterilization Number Title Intended forZ314.1 Ethylene Oxide Sterilizers for Health Care

Facilities Hospital engineering departments

Z314.2 Effective Sterilization in Health Care Facilities by the Ethylene Oxide Process

Sterile processing departments that perform EtO sterilization

Z314.9 Installation, Ventilation and Safe Use of Ethylene Oxide Sterilizers in Health Care Facilities

Hospital engineering and sterile processing departments in facilities that perform EtO sterilization

For an entire listing of health care standards and to ordered, contact a CSA sales representative at 1-800-463-6727 or by visit the Online Store at www.shopcsa.ca


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