The Best of Clinical Issues

Article Outline

• Perioperative prevention of deep vein thrombosis
• Individual radiation dosimeters
• Protective radiation-shielding devices
• Stacking sterile instrument trays
• Reprocessing flexible endoscopes before use
• Cooling hot instruments
• Safety of petroleum-based eye lubricants
• Eyewash stations in the OR
• Laser printer use in the OR
• Reuse of multidose vials
• Examination
  • The Best of Clinical Issues
    • Purpose/Goal
    • Objectives
    • Questions
• Learner Evaluation
  • The Best of Clinical Issues
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    • Content
• References
• Resources
• Copyright

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Perioperative prevention of deep vein thrombosis 

QUESTION: Several of the surgeons at our facility write orders for a variety of deep vein thrombosis (DVT) prevention modalities. Our intent is to use evidence in our practice to prevent DVT. What are AORN's recommendations for this important nursing intervention?

ANSWER: AORN has a “Guideline for prevention of venous stasis.”¹ It contains a wealth of information including definitions, prevalence, pathophysiology, and pathogenesis of the disease process. Assessment of risk factors is the first step in identifying interventions to prevent or treat DVT. In the guideline, risk levels are classified as low, moderate, high, and highest; and the risks are further matched with certain surgical parameters such as age, surgical classification, and type of anesthesia. Prophylactic treatment should be tailored to each patient's risk level and surgical parameters. For example, a patient who is older than 40 years of age with multiple risk factors (eg, previous venous thromboembolism, malignant disease) may be prophylactically treated with low molecular weight heparin (ie, enoxaparin sodium) or low-dose unfractionated heparin and graduated compression stockings (GCS) or intermittent pneumatic compression stockings.

Venous thromboembolism (VTE) prophylaxis treatment is one of six Surgical Care Improvement Project (SCIP) measures. The SCIP is a partnership of organizations, including AORN, that is interested in significantly reducing surgical complications. The measures are reported to the Joint Commission and the Centers for Medicare and Medicaid Services (CMS) and other insurance payers.²

Research continues to identify best practices for treatment of DVT. In a systematic review of GCS for prevention of DVT, analysis of randomized controlled trials suggests that GCS are effective in diminishing the risk of DVT in hospitalized patients. Data examination also suggests that use of GCS along with another method of prophylaxis is even more effective than GCS alone.³

Another review examined heparin and physical methods of preventing DVT. It was concluded that unfractionated and low molecular weight heparins protect against DVT in the lower limbs. Results indicated that foot and calf pumping devices both appear to prevent DVT, may protect against pulmonary embolism, and may reduce mortality; however, patient compliance remains a problem.⁴ Another study compared knee-length and thigh-length thromboembolic disease stockings (TEDS) and sequential compression devices (SCDs) for prevention of deep vein thrombosis. Knee-length TEDS and SCDs were more comfortable for patients than were thigh-length TEDS and SCDs, were less expensive, encouraged higher levels of compliance, and did not pose a risk of venous stasis as do the restricting bands of thigh-length stockings.⁵

Sifting through the large volume of evidence on DVT prevention takes patience, experience, and a trained eye. Organizations that provide systematic reviews of several studies (eg, the National Guideline Clearinghouse, the Cochrane Collaboration) enable practitioners to read summaries of the latest evidence. Deep vein thrombosis poses such a serious problem for many surgical patients that in 2008, the US Surgeon General's Office published a report announcing a call to action to prevent DVT and pulmonary embolism. It is a free document available at http://www.surgeongeneral.gov/topics/deepvein. Addressing this major health issue will take a collaboration of public, private, and government entities to provide resources to researchers and practitioners in health care systems and communities.

ROBIN CHARD

RN, PhD, CNOR

Perioperative nursing specialist

AORN Center for Nursing Practice

Reprinted from AORN J. 2009;90(1):119–120.

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Individual radiation dosimeters 

QUESTION: Recently, I moved from a large, trauma teaching facility to a smaller, rural facility. My previous facility used intraoperative fluoroscopy daily. All surgical team members wore dosimeters at their neckline, and protective shielding devices were examined every six months. At the new facility, intraoperative fluoroscopy unit (ie, C-arms) and mini C-arms are used infrequently. The staff members do not wear dosimeters. What are the rules and regulations regarding dosimeters for staff members?

ANSWER: Medical facilities with a radiation license are required to supply individual radiation monitoring devices for exposures to radiation and radioactive material. Individual monitoring devices must be worn by workers who are likely to receive an annual dose from sources external to the body in excess of 10% of the following limits:

External radiation dose monitoring is determined by the use of individual monitoring devices, such as film badges or dosimeters. An external device for monitoring whole body dose should be placed near the location expected to receive the highest radiation dose during the year. If the whole body is exposed uniformly, the individual radiation monitoring device typically is worn at the neckline on the front of the upper torso. AORN recommends that when single monitoring devices are used, they should be worn on the same area of the body by all surgical team members.² Individuals must comply with state regulations concerning placement of the radiation dosimeters.

Surgical team members do not need to wear a dosimeter or film badge if a radiation dosimeter evaluation reveals a radiation dose less than 10% of the specified 5 rems per year. If a subsequent evaluation shows that a 10% threshold was or will be exceeded, the dose received by the affected individual should be estimated to account for the time when monitoring was not provided, recorded, and reported.³ Further guidance on evaluating the need to provide monitoring is available in the US Nuclear Regulatory Commission (NRC) Regulatory Guide 8.34, “Monitoring criteria and methods to calculate occupational doses,” which can be accessed at http://www.nrc.gov/reading-rm/doc-collections/reg-guides/occupational-health/active/8-34/, http://www.nrc.gov/reading-rm/doc-collections/cfr/part020/, http://www.nrc.gov/reading-rm/doc-collections/cfr/part020/part020-1502.html, or http://www.reirs.com/reg_gds.htm.

Dosimeter or film badge requirements for pregnant workers differ from the requirements for workers who are not pregnant. Radiation exposure could cause genetic defects in the fetus or in the mother, resulting in fetal abnormalities.⁴ Pregnant workers should wear two dosimeters: one should be worn externally at the neckline and the other should be worn under the shielding apron at the abdominal level.² The dose limit to the embryo or fetus is 0.5 rems during the entire pregnancy.⁵ This is one-tenth the dose that an adult worker may receive in a year. If the pregnant worker has already received a dose exceeding 0.5 rems in the time frame between conception and declaration of the pregnancy, an additional dose of 0.05 rems is permitted during the remainder of the pregnancy. According to the Federal Register 10 CFR 20.1208(b), “Dose to an embryo/fetus,” licensees are required to make efforts to avoid substantial variation greater than a uniform monthly permitted dose rate of the 0.1 rems and to ensure that the 0.5 rems allowed do not occur in a short period of time during the pregnancy.⁵ Dosimeter readings for a pregnant worker should be performed monthly, not annually.²

The woman must declare her pregnancy in writing to the licensed medical facility in order to take advantage of the lower exposure limits and dose monitoring provisions. Additional information about radiation exposure for pregnant workers can be found in AORN's “Recommended practices for reducing radiological exposure in the perioperative setting” and on the NRC web site at http://www.nrc.gov/reading-rm/doc-collections/reg-guides/occupational-health/active/8-13/08-013.pdf.

The US federal and state governments play an important role in ensuring that ionizing radiation is managed responsibly to protect the public and workers involved with radiation activities. Allowable radiation exposure levels are set to provide an appropriate level of protection for both the public and workers. A malfunctioning radiation emitting device can only be detected by a dosimeter or film badge reading that has been reviewed monthly, quarterly, or annually.

DENISE MAXWELL-DOWNING

RN, MSN, CNOR

Perioperative nursing specialist

AORN Center for Nursing Practice

Reprinted from AORN J. 2008;88(1):104–105.

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Protective radiation-shielding devices 

QUESTION: Staff members at the health care facility where I work do not know when the protective radiation-shielding devices were last examined. Who is responsible for monitoring the examination of shielding devices? Do protective radiation-shielding devices need to be examined annually?

ANSWER: The US Nuclear Regulatory Commission (NRC) states that

executive management of the licensed facility assumes ultimate responsibility for the safe use of radiation products and equipment, and is required to implement an effective radiation safety program to achieve this goal.¹

Within health care facilities, the executive management team, the radiation safety committee, and the radiation safety officer (RSO) are responsible for providing effective management of the radiation safety program. Reducing exposure to radiation requires an integrated program with day-to-day operations controlled by an RSO. The RSO for the facility should have copies of the

To meet the recommendations of the NRC for dose-equivalent levels, the facility's radiation safety program goals should include measures to keep the radiation exposure dose limits low. The guidelines for ensuring radiation exposures are maintained as low as is reasonably achievable.¹

Radiation-emitting equipment used infrequently by a facility still has the potential to cause radiation exposure beyond the recommended dose-equivalent levels. Radiation exposure can occur when unprotected workers are near a radiation-emitting machine in operation. The degree of exposure depends on several considerations including the

Surgical team members who may stand with their backs to a radiation source should wear wrap-around protective shielding devices to decrease the risk of exposure. At least annually, licensed medical facilities should record exposure to ionizing radiation doses received during planned exposures, accidents, and emergency conditions for all individuals who are required to be monitored.³

According to AORN's “Recommended practices for reducing radiological exposure in the perioperative setting,” “all leaded protective devices should be checked for defects and wear at least annually or whenever damage is suspected.”^4(p459) The National Institute of Occupational Safety and Health standard 5.2.3.7.3 affirms this recommendation.⁵ A facility may decide to perform protective radiation-shielding device examinations more frequently based on their usage and method of storage. AORN recommends that all radiation aprons, gloves, and thyroid shields be stored flat or hung vertically to protect the devices from cracking, which reduces the effectiveness of the shielding barrier. When new radiation protection equipment is received, the facility should examine it for holes, tears, or cracks that may have occurred during transport. New radiation protection equipment also should be tagged or labeled for identification during future examinations.

Radiation can be either beneficial or harmful, depending on its use and how well it is controlled. Regulation of radioactive sources, by-products, and certain materials are needed so that people are protected from unnecessary or excessive exposures. State rules and regulations differ, so one facility may implement a radiation safety program differently from another facility. Following the facility's radiation safety program, the state's governing agency's rules and regulations, and AORN's “Recommended practices for reducing radiological exposure in the perioperative setting” will help ensure radiation safety for patients and health care workers.

DENISE MAXWELL-DOWNING

RN, MSN, CNOR

Perioperative nursing specialist

AORN Center for Nursing Practice

Reprinted from AORN J. 2008;88(1):105–106.

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Stacking sterile instrument trays 

QUESTION: During a session at AORN's 2008 Congress, the subject of stacking instrument trays was discussed. Is this a new AORN standard? If so, is there a weight limit or any other guidelines that should be considered when establishing policy?

ANSWER: Sterile items should be stored in a manner that protects package contents from physical damage (eg, compression, seal breakage, loss of package integrity) and reduces the potential for contamination.¹, ² The total weight of instrument containment devices should not exceed 25 lbs including the contents and containment method (eg, wrappers, rigid container systems, cassettes, organizing trays).¹ Excessively heavy instrument sets may compromise sterilization and drying. The focus should be on the set configuration (ie, how the instruments are distributed in the set) and the overall weight of the set. Furthermore, lifting and moving heavy instrument sets may cause health care worker injury.¹

Health care organizations should determine the best methods and materials for packaging sterile items based on the anticipated storage, handling, and environmental events that may be encountered. Loss of sterility of a packaged sterile item is event related. An event must occur to compromise package content sterility. Events that may affect the sterility of a package include, but are not limited to,

The number of contained instruments stacked depends on the strength of the storage system and ease of presentation in consideration for worker safety. Shelving used for container systems should be designed to accommodate the weight and configuration of the containers. Containers should be firmly seated on one another.² Ergonomic considerations for workplace safety should be considered for determining shelf height.

Instrument sets not packaged in rigid systems (eg, wrapped trays) should not be stacked because compression is inevitable and compromises sterility. Nor may these sets be stored on their sides because the contents may shift and compromise package integrity.

Other general sterile storage and fire safety guidelines should be followed.³, ⁴ All storage shelving should be kept clean and dry in a controlled environment in adherence with established parameters for temperature, humidity, and air exchanges.¹, ²

SHEILA MITCHELL

RN, BSN, MS, CNOR

Perioperative nursing specialist

AORN Center for Nursing Practice

Reprinted from AORN J. 2008;88(4):629.

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Reprocessing flexible endoscopes before use 

QUESTION: Recently, I was assigned to work in the endoscopy department and I discovered that the flexible endoscopes are not being high-level disinfected immediately before use. Is this necessary, or is this a sacred cow?

ANSWER: AORN's “Recommended practices for cleaning and processing flexible endoscopes and endoscope accessories” states that if the flexible endoscope has been processed and stored correctly within the previous five days, reprocessing immediately before use is not required.¹ The previous version of the recommended practices stated that flexible endoscopes should be reprocessed immediately before use, but the recommended practices have been changed based on evidence from the literature.²

In a prospective observational study,³ flexible endoscopes that were in use during the study period were tested for contamination prior to reprocessing before the first procedure of the day (n = 200). Personnel at this health care setting frequently reuse the endoscopes every day; therefore, only eight endoscopes were used to determine the contamination rate. The mean shelf life, defined as the time between the last procedure one day and reprocessing before the first procedure on the next day, was 37.62 hours (standard deviation 36.47) with a median of 18.8 hours (range 5.27 to 165.35 hours). This study did not test for anaerobic contamination. The results of the study revealed a nonpathogenic contamination rate of 15.5% and a pathogenic rate of 0.5%. The environmental nonpathogenic organism identified was coagulase-negative Staphylococcus. The study also revealed a 37.5% environmental contamination rate after 144 to 168 hours.³

Rejchrt et al⁴ evaluated the contamination of high-level disinfected endoscopes stored in a dust-proof cabinet for five days. The cleaning and disinfection process involved initial decontamination and manual cleaning with the endoscope immersed in detergent, after which the endoscope was high-level disinfected in an automatic reprocessor. The endoscopes were then hung in a dust-proof cabinet for storage. The surface of the endoscopes, the openings for the piston valves, and the accessory channel were sampled daily for five days. On the fifth day, samples of the accessory channels were obtained using a flush-through and brushing sampling method. Samples were cultured for aerobic and anaerobic bacteria, bacterial spores, and Candida species. All endoscopes were shown to be bacteria-free immediately after high-level disinfection. Skin bacteria were the only contaminates on the endoscope surfaces in four of 135 assays during the subsequent five-day test period. All the flush-through samples on day five were without growth. The study authors concluded that when proper reprocessing and storage guidelines are strictly followed, reprocessing endoscopes immediately before use may not be necessary for up to five days.⁴

Vergis et al⁵ completed a three-phase study using four endoscopic retrograde cholangiopancreatography (ERCP) scopes and three colonoscopes. In the first phase, the endoscopes were tested after high-level disinfection and daily thereafter for a period of 14 days. This test was repeated for the second phase to confirm the phase-one results. In phase three, the test was again repeated after high-level disinfection and again on day seven of storage. In the first phase, during the first five days of the study, six of 70 cultures (8.6%) were positive involving two colonoscopes and two ERCP scopes. No growth was noted in phase two, and in phase three, only one endoscope had a positive culture. The positive cultures grew only Staphylococcus epidermidis (S epidermidis).

The findings of a simulated study⁶ on the shelf life of flexible colonoscopes suggest that endoscopes may be stored for up to seven days without requiring reprocessing. The endoscope tested was artificially inoculated. The endoscope was then thoroughly cleaned manually, processed with peracetic acid, flushed with 100% isopropyl alcohol to facilitate drying, then hung in a cabinet for storage. This study also revealed no growth except in one test that grew an environmental, nonpathological contaminate (ie, S epidermidis).⁶

The environmental, nonpathological contaminate grown in all three studies on the surfaces of the scopes was S epidermidis. To help decrease this potential contamination, staff members should perform hand antisepsis and then don clean gloves before removing the endoscopes from the automatic endoscope reprocessor or from the high-level disinfectant solution. These actions also help protect staff members' hands from exposure to the high-level disinfectant solution and decrease the potential of any infective agents present on the hands of health care workers from contaminating the endoscope.⁵

The studies also incorporated the significance of proper storage conditions, including adequate drying, the position during hanging, and the type of cabinet used for storage. Adequate drying helps prevent an environment that is favorable to microbial growth. Adequate drying is accomplished by flushing the channels of the scope with alcohol and then purging the endoscope with forced air. Finally, the external surfaces are wiped with an alcohol-soaked cloth.³, ⁴, ⁵

After drying, the endoscopes should be hung vertically with the valves open; all accessories should be removed; and if required, endoscope protectors should be applied.⁴, ⁵, ⁶, ⁷ When a flexible endoscope is hung in the vertical position, coiling or kinking is prevented, allowing any remaining moisture to drain out of the bottom of the endoscope. Removing all accessories and opening all the valves supports airflow through the endoscope's channels and allows the contact points between the endoscope and the accessories to dry after high-level disinfection.

When an endoscope protector is used, the protector should not interfere with the flexible endoscope hanging straight. An endoscope protector is a ring-shaped device frequently made from sponge-type material slipped over the endoscope to keep the distal end from being damaged by hitting the walls of the cabinet. It also holds the endoscope away from the side of the cabinet allowing for airflow around the endoscope. If the endoscope is not entirely dry, moisture may collect in the endoscope protector, creating an environment favorable to microbial growth.⁷, ⁸, ⁹

An appropriate storage cabinet should have, at a minimum

Flexible endoscopes should be reprocessed immediately before use if evidence of improper drying exists when the endoscope is removed from storage.³, ⁴, ⁵, ⁶ Evidence of improper drying may include wet spots or stains on the bottom of the cabinet where the flexible endoscopes have been hanging. Flexible endoscopes should not be stored in the original cases. The original, foam-lined cases are difficult to clean, may be constantly recontaminated, do not allow for hanging in the vertical position, and are designed for shipping only. Endoscopes may be stored up to five days without reprocessing immediately before use if the endoscopes are thoroughly dried before storage and stored under proper conditions.

BYRON BURLINGAME

RN, BSN, CNOR, CST

Perioperative nursing specialist

AORN Center for Nursing Practice

Reprinted from AORN J. 2009;89(2):403–405.

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Cooling hot instruments 

QUESTION: My surgery center had an incident in which we think the patient was burned by a hot instrument. A vaginal speculum was contaminated, and it is the only one of that type that the surgeon will use. We had no other choice but to flash sterilize it. After the procedure, as the circulating nurse was taking the patient out of the lithotomy position, she noticed a red mark on the patient's perineum. The team discussed what might have happened to cause the reddened area. On receiving the speculum from the sterilizer, the scrub person removed the speculum from the flash pan, used a sponge to cool the lip of the speculum, and handed it to the surgeon by the lip. The surgeon then inserted the speculum. The team thinks that the weighted area of the speculum may still have been warm and could have caused the redness. What are AORN's recommendations for cooling instruments?

ANSWER: The newly revised “Recommended practices for sterilization in the perioperative setting” does address the cooling of a wrapped or container sterilized item.¹ It states that after the steam sterilization cycle is complete, the contents of the sterilizer should be removed and remain untouched for 30 minutes to two hours. This time frame allows for the equalization of the load contents and minimizes the formation of condensation.¹

When flash sterilizing instruments in the OR, staff members may be pressured to skip an important step in the sterilization process, whether it is cleaning, sterilization, or cooling.¹ When a dense, heavy, metal instrument is heated to 270° F (132° C), the metal retains the heat. The heavier and denser the metal, the longer it will take to cool the metal to room or body temperature.² This is comparable to your dishwasher at home; when the cycle ends, the heavy pots and pans are much hotter than a spoon.

Flash sterilization not only may burn the patient, but perioperative personnel as well. Great care must be taken when removing flash sterilized items from the autoclave to avoid thermal injury.³, ⁴ A revision of the recommended practices for sterilization is that a rigid sterilization container that is designed for flash sterilization cycles should be used. The rigid container system as well as the contents will be hot when removed from the sterilizer.⁴ Use of rigid container systems reduces the possibility of contamination during transport of flash sterilized items from the autoclave to the point of use.¹ To prevent the possibility of burning a patient with a hot, flash-sterilized metal instrument, immerse hot instruments in cool, sterile water. Check the instrument temperature again before use.

The Association for the Advancement of Medical Instrumentation (AAMI) states,

A problem analysis should be completed for any problem with any aspect of flash sterilization that could pose a risk to patients. The problem analysis should define and resolve the problem, and the system should be monitored to ensure that the problem has been corrected. There should be a planned, systematic, and ongoing process for verifying compliance with procedures. The results should be routinely summarized and submitted to Infection Control for review.^4(p112)

Flash sterilization should only be used when there is not enough time to process the instrument by the wrapped or container methods.¹ Decontamination of the instrument is still essential to the process. Improper decontamination may leave bioburden on the instrument and allow possible transmission of infectious agents.⁴ Use the guidelines in Table 1 for time and temperature requirements related to flash sterilization for different sterilizers. The safety of the patient should be at the forefront of all activities in the perioperative setting. To prevent thermal burns to the patient or perioperative personnel, ensure that the instrumentation is sterile and cooled before use.

Table 1. Examples of Typical Flash Steam Sterilization Parameters

1. ANSI/AAMI ST79: 2006—Comprehensive Guide to Steam Sterilization and Sterility Assurance in Health Care Facilities. Arlington, VA: Association for the Advancement of Medical Instrumentation; 2006:69–72.

* The sterilizer manufacturer's instructions for use of express cycles should be followed. One sterilizer manufacturer provides an express fash cycle that permits fash sterilization with a single-ply wrapper to help contain the device to the point of use. This cycle is not recommended for devices with lumens. Express cycles should only be used if the sterilizer is designed with this feature.

MARY OGG

RN, MSN, CNOR

Perioperative nursing specialist

AORN Center for Nursing Practice

Reprinted from AORN J. 2008;88(4):630–631.

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Safety of petroleum-based eye lubricants 

QUESTION: We are starting a laser program at my hospital, and there has been heated discussion in our OR about whether to use petroleum-based eye lubricants rather than water-based lubricants during head and neck surgeries. There are strong opinions on both sides of the issue. Which is correct?

ANSWER: Water-based eye ointments are recommended as eye lubrication for procedures involving the head and neck because these procedures are performed in an oxygen-enriched environment. The composition of water-based lubricants is mostly water and thus will not burn.¹ Petroleum-based ointments, on the other hand, will ignite in an oxygen-enriched environment if there is sufficient heat to cause vaporization.¹

Petroleum-based eye ointments have been identified as factors in facial fires during surgical procedures of the head and neck.², ³ The American National Standards Institute's standard Z136.3-2005, section 7.6.1, states there is a potential for fire when a class 4 laser is used with petroleum-based ointments.⁴ The AORN “Recommended practices for electrosurgery” and “Recommended practices for laser safety in practice settings” list petroleum-based ointments as a combustible substance and caution against their use.⁵, ⁶, ⁷

In 2008, the American Society of Anesthesiologists (ASA) issued the “Practice advisory for the prevention and management of operating room fires,” which designates head and neck procedures in which electrosurgery is used as high-risk procedures.⁸ Surgeries of the head and neck involve all of the components of the fire triangle: fuel, an ignition source, and an oxidizer. Potential fuel sources are the drapes, the prepping agent, or a petroleum-based lubricant. Potential ignition sources are the electrosurgical unit or laser. The oxidizers are oxygen and nitrous oxide.⁹

Corneal abrasions are the ocular complications that occur most frequently during general anesthesia.¹⁰ The controversy regarding which type of eye lubricant to use stems from what is regarded as the best protection against a corneal injury. When a patient is under general anesthesia, eyelid closure is impaired and there is decreased tear secretion.¹¹ Instilling ointments into the eye and taping the eyelid closed offer protection.

A perioperative ocular comfort study of 92 patients undergoing one-hour surgeries compared clear, water-based hydrogel and a petroleum-based ointment.¹¹ No significant differences were found between the two study groups in subjective assessment of burning, eye dryness, and itching; however, the group that received the ointment reported blurred vision and a sensation of a foreign body in the eye.¹¹

Several studies have compared paraffin-based ointments to 4% methylcellulose.¹⁰, ¹² Paraffin is a petroleum-based product. Methylcellulose, found in nonpetroleum-based lubricants and artificial tears, is a viscous agent that prolongs contact time with the eye.¹³ There was no difference in the incidence of corneal abrasions in these studies. The group that received paraffin-based ointment reported blurred vision and foreign body sensation.¹⁰, ¹²

The three fire elements of heat, fuel, and oxidizer are present during surgery. Electrosurgical and laser procedures around the head and neck have been identified as higher risk procedures for fire by the ASA.⁸ Surgical fires can be prevented by interrupting the fire triangle.¹ Use of water-based eye lubricants during head and neck procedures eliminates a potential fuel source. Check the product description for a list of ingredients to determine whether an eye lubricant is water- or petroleum-based.

MARY OGG

RN, MSN, CNOR

Perioperative nursing specialist

AORN Center for Nursing Practice

Reprinted from AORN J. 2009;89(5):909–910.

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Eyewash stations in the OR 

QUESTION: During the remodeling of our ORs, the eyewash station was removed. Do we need to replace it?

ANSWER: An eyewash station is needed to provide emergency first aid in cases of exposure to injurious chemicals, materials, or bloodborne pathogens. Eyewash stations are required by the Occupational Safety and Health Administration (OSHA) under the Eye and Face Protections Standard¹ and the Medical Services and First Aid Standard.²

In the OR and central supply environments, possible injurious materials include ethylene oxide, glutaraldehyde, hydrogen peroxide, disinfectants, antiseptics, and cleaning solutions.³, ⁴, ⁵, ⁶ There is also potential for biological exposures to blood and body fluids in the perioperative area.⁷ The Medical Services and First Aid Standard states that an eyewash station must be available within the work area for immediate emergency use when there is an exposure to injurious materials.² “Immediate use” is not defined, however. When deciding on the placement of the eyewash stations, perioperative administrators should remember that the person who experiences an exposure to an injurious chemical will probably be in pain, have impaired vision, and be frightened by the circumstances. The injured person should have a clear pathway to the eyewash station.

The American National Standards Institute (ANSI) establishes minimum criteria for the performance of eyewash stations; ANSI standard Z358.1 provides the requirements and functions of the eyewash station.⁸ The ANSI standard is accepted by OSHA in its standard letters of interpretation as a means to comply with the Medical Services and First Aid Standard.⁹, ¹⁰ The ANSI standard has been integrated into several state occupational health and safety codes.¹⁰ Check with the state health department for the requirements in your state.

The ANSI eyewash station requirements include the following:

Prevention of eye-splash injuries is very important. Education, protective eyewear, and adherence to manufacturer processes are key components of safety and prevention. Education topics include environmental hazards assessment, possible complications, needed protective measures, what to do in the event of an eye splash, and how to use eyewash stations safely. Material Safety Data Sheets should be easily accessible to provide workers and emergency personnel with information regarding the toxicity, health effects, and required first aid of the injurious substance.¹³

Eyewash stations are required by OSHA for emergency first aid.² In the event of an eye splash, a properly functioning eyewash station is essential for lessening the harmful effects of sterilants, cleaning solutions, ethylene oxide, acids, bodily fluids, and caustic substances in the perioperative environment.

MARY OGG

RN, MSN, CNOR

Perioperative nursing specialist

AORN Center for Nursing Practice

Reprinted from AORN J. 2009;89(5):912–913.

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Laser printer use in the OR 

QUESTION: We are exploring the possibility of putting a laser printer in one of our ORs. We would like to print labels for multiple tissue specimens as is required for tumor tissue margin determination. Is it safe to place a laser printer in an OR?

ANSWER: AORN does not have a statement about the use of laser printers in the OR, and a recent literature search revealed that there have been no studies regarding laser printers in ORs. Research has been conducted on laser printer particle emissions in office settings, however, and in controlled test chamber conditions. In one study, 60% of the laser printers tested had no particle emissions.¹ The other 40% of the laser printers did have particle emissions, and 27% of these were high-particle emitters.¹ Another study showed that laser printers that emit ultrafine particles appear to do so in the beginning of the printing cycle, which results in the highest release of particles. Particle release may be different for other types of printers and may decrease with subsequent printings.²

Laser printer components are primarily made of polymeric materials containing additives that include plasticizers and flame retardants. They also contain chemical residues from the production process. They use electrical current, which results in hot spots within the laser printer, and this can produce volatile organic compounds and ozone in addition to the particle emissions.², ³ The paper, toner, and ink also may add to the emissions.³ Personnel may be exposed to these emissions when they use the laser printer.

Until further research is conducted, AORN cannot make a recommendation for or against the use of a laser printer in an OR. There is no way of knowing whether the health care organization's ventilation system will disseminate the emitted particles or other pollutants that may be produced. There is also a concern about the noise printers create while in use. Researchers have not identified mitigating measures for decreasing possible health effects from laser printer use and have recommended further studies.¹, ², ³

JOAN BLANCHARD

RN, MSS, CNOR, CIC

Perioperative nursing specialist

AORN Center for Nursing Practice

Reprinted from AORN J. 2009;89(5):914.

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Reuse of multidose vials 

QUESTION: We have been reading about the outbreaks of hepatitis C in ambulatory centers related to reuse of sterile supplies. Should we be reusing needles, syringes, or multidose vials? What are safe practices for intravenous systems?

ANSWER: Needles, cannulas, IV bags or bottles, and IV tubing are single-use items and should not be reused on multiple patients.¹ Multidose vials should be used only in controlled situations such as using one multidose vial of insulin repeatedly on one diabetic patient or using multidose vials in the pharmacy where they are used for compounding in an aseptic environment with aseptic technique and without the possibility of patient-to-patient contamination.²

Multidose vials should not be used on patient care units or in the perioperative environment for multi-patient use for several reasons. Research has shown that 25% of health care personnel use needles they have used on a patient to withdraw medication from a multidose vial.³ With the use of multidose vials, it also is important to keep the following issues in mind:

The design of the vial, where and how the vial is stored, the number of times the vial is entered, air from the environment that is injected into the vial, and the use of medication from a multidose vial for patients that have very contagious diseases also need to be considered.

Additional steps that should be followed for safe injection and IV practices include

Hand hygiene should be performed before a person handles any medications requiring the use of a syringe, multidose vial, or IV bag or bottle.⁵

More than 100,000 patients have had to be asked to undergo testing for hepatitis B virus and hepatitis C in the last 10 years because of a failure of health care personnel to follow good aseptic technique and infection prevention and control practices. “The One and Only Campaign: One Needle, One Syringe, Only One Time” has been started by 10 coalition partners to empower patients and re-educate health care personnel to prevent disease transmission.⁶ Since 1998, the Centers for Disease Control and Prevention has identified 33 hepatitis outbreaks that occurred as a result of poor infection prevention and control practices. For further information on this campaign, go to http://www.OneandOnlycampaign.org.

JOAN BLANCHARD

RN, MSS, CNOR, CIC

Perioperative nursing specialist

AORN Center for Nursing Practice

Reprinted from AORN J. 2009;89(6):1128–1129.

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Examination 

The Best of Clinical Issues 

Purpose/Goal 

To educate perioperative nurses about providing safe perioperative nursing care.

Objectives 

After reading and studying the article, nurses will be able to

To receive continuing education credit, read the article, and complete this examination and the learner evaluation online at http://www.aorn.org/ce. Please note that this CE article with the examination and evaluation will be available online after January 15, 2010.

Questions 

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Learner Evaluation 

The Best of Clinical Issues 

This Evaluation is used to determine the extent to which this continuing education program met your learning needs. Rate these items as described below.

Objectives 

To what extent were the following objectives of this continuing education program achieved?

Content 

Event: #09306; Session: #1174; Fee: Members $13.50, Nonmembers $27

The deadline for this program is December 31, 2012.

A score of 70% correct on the examination is required for credit. Participants receive feedback on incorrect answers. Each applicant who successfully completes this program will be able to print his or her certificate of completion online.

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Resources 

1. A patient safety threat—syringe reuse. Centers for Disease Control and Prevention . http://www.cdc.gov/ncidod/dhqp/PS_SyringeReuseFS.html Accessed March 23, 2009.
2. Injection safety FAQs for providers. Centers for Disease Control and Prevention . http://www.cdc.gov/ncidod/dhqp/injectionSafetyFAQs.html Accessed March 23, 2009.
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